Journal - American Medical Association

p

w

[)m.m

THE JOURNAL

OF THE

American Medical Association,

CONTAINING

THE OFFICIAL RECORD OF ITS PROCEEDINGS,

AND THE

REPORTS AND PAPERS PRESENTED IN THE SEVERAL SECTIONS.

Edited for the Association
UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.

VOLUME XIII.
JULY— DECEMBER.

1 ^'^^

CHICAGO :

PRINTED AT THE OFFICE OF THE ASSOCIATION.

1889.

" The American Medical Association, though formally accepting aiid publishing
the reports of the various Standing Cotmnittees (and Sections'), holds itself wholly
irresponsible for the opinions, theories, or criticisms therein contained, except other-
'U'ise decided by special resolution." — Transactions, 1851.

IS

EDITORIAL WRITERS FOR VOLUME XIII.

Wm. B. Atkinson, Philadelphia, Pa.
Robert H. Babcock, Chicago, 111.
Frank Billings, Chicago, 111.
Alfred L. Carroll, New York City.
W. E, Casselberry, Chicago, 111.
Archibald Church, Chicago, 111.
J. C. Culbertson, Cincinnati, O.
Wm. G. Eggleston, Chicago, 111.
James M. French, Cincinnati, O.
E. J. Gardiner, Chicago, 111.
Junius C. Hoag, Chicago, 111.

John H. Hollister, Chicago, 111.

Bayard Holmes, Chicago, 111.

W. W. Jaggard, Chicago, 111.

S. J. Jones, Chicago, 111.

Bransford Lewis, St. Louis, Mo.

Charles H. Lodor, Chicago, 111.

L. L. McArthur, Chicago, 111.

William Porter, St. Louis, Mo.

William L- Worcester, Little Rock, Ark.

Richard M. WyckofiF, Brooklyn, N. Y.

CONTRIBUTORS TO VOLUME XIII.

P. S. Abraham, London, Eng.

Dudley P. Allen, Cleveland, O.

W. W. Allport, Chicago, 111.

Edmund Andrews, Chicago, 111.

George Apostoli, Paris, France.

S. T. Armstrong, U. S. Marine -Hospital Service.

I. E. Atkinson, Baltimore, Md.

William Atkinson, New York City.

William B. Atkinson, Philadelphia, Pa.

A. R. Baker, Cleveland, O.

Henr>' B. Baker, Lansing, Mich.

Francis S. Bascom, Salt Lake City, Utah.

John M. Batten, Pittsburgh, Pa.

A. N. Bell, Brooklyn, N. Y.

D. W. Bland, Pottsville, Pa.
Alexander Boggs, Paris, France.

E. F. Brush, Mt. Vernon, N. Y.
J. H. Bryan, Washington, D. C.

L. Duncan Bulkley, New York City.
A. T. Cabot, Boston, Mass.
J. G. Carpenter, Stanford, Ky.
William Carr, New York City.
W. E. Casselberry, Chicago, 111.
Charles V. Chapin, Providence, R. I.
Julian J. Chisolm, Baltimore, Md.
R. Cleary, Washington, D. C.
Phineas S. Conner, Cincinnati, O.
Leartus Connor, Detroit, Mich.
M. F. Crain, Rutland, Vt.
T. D. Crothers, Hartford, Conn.
H. Holbrook Curtis, New York City.
Ephraim Cutter, New York City.
William H. Daly, Pittsburgh, Pa.
H. C. Dalton, St. Louis, Mo.
N. P. Dandridge, Cincinnati, O.
N. S. Davis, Jr., Chicago, 111.

CONTRIBUTORS.

N. S. Davis, Sr., Chicago, 111.
J. H. Davisson, Los Angeles, Cal.
W. W. Dawson, Cincinnati, O.
Francis Delafield, New York City.
William B. Dewees, Salina, Kan.
Charles W. Dulles, Philadelphia, Pa.

B. A. Duncan, West Point, Miss.

J, H. Eldridge, East Greenwich, R. I.
Geo. E. FeH, Buffalo, N. Y.
Christian Fenger, Chicago, 111.

C. M. Ferro, Tracy, Minn.
T. W. Fisher, Boston, Mass.

W. Freudenthal, New York City.

Geo. E. Frothingham, Ann Arbor, Mich.

Henry D. Fry, Washington, D. C.

G. M. Garland, Boston, Mass.

William Goodell, Philadelphia, Pa.

John W. S. Gouley, New York City.

Sir James Grant, K.C.M.G., Ottawa, Can.

J. A. S. Grant (Bey), Cairo, Egypt.

T. B. Greenley, West Point, Ky.

N. Guhman, St. lyouis, Mo.

John B. Hamilton, Surg.-General U. S. M. H. S.

Junius C. Hoag, Chicago, 111.

Peter Hooper, Philadelphia, Pa.

Charles C. Hunt, Dixon, 111.

T. J. Hutton, Chicago, 111.

J. T. Jelks, Hot Springs, Ark.

H. A. Johnson, Chicago, 111.

Joseph Jones, New Orleans, La.

Herbert Judd, Galesburg, 111.

G. A. Kennedy, Macleod, Can.

R. R. Kime, Petersburg, lud.

J. A. Larrabee, Louisville, Ky.

Thomas Legare, Charleston, S. C.

Bransford Lewis, St. Louis, Mo.

J. Berrien Lindsley, Nashville, Tenn.

John Noland Mackenzie, Baltimore, Md.

Henry O. Marcy, Boston, Mass.

H. C. Markham, Indepeiidence, la.

G. R. Martina, Glenns Falls, N. Y.

Geo. O. Meade, London, Eng.

Perry H. Millard, Minneapolis, Minn.

Geo. Minges, Dubuque, la.

E. E. Montgomery, Philadelphia, Pa.

Robert T. Morris, New York City.

Harold N. Moyer, Chicago, 111.

Wolfred Nelson, New York City.
A. J. Ochsner, Chicago, 111.
Charles T. Parkes, Chicago, 111.
James A. Pilcher, Asst. Surg. U. S. A.
P. Brynberg Porter, New York City.
William Porter, St. Louis, Mo.
Wm. Warren Potter, Buffalo, N. Y.

D. W. Prentiss, Washington, D. C,
Joseph Price, Philadelphia, Pa.

A. E. Prince, Jacksonville, 111.
John H. Ranch, Springfield, 111.
J. C. Reeve, Dayton, O.
C. W. Richardson, Washington, D. C.
Wm. C. Rives, Newport, R. I.
John O. Roe, Rochester, N. Y.
George H. Rohe, Baltimore, Md.
N. Senn, Milwaukee, Wis.
Frederick C. Shattuck, Boston, Mass.
Hon. Wm. P. Sheffield, Newport, R, I.
John V. Shoemaker, Philadelphia, Pa.
Henry H. Smith, Philadelphia, Pa.

E. C. Spitzka, New York City.

Geo. M. Sternberg, Major and Surg. U. S.
William S. Stewart, Philadelphia, Pa.
Charles G. Stockton, Buffalo, N. Y.
I. S. Stone, Lincoln, Va.
Horatio R. Storer, Newport, R. I.
J. L. Thompson, Indianapolis, Ind.
Robert Tilley, Chicago, 111.
Laurence Turnbull, Philadelphia, Pa.
Henry E. Turner, Newport, R. I.
James Tyson, Philadelphia, Pa.
J, VanderLaan, Muskegon, Mich.
Albert Vanderveer, Albany, N. Y.
Victor C. Vaughan, Ann Arbor, Mich.
H. H. Vinke, St. Charles, Mo.
George E. Waring, Newport, R. I.
J. Collins Warren, Boston, Mass.

F. E. Waxham, Chicago, 111.
William H. Wel.-,h, Baltimore, Md.
Edward F. Wells, Shelbyville, Ind.
Claudius G. Wheelhouse, Leeds, Eng.
Joseph A. White, Richmond, Va.
Wm. C. Wile, Danbury, Conn.
Henrj' W. Williams, Boston, Mass.
William L. Worcester, Little Rock, Ark.
Jonathan Wright, Brooklyn, N. Y.

A.

THE

J ournal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.
PUBLISHED WEEKLY.

Vol. XIII.

CHICAGO, JULY 6, 1889.

No. I.

ADDRESSES.

THE PRESIDENT'S ADDRESS.

Veli-rered at the Fortieth Annual Meeting of the American Medical
Association, Newport. R. T.,Jnne 25, iSSq.

BY \V. W. DAWSON, M.D.,

OF CINCINNATI.

The Premier, Mr. Gladstone, after quoting the
statistician who estimates the English-speaking
people at the close of the next century at one
thousand millions, says: "What a prospect is
that of many millions of people, certainly among
the most manful and energetic in the world, occu-
pying one great continent." This destiny in
numbers is startling, but the assertion of Dr. Dol-
linger, a German scholar, portrays the culture of
the future almost as strikingly when he says
"that the intellectual primacy of the whole world
is certain to fall to the Anglo-Saxon race." Most
of that race will be in America.

Looking to such a future the position of the
learned professions is certainly conspicuous —
their obligations imperious. Medical men should
be loyal to this grand destinj'.

An eminent modern critic, in discussing civili-
zation in America, while admitting that we have
well solved the political and social problems, asks
what have we done to solve the human problem,
"the humanization of man in society." The
struggle in his own country', he a.sserts, has re-
sulted in "an upper class materialized, a middle
class vulgarized, a lower class brutalized."

We trust that our efforts have yielded better
fruit ; and since medical science and medical men
are prominent factors in society, among every
people, we may well ask, what have they accom-
plished, what part they have here taken in the so-
lution of the vital problem? In the " Centur>' of
Medicine," Prof. E. W. Clark in his classical ad-
dress says :

" It is not an extravagant assertion to say, that
in all this turmoil, change and progress f referring
to the revolutions and changes in society, religion
and government for the past century), medicine
has kept abreast of the other natural sciences, of
politics, and of theology, and has made equal
conquest over authority, error and tradition," and
it may be added, has contributed largely to man's

comfort, happiness and advancement. To inten-
sify this, reference need only be made to some of
our triumphs, to Vaccination, to Anaesthesia, to
Sanitation, the prevention of pestilence, the
lengthening of human life. It is, however, more
especially the contributions of the profession in
America to which attention is desired at this
time. What are we doing in the humanization
of man, in the work of civilization ?
I Are our medical practitioners and our medical
I teachers what they should be ? We shall see.
I Criticisms abound concerning the defects of med-
1 ical education. Those who do not condemn, often
ridicule. These criticisms and .strictures are made
for the most part, it must be said, by gentlemen
unacquainted with teaching, without anj' practi-
cal knowledge of the constitution of medical col-
leges, or of the toil, devotion and sacrifice made
necessary' by those engaged in didactic and clini-
cal instruction.

These censorious addresses are delivered before
and to a body of professional gentlemen, the peers
of any, .some of whom have grown gray in the
hard service, others are still in the prime of life,
with reputations coextensive with civilization.
The rest are young, full of life and enthusiasm,
fired with ambition to render loyal service to that
profession which thej' have chosen. Can our sys-
tem be so defective? The pessimistic orator seems
to forget that he is the product of the system of
medical education which he is so severely con-
demning. Some one has said, " By retrospection
and introspection an individual, like a profession,
ma}' be benefited." In this self-examination we
should have but one motive, the elimination of
error, the development and support of truth.
' Education cannot make all great or equal. It
tends, however, to make all safe. In the crucible
of private, practical life, evolution asserts itsell
and the fittest survive.

In making a retrospect of our profession it may
be well to look for a moment at medical teaching
in this country.

The way is long between Aristotle and Bichat,
and Buckle says that he found no middle-man in
this long period; it is darker than it is long. Dur-
ing all this time medicine was not taught legiti-
mately. The renaissance, if it may be so called,
began with Hunter and Bichat. No real progresSj

THE PRESIDENT'S ADDRESS.

[July 6,

however, could be made while oxygen remained | the chairs. Yes, not only without patronage from
locked in the silent embrace of all organic and in- ! the Government, but society, from some unknown
organic nature. Priestly, escaping from the reli- cause, has ever been against legitimate medicine,
gious and political contests, and it may be perse- depending upon the scientific physician in time
cutions, of the old world, came to this country to | of trouble, yet, in the interim, openly supporting
demonstrate his great phlogiston, oxygen. j all sorts of shams, frauds and impostors.

Bichat and Hunter restored the proper study of ; Elsewhere, college work is provided for by the
medicine. They represent the turning-point from [ State ; especially laboratory investigations— the
idealism, speculation and theory, to accurate and | nature and the genesis of disease. Hence, it is
close obser\-ation. The latter,' John Hunter, in not strange that, in such departments, we may
1767, was lecturing and taking students into his ' not be so far advanced as our European brethren;
own house, and it is curious to know that here, in but, while they have been engaged in experimen-
far off America, Shippen and his contemporaries ' tal studies, we have developed the practical. But
in Philadelphia and New York, about the same ever>'where is seen among us an earnest, a burn-
time, or very soon after, began teaching medicine ' ing desire for higher culture, for more exact and
and surgery upon essentially the same plan. Of , accurate knowledge. Especially is this true of
these men, one who so recently passed away, that | our younger members and of those about entering
you can almost hear the sound of his voice, and I the profession.

feel his magnetic presence, when speaking of the j A movement is being made to concentrate those
men who lived at the close of the last, and during who have had preliminar>- advantages — those who
the earlv part of this centurj-, said, and justly said, ; enter the profession as college-bred. No objection
"Not a few of them were the worthy peers of can be urged to this if it be not too exclusive. All
Roux, Abernethy, Crampton, Bell, Graefe, and efforts, in fact, to refine our profession without

emasculating it, should meet with judicious ap-
proval.

THE PHVSICI.\N OF THE FUTURE.

Whence are medical students to come? What
facilities are now afforded, and what does the fu-
ture promise for the education of our young men,
the class from which the medical student, the
" coming doctor," is to be selected? The answer
to this question will give some comfort, we trust,
It may be profitable for us to inquire and deter- 1 to the pessimist, and soothe the restless and at
mine what part the profession in America has I times unreasonable critic. And now as to our re-
taken, in placing medicine upon the high ground sources for this work.

which it occupies. What have we done, what are ! By the last census it was shown that nearly four
we doing, and what forecast can we make of the ' thousand institution.s — schools for higher learning
future? I — existed in the United States, and that nearly

At the close of the eighteenth centur>', Boer- 1 four hundred of them ranked as Colleges or Uni-
haave declared that all that had been learned up: versities. In these are massed, yearly, sixty
to that time was comprised in three propositions : ] thousand pupils. They, together with two hun-

Scarpa."

To quote again :

' ' During the past centurj', medicine has been en-
franchised from superstition, (/waw'-charlatanism,
bold empiricism and speculation, and has devel-
oped into a symmetrical science, affiliated with
the other natural sciences, studied by the same
methods and by the same appliances as they are,
and like them, has been planted upon the solid
basis of fact and demonstration."

Keep the head cool, the feet warm, the bowels
open. All other pages in the volume which he
left were blanks. . Many pages, however, it will
not be denied, have been filled during the present
centurj'. What have been our contributions?
Have they been such as to rank us with the ac-
knowledged conservators of mankind ?

In giving attention to this subject let us for a

dred thousand common, or primary schools, in
the higher grades of which the curriculum nears
that of many colleges at home and abroad, a third
of a century ago, may be looked upon to supply,
year after year, a better material from which med-
ical students will be drafted.

Prof Charles W. Eliot, in his beautiful and
forcible Centennial response, enumerated our edu-

moment reflect upon the peculiar position of the cational facilities more generously. He painted

profession and of medical teaching in this coun
tr>'. For many years (and even now) with few
exceptions, medical colleges were the creation of
the members of the profession, most often of the
faculties composing the schools, without endow-

ment— indeed, it may be said that almost every-
thing on this continent is endowed, except medical situated in the far away mountains, and
colleges — without Governmental aid, depending Pacific — nuist be impressed with the

our future more hopefully when he spoke of the
8,000,000 children in elementary schools, 250,000
in secondary schools, 60,000 in colleges, with
360,000 teachers to train and develop them.

Every one traveling through the States — espe-
cially those of the West and South, and those

on the
onward

for their support upon the sacrifice of time and ! march of public instruction, the gradually in-
money on the part of the gentlemen occupying ' creasing general intelligence, and the vast sums

iSSg.]

THE PRESIDENT'S ADDRESS.

that are aunuallj^ expended for the education of
the people. Public school buildings, by their
size, adaptation and attractive surroundings, give
an impression which the most skeptical must feel,
a promise of the future which cannot be mis-
read. From such as these, scientific medicine
must reap a share. Ever>' teacher, every one con-
nected with the examination of candidates for the
medical degree, knows — and the knowledge is re-
assuring— that, year after j-ear, the grade of the
medical student is advancing, that the material
out of which the practitioner is made is constantly
growing better, becoming stronger; in other words,
that the preliminary education of our students is
steadily becoming more broad and comprehensive.
I gave utterance to this view a few years ago, in
an address which I had the honor of delivering to
the State Medical Society of Ohio. Time, I be-
lieve, has confirmed what I then said. This con-
firmation is seen in our graduates as they go forth
to take up the line and battle of life. Are they
not the equals of the graduates in other profes-
sions, in law and theologj' ? As life advances,
are they not the peers of any, in all the useful
elements of true manhood? Are they not the
citizens of best rounded characters, citizens most
relied upon by their neighbors in foul as well as
fair weather?

Again, in addition to facilities already referred
to, the most generous provisions are being made,
all over our land, for institutions which will be
worthy to be called Universities. From these,
graduates will emerge worthy to rank by the side
of those bearing the prized degrees from Oxford,
Cambridge, Paris, Heidelberg or Leipsic.

During the summer of iSSS, I witnessed the
beginning of a Universitj' in California which,
in scope and equipment will surpass, probably,
any school upon the continent. Should Governor
Stanford live to develop his conceptions, that far
off State will have an institution of which not
only the Pacific Coast, but our entire country ;
yes, all civilization, will feel justly proud. It
may be so liberally endowed that it will command
the best abilities of the world.

Of course, upon such an occasion as this, it
would hardly be expected that I should in detail
refer to the many liberal donations and bequests
which have been made, by generous citizens, for
developing higher culture — a more comprehensive
education. I will, however, be pardoned for re-
ferring to a few, and I may say, without being
too enthusiastic, that the future is aglow with
promise. The high-hearted examples which have
been set will be followed bj' other favorites of
fortune, and this country may surpass the world,
not only in common schools, but in her institu-
tions for broader and deeper education.

In looking at this promising future, may we
not hope that, before another half centurj- closes,
students from the old world will flock to this, to

sit at the feet of the wisdom here installed? Is
it too much to hope that, in the not far ofi" future,
the preliminarj- education of our students will be
equal to that required in the best schools of the
world ?

Defective as has been much of the material, yet
have we not produced some marked results? Our
best are equal to the best anywhere ; mediocrity
always and everywhere finds its own. The poor
in medicine, the weak brother, however much we
may deplore him, however much we may train
him, we have, like the poor, alwaj-s with us.
This is the lot of humanity in all lands, among
all peoples, new or old, A word as to the physi-
cal qualities of ' ' the coming doctor. ' ' Recently
a distinguished foreign traveler, in speaking of
our educational facilities and national peculiari-
ties, said : " Students are much calmer than their
colleagues in Europe. Thej- don't at all trouble
themselves about politics or affairs outside their
line of duty, and with the practical sense which
animates the nation, they tr>' to make the best
use of their time. They fight no duels, and it is
only for health and recreation that thej' take part
in various sports and games." These remarks
apply with equal, in fact, with greater force, to
medical students.

It is to the country schools, not to the city-bred,
that medicine must look for many of her strong
recruits. Cities too often emasculate — young men
are vitiated by indulgence and vice before they
become possessed of serious thoughts, before they
realize the elements of a health^-, vigorous life.
It is this country-bred, this excellent material
which is, as we have seen, yearly growing better
and better qualified to enter upon the duties of
the profession. From these we must look for the
men of distinction, the leaders of the future.

Is this picture overdrawn ? One word more.
In many of the States of the Union, in addition
to the liberally supported free schools and schools
for higher education, alreadj' colleges have been
established through the munificence of the Gen-
eral Government, in which the degrees of A.B.
and A.M. may be obtained. They are absolutely
free colleges, at which the poorest boy in the
commonwealth may receive a classical education.
And here you will allow me to say, we cannot in-
sist too strongly upon the necessity of classical
education ; without it the medical man must ever
be at a disadvantage. Without a knowledge of
Latin and Greek, sure and distinguished success
is uncertain. The student may neglect Algebra
and the Higher Mathematics, but let him, bj- all
means, have a liberal knowledge of languages.

At the last commencement of one of our
western schools, "40 per cent, of the graduating
class had been admitted on diplomas from literary
or scientific colleges. The balance of the class
had received from one to five years of academic
or collegiate instruction." This college is with-

THE PRESIDENT'S ADDRESS.

[July 6,

out endowment — depending entirely upon the
learning, devotion and sacrifice of the Faculty.

But to return. Prominent among the States
in providing institutions for advanced culture,
the great frontier State, Texas claims a high po-
sition. The University of Texas will be one of
the most liberally endowed : millions of acres of
land have been donated for universitj- purposes.
There, in that Empire State, may yet be seen one
of the greatest schools of literature, science and
philosophy on the Western Continent. The Uni-
virsity of \"irgiuia, projected in the early days of
the centurj-, by her great commoner, Thomas
Jefferson, has yearly sent forth graduates equal in
all the elements of advanced scholarship to those
from any school. This maj- seem high praise,
but the records of her alumni justify me. The
same ma}- be said of Har\-ard, Yale, Princeton,
Columbia, Cornell, and of most of our older in-
stitutions. " The University of California has
already an annual revenue of about $200,000.
The Michigan University, with a yearl)- income
of almost a quarter of a million of dollars, has
well nigh two thousand students, taught by more
than one hundred teachers.

Let us not, gentlemen, be impatient ; the influ-
ences are already projected which will give us
students equal to — up to — the highest standard of
preliminary- preparation. If we have accom-
plished so much in our primitive stage, what may
we not expect when all our great preparatory
works come full}- into action ?

From this view of the resources from which
medical students are to be drawn, and of the lib-
eral preparations and facilities for their culture,
we ma}- well ask, what is the profession doing to
profit from such advantages?

Some of the classical schools at Oxford and
Cambridge were organized as early as the thir-
teenth centur}-, but the systematic, scientific study
of medicine and surgery came long subsequently
— not for four hundred years later — about the
middle of the eighteenth century. It was first
projected in Great Britain, and soon after in our
Atlantic cities. Unlike the Old World, our
fathers had a wilderness to conquer before pro-
gress could be made. When the Pilgrim Fathers
left England, reading and writing were rare ac-
complishments ; chimneys in that countr\- had
just been invented, and flock beds were luxuries.
The adventures — the emigrants to these shores
from that ancient and imperfect civilization — had
much to learn, but in the midst of their pitiable
ignorance, facing great hardne.ss and pressing
wants, they were quick to provide educational
opportunities for all. The result of tlieir efforts
are apparent — they are before us. Could more
have been accomplished in one century ?

MEDICAL SCHOOLS.

Our medical colleges now number a few more

than one hundred. They may be classed as : i,
Metropolitan, those in large cities. 2, Medical
colleges in less pretentious cities. 3, Medical
colleges in small cities. 4, State medical colleges.
For convenience, however, we may speak of them
as Metropolitan and Provincial.

Before speaking more definitely of our medical
institutions, allow me to refer for a moment to
the proposition, that medical schools in our coun-
try have been developed by the labors, by the
self-sacrifice of the profession. As previously
stated, it may be said that in this countrj- every-
thing is endowed except medical colleges, schools
for teaching medicine. Yes. all financial responsi-
bilities have been and are assumed by the facul-
ties, by men who give every hour not devoted to
"earning the guinea" to college work, and in
most instances, without pecuniary reward. It is
only recently that the wise, the generous, the
favorites of fortune, and a few of the States, have
conceived the idea of endowing medical schools,
institutions where medicine and surgen,- can be
cultivated without the embarassmeuts of financial
responsibility. In the presence of such facts, the
work of the grumbler seems indeed ungracious.

In our Metropolitan colleges, ever}- physician
may feel a just pride ; their graduates, most of
them, will compare favorably with those educated
anywhere on this earth.

The accomplished Dr. Senn, after a liberal ex-
perience with foreign schools, said: "There is
no question in my mind, that the average Ameri-
can student learns more in one month, than the
average German student in three. He learns
more, not because he has better teachers or better
facilities, but he makes better use of his time. I
am satisfied that in our last graduating class, I
had at least a dozen students, who, after studying
three years, would pass a brilliant examination
in any English or German university. They
would have felt at home, even in a dress coat in
\'olkraann's Klinick passing their final examina-
tion."

Provincial schools do praiseworthy, yes, thor-
ough w-ork in training young men, not only in
rudimentary branches, but in practical, clinical
studies. ^Iany supplement these by hospital at-
tendance in the great cities, and by post-gradu-
ate courses. It is gratifying to know that these
organizations are being established in all of the
great medical centres.

The advance in medical education is again
most distinctly pronounced by a remark recently
made by one of our distinguished fellows, an
American-bred physician, of whose fame we are
all justly proud. In a conversation. Dr. Batty
said: "When I began the practice thirty years
ago, there was .scarcely a graduate within fifty
miles of my residence ; now, however, there is
hardly a practitioner in the same territon.- who is
not a graduate, and, year after year, a portion of

1889.]

THE PRESIDENT'S ADDRESS.

our young men leave home to avail themselves of
clinical advantages, to attend post-graduate
instruction." Could anything show more forci-
bl}' the conservative and steady growth of med-
ical culture?

HAVE MEDICAL COLLEGES INCREASED TOO
RAPIDLY?

Should the}' be established in small cities where
clinical material is limited, where it must be com-
paratively scarce ? Before answering this, it maj'
be well to reflect upon the proposition, that in
our own country, as well as elsewhere, great
achievements have often been made in the
Provinces and not always under the shadow of
the Universities. One of the great operations
waited for years for a metropolitan disciple — one
to take it up — and that too, long after the prov-
inces, at home and abroad, had demonstrated its
vital utility, its claim upon the scientific and
skillful surgeon.

As our population increased from three to
sixty-five millions, the demands for medical men
were great — colleges increased necessarily. Have
they multiplied in undue proportion ?

In answering this question, I beg again to
quote from my beloved master, Samuel D. Gross,
to whom this question had been put. After ma-
ture deliberation, he said: "Our colleges are
uot annually graduating one phj-sician for each
county in the States and Territories. This is
certainly not exceeding the demand." A con-
siderable proportion of those who graduate never
€nter the ranks — death and desertion claim a
large share. It would simply be impossible for
the metropolitan schools to graduate all required.

For the introduction of young gentlemen into
the profession, there is a mutual responsibility
between teachers and preceptors. In ver}- truth
it maj' be said that colleges do their dut}', their
very best, with the students furnished by the pre-
ceptors. Give us liberally educated young gentle-
men, and we will furnish graduates worthy of the
degree. Medical colleges, however, do not make
the physician. They merely furnish the founda-
tion work ; the individual must do the balance.
In no place is evolution so marked — the fittest
will and should survive.

LABOR.ATORV WORK.

Huxlej- says : "The microscope extends the
realm of Pathological Anatomy to the limits of
the invisible world."

"The intimate alliance between morphology
and medicine has made the natural history- of dis-
ease attain a remarkable degree of perfection."

Dr. George M. vSternberg, the distinguished
Pathologist, recently connected with the Smith-
sonian Institution, in referring to some of the
laboratories established in this country for the
studv of Pathogenic Microorganisms, savs : "It

is no longer necessary to go abroad for instruction
in this department of science, since the Labora-
tor>- of Prof Welsh, in Baltimore, and the Hoag-
land Laboratory, in Brooklyn, afford facilities
which are unsurpa.ssed by any of the laboratories
of the old world."

Indeed, it may be said that provisions for the
study of Pathogenic Microorganisms are estab-
lished in most of the leading schools of this
country — in New York, Philadelphia, Boston,
Baltimore, and the cities of the West and South.

You will pardon me for mentioning some of the
investigators.

Johns Hopkins' Universitj- has for its Director,
Prof William Welsh. The Hoagland Laboratory,
of Brooklyn, New York, established through the
generosity of Dr. C. N. Hoagland, has been built
and equipped in the most complete manner for
research work in Bacteriology and Experimental
Pathology. Prof. George M. Sternberg is to be
the Director of this advanced institution.

At the University of South Carolina, Dr.
Meade Bolton, who has had the best of training
at Berlin and Gottingeu, is at the head of a labor-
aton,-. Dr. H. C. Ernst has the direction of a
Bacteriological Laboratory in connection with the
Har\-ard School of Medicine.

Prof James T. Whitaker, who had the honor
of being the first American student of Robert
Koch, demonstrated, at Cincinnati, in 1882, the
tubercle bacillus, after a lecture upon the subject
before the Philadelphia Academy of Medicine.
In 1S87 the Medical College of Ohio imported a
complete outfit for Bacteriologic study. The con-
ductors of the Laboratory-, Drs. Rachford, Cam-
eron and Freeman, during the first course, had
the opportunity of doing some good work in the
discovery of the tj-phoid bacilli in the reserv'oir
supplied from the Ohio River, then at a very low
stage. The discovery led to the general adoption
in the city, as advised by leading physicians, of
boiling all drinking water, a plan which un-
doubtedly limited the spread of the disease.

Among others may be mentioned Dr. Prudden,
of the College of Physicians and Surgeons, of
New York : Dr. Geo. A. Kemp, of Brooklyn ;
Dr. !Mall, of Baltimore ; Dr. Booker, of the same
city ; and Dr. Frank S. Billings, of Lincoln,
Nebraska.

One of the earliest, most accomplished and ac-
curate cultivators of microorganisms, is Dr.
James E. Reeves, of Chattanooga. His tech-
nique is singularly beautiful. Many of his prep-
arations are to be found in the National Museum.

Dr. \'ictor C. Vaughan and Dr. Heneage Gibbs,
conduct laboratory- work at Ann Arbor.

The University of Pennsylvania has at the head
of its laborator}- Dr. John Guiteras, a Pathologist
who has distinguished himself in the study of the
origin and spread of yellow fever.

Thus it will be seen that in all parts of our

THE PRESIDENT'S ADDRESS.

[July 6,

countrj' — East, West, North and South — labora-
tories are being established for original work.

HISTORY OF MEDICAL TEACHING IN THIS
COT.TSITRY.

A brief review of medical teaching in this
country will be pardoned — it may be profitable —
it will certainly illume the present, and may be
somewhat of interest to the future.

The first medical lectures were delivered by Dr.
John Morgan and William Shippen, in 1767, in
Philadelphia. Dr. Rush and Dr. Physic soon
after participated, and in 176S the medical de-
partment of the University of Pennsylvania was
organized ; that great school which is steadily ad-
vancing to the highest station. Philadelphia was
a small, a provincial city at that time ; now she
is only second to the great metropolis in numer-
ical strength, but second to none in the thorough
equipment of her medical schools.

Contemporaneous with Philadelphia, an or-
ganization was projected for medical instruction
in New York. In 1767, the first steps were
taken which resulted in the school, ever since
known as the "College of Physicians and Sur-
geons," one which challenges the confidence of all.
The medical colleges of New York, endowed, not
by government, but by her public spirited citizens,
have won the honors which they wear so well.

In 1785, the first school was organized in
Boston. The chairs were four, and the session
four months. Harvard is the outgrowth of this
humble beginning of that provincial faculty.

In 1 800, the first medical instruction was given
in Baltimore ; since then, the schools of Maryland
have occupied a deservedly high position. Re-
cently one of her citizens made an endowment bj'
which the "Johns Hopkins University" will be
equipped for the most thorough work, experi-
mental work, laboratory studies, a range and
grade of investigations en report with the spirit of
the times.

This great benefactor has also given to Balti-
more one of the most completely equipped hos-
pitals to be found on this earth.

The great Mississippi Yalle^' was yet unknown,
but soon after the close of the Revolution, emi-
gration began, and as early as 1799, Dr. Samuel
Brown organized the medical department of
Transylvania University. Dr. Benjamin Dudley
effected a reorganization in 1S19. This school,
after many prosperous j-ears, having graduated
men who acquired distinction at home and abroad
was transferred, or rather, most of the faculty re-
moved to Louisville, when and w'here the Uni-
versity of Louisville was founded.

During the early part of the centurj-, medical
schools were organized in .several of the Eastern
States, usually under State or Church patronage.
Most of them exist to-day. Some of the most
distinguished men in our profession have been as-
sociated with these institutions.

As the West and South were peopled, medical
schools were established in cities and promising
towns. As early as 18 19, Dr. Daniel Drake se-
cured the charter of the Medical College of Ohio,
and had it legallj- connected with the Cit}- Hos-
pital. The faculty constituted the hospital staff,
the members of which were required to give clin-
ical lectures — the first forn-ard step on the conti-
nent, in blending didactic with clinical instruction.

The physicians in South Carolina began med-
ical teaching in 1823, and those of Louisiana in
1835. In both of these States schools of high
character have been maintained.

In closing this verj- brief review of our col-
leges. Metropolitan and Provincial, I think it
may be said that j-ear after year the standard of
the Doctorate is being elevated, preliminary- ex-
aminations and graded courses are being adopted,
the smaller schools, to which most blame is at-
tached, whether justlj' or not, with a disregard of
self-interest seldom seen, are yearly reducing the
size of their classes by insisting upon higher pre-
liminary education, by extending the curriculum
and bj' graded instruction.

MEDICAL JOURNALS.

Medical journals, Metropolitan and Provincial,
are the heralds, the vanguards of medical pro-
gress, the exponents of professional culture.
They are closely associated with the colleges in
education and in post graduate instruction. In
them appear the best thoughts of the best men ;
they constitute the great forum of intellectual
combat : upon their pages pretension is analyzed
and estimated, and worth recognized ; that which
is new or original is endorsed, or rather en-
couraged ; it is onlj' the plan, the original in-
vestigation which is endorsed ; the results, the
conclusion must be subject to the crucible of test
and trial.

The London Lancet and the American Journal
of the Medical Sciences were almost contemporaries
— who can overestimate their value — their influ-
ence in medical progress. While our journals,
both Metropolitan and Provincial, are freighted
with the best thoughts of the best men, yet, it
must be confessed, that trash and light material
— ver>' light material — may be found in all, but
the reader, nevertheless, will find much that is
not worthless.

The Journ.\l of this Association has won its
way to its present high position by its dignified
course and its essentially scientific character ; but
has it reached its full usefulness ? A learned and
distinguished author, and a highly prized fellow
of our A.s.sociation, at my suggestion, gives his
views upon this question.

Dr. Comegys says : " The undertaking, seven
3'ears ago, to establish a weekly journal, was a
happy conception, and has been carried on as
successfully as the resources of the Association

1889.]

THE PRESIDENT'S ADDRESS.

would admit. To Dr. X. S. Davis unstinted
praise is due ; proportionate praise is also due the
Board of Directors with whom he has been
associated.

' ' A large number of the members believe that
it is entirely feasible to enlarge The Journai,
and give to it increased capacit}- for usefulness ;
indeed, that it should be made more fulh- capa-
ble, as the organ of the Association, to assert and
maintain the dignitj- and power of the medical
profession as one of the greatest factors in civil
life : that to it society' must ultimately turn, to
find, not onlj^ the resource to assuage the distress
arising from the diseases and accidents of life, but
as to its protection from all those evils that iill the
land with apprehension of desolation and ruin.

" We know to what ati immense extent we can
estop the approach of the pestilences that deso-
late lands and which menace, through the paths
of commerce, the whole area of civilization. We
know what we can do to improve the homes and |
places of labor of the lower and toiling classes of!
cities and other crowded centres of population, j
There is nothing, indeed, connected with our own
social State, which the medical profession should
not super^-ise and which it should not have the
power to control. A great organ is necessarj- to
enlighten, strengthen and lead the profession in
all directions to bring, to bear its beneficent
agency for the correction of the terrible evils of
society.

" Such a journal must be made encj-clopaediac
in character, in which can be found the proceed-
ings of distinguished societies of this country- and
of Europe, the work of the chief actors of med-
ical progress in all parts of the world. Twelve
thousand subscribers would give $60,000, this
would insure $40,000 from advertisements, mak-
ing an income of $100,000, which would sustain
one of the grandest journals in the world.

"The British Medical Joufiial in fifteen j-ears
has 14,000 subscribers and an income of $125,000.
May we not hope to reach this, and when we do,
who can compa.ss the good which the American
Medical Association will accomplish."

THE MEDICAL AND SURGICAL LIBRARY AND
MUSEUM AT WASHINGTON.

Another important factor in professional culture
is the great Librarj- and Museum at Washington,
evoked by the efforts of an American bred physi-
cian, John S. Billings. The Library of the Sur-
geon-General's office of the army now contains
92,000 volumes, and 137,000 pamphlets, being
the largest collection of medical literature in the
world, and it is not only the largest, but the
most useful. This is because it has an Index
Catalogue, which not only shows what the Li-
bra^^• has of the works of any author, but for
any given subject, indicates all the original arti-
cles in journals and transactions, as well as the

books and pamphlets which relate to it, and thus
forms a Medical Bibliography which saves an
enormous amount of time and labor to those en-
gaged in medical literarj' research. This cata-
logue is being published at the rate of one volume
a year, nine volumes have been issued, and six
more will complete the work. The Armj- Med-
ical Museum is a great pathological school, and
now contains over 15,000 specimens, being one of
the eight largest museums in the world, and
richer than anj- other in illustrations of Military
Medicine and Surgerj'. This Librar}- and Museum
are national in scope and character. Thej- have
at least been .securel)- placed in a fire-proof build-
ing well adapted to their needs, thanks to the
efforts of the medical profession, and we should
see to it that thej- are maintained and increased to
the highest degree of completeness and efficiency.
The Medical Profession asks very little of the
General Government, but it does ask that these
two institutions shall be made as useful as possi-
ble. The number of copies of the Index Cata-
logue, which Congress authorizes to be published
is hardly sufficient to meet the demand, and the
repeated requests for authority to publish an illus-
trated catalogue of the Museum for distribution
to the profession have not yet received any atten-
tion from Congress, and it is time we took the
matter in hand. When we, who are the famil)'
physicians of our Senators and Members, saj- to
them that this is a thing that ought to be done
and must be done, it is prett}- certain that it will
be done. There is nothing that will do more to
promote higher medical education, to stimulate
research, and to crown American Medicine with
honor, than to give ample means to this great
L,ibrarj- and Museum to obtain materials and to
publish widel}- the results.

MEDICAL AND SURGICAL HISTORY OF
THE WAR.

This matchless record of Militarj^ Medicine and
Surger}-, is a marked testimou}' to the profession
of our land. Let us for a moment compare it
with similar work elsewhere. After the great
Crimean war was over, its experiences, collected,
weighed and analyzed, how strange in the light
of present surgerj', and in what contrast with the
lessons taught in our great conflict, is the record
of McLeod upon one vital operation — trephining
for fractures of the skull. In his " Notes on the
Surger}' of the Crimean War, ' ' that distinguished
gentleman sa}"s :

"If any patients were lost from not having
been operated upon, I never saw any of them,
but I do know of some patients who died because
they were subjected to operation."

And what a fearful commentar}' upon militarj-
surgerj- of that campaign McLeod makes when
he writes :

' ' Thus it would seem as if severe fatigue,

8

THE PRESIDENT'S ADDRESS.

[July 6,

irregular, and, it might be, intemperate diet, are
less injurious to men with fracture of the skull
than the probings, pickings and trephinings which
form the more orthodox and approved prac-
tice."

It may be truly said that the judicious use of
trephine during the conflict between the States,
supplemented after the war by American sur-
geons, especially by one of our fellows, Prof. W.
T. Briggs, led up, led surely, safely and steadily
to the achievements of Victor Horselj-, the master
of us all in brain surgery.

MEDICAL SOCIETIES.

Our medical societies, local and National, are
great factors in professional progress. Not alone
are they_ valuable for their social opportunities, but
in and through them a vast amount of valuable
matter is presented.

MEDICAL LITERATURE.

Had Sidney Smith been a physician and given
to reading, he would not, even in 1850, have
asked the questions : "Who reads an American
book ?" " What does the world owe to American
physicians and surgeons?"

This reverend gentleman, this famous critic,
could not have heard of Ephraim McDowell,
whose brief paper, detailing his first three cases
of ovariotomj-, published in "The Philadelphia
Repertory," in 1817, was of more value, did more
for the conservation of human life than a score
of ordinary publications. Our first half-century
may be poor in books, but it abounded in strong,
brave conscientious and devoted men, men who,
with the most limited resources, accomplished
the grandest results. They compelled success
because they deserved it.

The ink was hardly dry upon that cynical pen
when anaesthesia was presented bj- the profession
so poor, as he supposed, in valuable works.

But w-hat countrv' or age can match, in great
contributions to the relief of the suffering,
McDowell, Sims, Bigelow, Sayre, Batty and
Emmett, and that trinity of men — Wells, Morton
and Jackson — who gave anaesthesia to the world.
Think of anaesthesia and of its influence upon the
progress of medicine and surgerj'. But yesterday
a writer in the London Lancet gave a graphic his-
torj' of its reception in London ; how the great
Listen, having a patient who could not ner\-e
hira.self up to the point of consenting to have a
limb amputated for strumous disease of the knee-
joint, decided, that, "if the insensibility could be
insured and maintained for one minute, he would
amputate." Reflect for a moment on the hesi-
tancy of the great surgeon of University College
Hospital, as he stood by the side of that patient;
he could hardly believe the novel report as it
came over the sea. Willing and anxious as he
was to operate, he hesitated to urge the poor pa-

tient to make the experiment — experiment it then
was. In a week, however, it was legitmate prac-
tice all over the world.

The heart of every American physician is filled
with thankfulness when he remembers that in the
Providence of God this great boon to humanity
was vouchsafed to his country. The very ground
upon which stands Massachusetts Hospital is sa-
cred to us all. Associated with the discoverers
must ever be the name of Dr. Haj'ward, who per-
formed the first operation under the strange
letheon. Previous to this operative surgery was
slow, tedious and almost cruel. Contrast it to-day
with what it was previous to 1847. What grand
strides it has made under the direct support of
anaesthesia and its almost equal co-laborer, anti-
sepsis ; the great cavities are invaded, and invaded
safelj' ; the abdomen has become a familiar field,
and who can forecast the surgerj' of the brain ?

Since Emmett's operation we hear no more,
neither in this countrj' nor abroad — neither in
London nor Berlin, neither in Paris nor Vienna —
of that culmination, that ultima tlmle of ignorance,
"ulceration of the os. " What a disgrace that
term was to the surgery- of the world !

The ignorance in diagnosis was only surpassed
by the cruel treatment which it evoked, the ap-
plication of caustics to the tender everted mem-
brane of the cervical canal.

Has the operation, Bigelow's litholapaxy, the
crushing and evacuation of a stone at one sitting,
been truly estimated ? Its adoption in one cele-
brated case might have changed the destinies of
Europe. Previous, to Bigelow, lithotrity was an
uncertain, and, in most hands, a cruel operation :
" Crush all possible at a short sitting, and allow
the fragments to pass lia naturalis." Bigelow
realized that if anaesthesia is safe for two minutes,
it is safe for two hours or more ; hence, he said.
" Crush it at once, and evacuate the bladder by
an aspirator." The operation, in proper cases,
is as practical as the description is brief and
efficient.

The accomplished Edmund Owen, M.B., F. R.
C.S, upon calculus, says : " With rare exceptions
only two operations are now practiced — suprapu-
bic lithotomj' and crushing, with evacuation at a
single sitting." A high compliment from an
eminent authority.

The stor\- of Ephraim McDowell, though so
often repeated, humanity never tires of hearing.
To us he belongs, and to us only ; we cannot
share his fame with another ; we would not if we
could. Who can measure the relief which his
operation has bestowed upon suffering woman ?
— not only woman, for his was the genius which
opened the way for laparotomy in both sexes.

CLOUDS.

What has been accomplished by the profession
in this country, self-reliant, and as we have here-

1889.]

THE PRESIDENT'S ADDRESS.

tofore said, without governmental or social sup-
port, is certainly worthy of congratulation, and
gives ground for hopes of a rosy-hued future ;
but, alas ! there are some dark clouds to be seen
— some spots on our sun of promise ! Have we
inherent defects in our organic law — our esprit de
corps?

Upon the face of our promising future some
omens of evil appear, indications which look not
up but down, not forward but backward, not to
the elevation but rather to the degradation of our
profession. Heretofore we were an organization
into which no species of fraud could enter ; pre-
tension, ignorant pretension, stopped at the door.
No ism ox path}' was admitted ; something more
than a diploma, " a legal diploma," was required
— a clean bill of conduct, free from false assump-
tion, assumption of universal knowledge, of spe-
cific remedies, of imaginarj- potencies ; in fact,, of
all shams and false claims, a guild in which there
was the greatest freedom for the truth, the largest '
libertj- for the right. No vendor of secret reme-
dies was admitted, because of the ignorant pre-
sumption in which they were conceived and prop-
agated: but, alas, that we should have fallen upon
the evil times when ' ' patented processes ' ' are at-
tempted, when "processes" of valuable remedies '
are kept secret. These remedies with "patent
processes" are in daily use. This is one of the
dark spots in the picture. It came in with the
" legally qualified practitioner." What is anti-
pyrin, antifebrin, salol, sulfonal? The reliant pa-
tient may well propound such questions. Who
can answer them ? Are we relegated at one fell
move back into outer darkness, the associates of '
vendors of " secret remedies, " of " patented pro-
cesses?" What higher is a " patented process "
than a ' ' patented nostrum ? ' ' The profession was
never so low as to countenance the latter ; but
have we not, in these latter daj-s, become propa-
gandists of patented and, therefore, secret pro-
cesses?

LAWS FOR THE REGULATION OF THE PRACTICE
OF MEDICINE.

It may be asked, has the standard of profes-
sional excellence been raised b}- laws enacted in
many of the States for the regulation of the prac-
tice of medicine?

These laws banish the poor creatures without
diplomas, but make respectable, ^waw'-respectable,
all who have so-called diplomas from whatever
source. Shams and pretenders are in this way made
" legal," and claim whatever protection and rec-
ognition that term may give or imply. A char-
tered institution, in most of the States, represents
a formal application for incorporation to a Secre-
tary of State, the signature of that officer, and
nothing more. The process of graduating from
such — the faculty often consisting of but a single
person, or a man and his wife — would hardly be ,

called a farce; the subject is too serious. "Le-
gally qualified ! " think of it ; and yet this legal-
ly qualified creature will claim and expect to meet
the highest and the purest. Is this an advance
upon the requirements of the Code, the morals
and esprit de corps of which have never been ques-
tioned?

What has been the eS"ect of these diplomas ?
Let any candid man answer. Have they not
tended to make vice and presumptuous ignorance
respectable ?

Let us be true to ourselves ; pitch cannot be
touched without defilement. Our profession must
be kept pure or else it will degenerate and sink to
the level of a trade.

In State Boards of Health, by the side of phy-
sicians, we find these " legally qualified " prac-
titioners. Where lies the responsibility? Is it
with us? Our self-examination on this subject
should be searching. If we have failed in our
duties to humanity, let us be swift to acknowl-
edge it, and be still more eager to correct our
error.

The presence of this body of professional gen-
tlemen, representing our entire countrj-, furnishes
sufficient argument for the existence of a Nation-
al Organization ; one embracing the virtue and
strength of the profession, one to which ail ques-
tions should be referred for just and final decision.
Questions will arise, differences of opinion will
occur between honest men. We must have some
tribunal, some body, to which these questions,
these differences of opinion, can be relegated for
solution. The golden rule is a principle, not a
law ; it cannot interpret itself Its application to
life in detail must be defined. In this respect we
are like other men and other organizations. Our
mora/c, however, is higher : it has a zeal, a spirit,
a hope and confidence peculiarly our own. If we
would have our organization pure, we should
make it strong — strong enough to eliminate all
that is not true or truthful. We are mortals, not
transcendentalists. We cannot live as the com-
mune. We must have laws; remembering always
that they are not made for the righteous, but for
the sinner. "They that be whole need not a
physician, but they that are sick." I will not
attempt to defend the ethics of our profession.
It would be a poor compliment to your intelli-
gence, to your manhood; for there is not a clause
in our Code which a gentleman could not cheer-
fully obey. Organize whatever we may please :
Associations of Specialists, of Physicians, of Sur-
geons ; Academies of Physicians ; Congresses of
Physicians and Surgeons ; but let us not lose our
loyalty to this parent Association. Projected al-
most half a centurj- ago, when medical societies
were few, it has annuall}- convened — in the North,
in the South, in the East, in the West, and in the
far West, on the Pacific shore. If you will ex-
amine its j-early roster, you will find that it em-

lO

OUR DUTIES AS JOURNALISTS.

[July 6,

braced the best and the wisest. Almost all who
were present at the beginning are at rest ; their
places have been filled b\- worthy men. Thus
j-earh^'new life — new men being added — this As-
sociation can not grow old.

' ' When a people hold their lives and property
as nothing, the enemy has alreadj^ suffered de-
feat." So too, when virtue will not compromise
with vice, the victor\-, although it ma\- be long
delayed, will sureh- come.

Of the American Medical Association, let us
unite in saying, csto pcrpctua.

OUR DUTIES AS JOURNALISTS AND
THE REFORMS WE SHOULD PER-
SISTENTLY ADVOCATE.

Presidential Address Delivered before the American Medical

Editors' Association at its annual yneeting held at

Xezifort. R. I.. June 23d, 1SS9.

BY WILLIAM C. WILE, A.M., M.D..

OF DAXBrRY. COXN'.,

EX-VICE-PRESIDEKT OF THE .\MF,RICAS MEDICAL ASSOCIATION',

MEMBER OF THE BRITISH MEDIC.\L ASSOCI.ATION, EDITOR

OF THE NEW ENGLAND MEDICAL MONTHLY. ETC.

To fill with satisfaction to myself, and with
justice to 3-ou, the high office bestowed upon me
by the Association of American Medical Editors,
is a most difiicult and embarassing task. The
high rank and standing of the Society, its
mighty itifluence throughout the land, to sa}-
nothing of the talent, the brilliancy and the
scholarship of its individual members — all seem
to demand of me certain special gifts and qualifi-
cations which I feel .scarceh- able to supply.

The most intelligent audience, however, is
often the least given to criticism, hence I venture
to address you with some slight degree of con-
fidence, yet, at the same time, with a full appre-
ciation of the honor conferred upon me.

It is useless to comment further upon the
power which this Association may yield, not only
as regards the medical profession of which it
forms so important a part, but in other fields,
where energj' and influence are no less urgently
demanded. It remains for me onh- to indicate
the reforms which seem to be most urgently
needed, with the full confidence that by the as-
sistance afforded by the medical profession they
will be brought to a happy termination.

What then shall be our line of action during
the years to come ? What changes should be
inaugurated ? What project.s already undertaken
should be carried on to completion ? These are
questions which it becomes us at this timetocon-
.sider and decide upon. In their treatment, how-
ever, we are hampered by the superabundance of
facts and suggestions which present themselves,
and which by reason of their importance demand
special consideration. Let. us, however, study
those requirements which may be held as essen-

tial to the prosperity and healthful growth of the
medical profession.

The subject of medical education as it exists
in the countrj' to-day has been often commented
upon and held up to criticism. It is a widely
recognized fact that year after j-ear there go forth
from our colleges hundreds of young mefl who
are totally and manifestly unqualified for the work
before them. As candidates for admission, they
are, in many cases, unfamiliar with the first princi-
ples of English composition, to say nothing of the
other priman,- branches of learning. As gradu-
ates they have been found familiar with not one-
half of the diseases obsen'ed in general practice,
much less with the various specialties of medi-
cine. Not only are such men allowed to enter
the colleges, but the\' are solicited and encour-
aged so to do, by inducements without number,
so that no one, of whatever race, nationality or
condition, be he moral or immoral, ignorant or
well informed, can have any plausible excuse for
not stud3-ing medicine, and not taking a diploma
after receiving two courses of lectures.

For these reasons our system of medical edu-
cation has become unfavorably known through-
out all foreign countries, and such reputation is
working us irreparable injurj-. The present state
of civilization demands for our profession not
stock companies which derive their revenues
wholly from the fees of their students, and which
consequently make large pecuniary demands
without any adequate returns, but rather, institu-
tions which are able to exercise independence and
can, to a certain extent, choose their own stu-
dents, and can insist upon a four years' study of
medicine. There should be three years of clini-
cal work besides such instruction, with frequent
examinations by the faculty, and no student
should be awarded a diploma who has not a good
knowledge of practical anatomy, surgen,' and
obstetrics, as well as a fair clinical acquaintance
with the various specialties of medicine. I be-
lieve that b}- proper legislation such a curriculum
will be adopted and carried out by even,- college
in the country, while the various mushroom in-
.stitutions which now exist will be compelled to
go into bankruptcy from lack of support.

To bring about such reforms is to excite much
hostile feeling and adverse criticism, for both
mone\- and influence are pledged for the main-
tenance of diploma mills, and sympathy is often
enlisted even for an unworthy cause : yet with
the means at its disposal, it certainly lies in the
power of the profession to protect itself and the
public as well from the dangers which have been
so long in active existence. Recognizing as we
do the many shortcomings of the medical col-
leges and the men they graduate, it seems ur-
gently required that some remedial measure
should be at once advocated and put into opera-
tion.

iSSg.

OUR DUTIES AS JOURNALISTS.

II

We are practicallj' aware of the fact that nianj'
of the existing laws governing the practice of
medicine are of ver}^ limited application, and
avail little as regards the suppression of quack-
er\- in its various forms, and the protection of the
medical profession. Most harmful and disrepu-
table systems of practice are thus allowed to ex-
ist and indeed to flourish, and it is difiRcult and
at times impossible to secure the conviction of
anj^ one guilty of malpractice. Those who hold
diplomas and are now engaged in medical work
are, to a great extent, beyond our jurisdiction.
It is in the prevention as much as in the treat-
ment of these evils that we are specially con-
cerned. To prohibit the manufacture of ignor-
ant and unscrupulous practitioners, no less than
to convict and punish those who already exist,
should form our chief aim and purpose.

One of the measures which promises the best
results is the establishment of State Boards of
Medical Examiners, which might be appointed
by the Governor of each State, upon the recom-
mendation of its own medical society. To such
bodies should be entrusted the sole licensing
power, with the privilege of rejecting all appli-
cants who are found to be notoriously incompe-
tent. Such action has already been taken by at
least four States, and in a modified form by five
others, all of whom have recognized the fact that
it is only in this way that satisfactory results may
be attained. We have over one hundred medical
colleges in the United States, and the number is
steadily increasing. In most there are no pre-
liminar}' examinations worth mentioning, indeed
so great is the competition among the latter that
the college which should presume to demand
anything but money of the applicant would soon
find itself supplanted by the great number who
demand nothing at all.

Again, in the various schools of a higher
grade there is a disposition to insist upon techni-
cal and purely theoretical points, and a disregard
of the more practical aspects of medicine. To
these various faults and deficiencies there may be
applied a like remedy.

State examining boards requiring of the appli-
cant a high standing of scholarship and a thor-
oughly practical acquaintance with the duties of
the profession, would quickly eradicate the
worthless institutions, would institute improved
methods of instruction, and would enhance the
value and the dignity of those medical schools of
the first class which are now taking the lead in
these measures of reform.

Thus with the increased preliminary require-
ments an extended and graded college course,
with its many improved facilities for instruction,
and the final test exerci.sed by an independent
examining board, there is an absolute certainty
of limiting the number of schools and the num-
ber of graduates, and likewise of bringing to the

profession a degree of dignity and status un-
equalled at any time in its past history.

The policj' of protection holds good in the case
of medical practitioners as well as in the impor-
tation of foreign labor and manufactures. While
American physicians are prohibited by the most
stringent laws and regulations from practicing in
Europe, yet on the other hand, a foreigner with
little or no education ma}' come to this country
and practice his calling without fear of molesta-
tion. The result is a large influx of incompetent
and otherwise undesirable men, who come to join
the three thousand or more graduates who are
turned out yearly by the various medical colleges
of this country. The laws governing the prac-
tice of medicine in Europe are most stringent and
effective, and few, if any, enter the profession
there before attaining a fair knowledge of its du-
ties. In Germany, Russia, Switzerland, Italy,
Spain, Portugal and other countries, a rigid state
examination is demanded. In France the re-
quirements are equally high, while in some parts
of Europe the applicant for a license, in addition
to his other qualifications, must be a naturalized
citizen. In short, we have nothing in this part
of the United States at least, which compares in
eiScacy with the requirements adopted by most
other countries. The consequence is we receive
upon our shores not only those who have failed
to obtain licenses, but also those who have never
applied for them ; moreover, many of the medi-
cal immigrants have little or no knowledge of our
institutions or language. They are foreign
taught, and know nothing of American methods
of treatment. For these latter reasons alone they
should be debarred from practice. This state of
afi'airs would, I believe, find an efEcieut remedy
in the supervision exercised by the State Boards
of Examiners, who might sit in judgment upon
these cases as well, and therelaj' render their
country' a valuable service.

While the quack, the pretender, and the in-
competent doctors demand, and often receive,
fees which are quite out of proportion to the ser-
vices rendered, the regular physician is too often
defrauded of his just dues. In all other profes-
sions scientific work demands a more or less ade-
quate compensation, and by virtue of existing
safeguards satisfactory returns are generally made
for services rendered. In the medical profession,
however, there exists comparatively little protec-
tion against possible losses. The physician is at
the mercy of the dishonest patron, and it is only
after a long period of attendance, involving per-
haps a great expenditure of phj'sical and mental
labor, to say nothing of loss of time, that he be-
comes aware of the moral and financial standing
of his patient, who is oftentimes inclined to de-
preciate rather than extol the service which he
has neglected to pay for.

This state of afi'airs has existed for years — the

12

OUR DUTIES AS JOURNALISTS.

[July 6,

patient going the rounds of the medical faculty
and receiving advice and medicine gratis, while
the physician suffers in reputation as well as in a
pecuniary way. It is time that these acts of dis-
honesty meet with the punishment which they so
richly deser\-e. During the last few years there
has been an effort made in various localities to
remedy this evil, and by a plan which has met
with success wherever it has been adopted. I
would advocate therefore, the establishment in
every town and city of a Physicians' Protective
Alliance, by which a complete record may be
kept of all who are able but unwilling to pay for
medical attendance, together with such other
facts as occasion requires. With such a method
in operation the receipts of the physician would
be more in proportion to the amount of labor ex-
pended, and his services held in far greater esti-
mation.

There has arisen no question of more vital im-
portance than that which concerns the protection
of our countrj' from the invasion of contagious
diseases. Yet it is a most singular fact that few
civilized nations possess regulations which are so
lax and inefficient as ours. Those which now
obtain have been inaugurated after long, persis-
tent and laborious effort. Although appropria-
tions have been obtained from the government to
be used in the time of need for the suppression
of epidemics, yet by reason of the few existing
laws and the many restrictions placed around
them such sums cannot, and never will enable us
to exercise the proper sanitarj- precautions.
Under existing circumstances quarantine is main-
tained, if maintained at all, by individual States,
whose laws pos.sess no uniformity whatever. It
has been stated that there are but three ports in
this country where proper precautions are in
force. The efficient quarantine of one port, how-
ever, not only fails at the present time to protect
its own State, but really adds to the dangers of
the adjoining States, which possess no .safeguards.
Given one harbor of entry, where infected vessels
maj- repair, the quarantine of all others must
necessarily prove of little avail, and it is apparent
from this exposed condition of our coasts and the
free intercourse existing between the States, we
are in constant danger of infection from various
sources. An occasional appropriation to be used
in cases of emergency, when danger is imminent,
fails utterly to meet our wants. At the same
time it is not just that individual States, situated
on the seaboard, should be compelled to bear the
expense of protecting the inland States. Although
by means of a large expenditure of money we
have thus far protected many of our seajxjrts,
still many thousands of dollars have been fool-
ishly wasted, and no permanent or definite re-
sults obtained. This applies not only from dan-
gers from foreign sources, but also to those which
ari.se in our midst, and by reason of faulty safe-

guards are allowed to increase and multiplj- and
to extend from one communitj- to another. It is
important that the health laws of all towns, cities
and States should be clearly defined and identical
in their provisions, and at the same time readily
executed. It seems wholly improper that the
}>Iarine Hospital Ser\-ice should any longer at-
tempt to carrj- on any portion of this important
work, in fact it would be difficult to determine
what special qualifications this department pos-
sesses that it should assume an interest in such
matters and constitute itself an almoner of the
health funds. It certainlj- has many and import-
ant duties of its own, and should therefore be al-
lowed the time nece.ssar}^ for their proper perform-
ance. Upon reviewing the question, therefore,
from its various standpoints, there appears to be
no better way of remedying the numerous evils
and shortcomings which exist than the establish-
ment of a National Bureau of Health, which
should form a distinct department of our national
government, and to which should be entrusted
the general supervision and enforcement of all
measures relating to sanitation, as well as to
coast and inter-State quarantine. The appro-
priations allowed this Board should be generous,
and there should likewise exist a permanent fund
which could be drawn upon in sudden emergen-
cies which might arise.

Having secured in this way a general uniform-
ity of all sanitary laws and regulations, with in-
telligent methods and with abundant means for
carni-ing them into execution, we may expect
more brilliant and lasting results than have here-
tofore been attained. In this Department of
Health it would be highly prop>er that the chief
executive officer be made a member of the cabinet
as evidence of a proper appreciation of the dignitj-
and importance of one of the most practical
branches of human education and knowledge.

That the work of this Board may be carried
on with the best results, and in order that there
may always be found intelligent aid and cooper-
ation, it is important that the students of all of
our colleges should receive instruction in sanitary
science. In this latter there has recently been a
rapid advance, and in no other department of
medicine have greater or more brilliant results
been noted.

No specialty can be pursued with better and
more definite results than this one, and as the
most intractable and fatal disea.ses seem to be the
very ones which are most easily averted, it fol-
lows that no practitioner who is unfamiliar with
the first principles of this .science, can perform his
duties with the greatest profit to hini.self and with
ju.stice to his patients. In these matters the phy-
sician is, as a rule, wholly self-educated, and in
the investigations he may wish to make, labors
under disadvantages which a proper preliminary
training would have obviated. So urgent, how-

1889.]

OUR DUTIES AS JOURNALISTS.

13

ever, are the present demands of preventive med-
icine, that we have reason to hope that, with the
necessarj' encouragement on our part, every med-
ical college will be obliged to recognize their im-
portance by establishing a chair of sanitan,' sci-
ence, b}- which students may acquire all of the
known facts relating to biology and allied topics,
together with the necessary data for future inves-
tigations. Said an English writer more than
thirty years ago, "Redoubled attention should
be devoted to hj-giene, both public and private,
with a view of preventing disease on a large scale
and individually in our sphere of practice. Here
the surest and most glorious triumphs of medical
practice are to be achieved." The discoveries
which have been made and the results which
have been attained during the past few }'ears, are
but the fulfilment of this prophecj^ aud should
render the student more devoted to sanitarj- sci-
ence than ever before.

Facilities for bacteriological work have been
heretofore lacking, and American students in this
department of science have been obliged to either
carrs- on such investigations under the greatest
possible difficulties at home, or to pursue their ^
studies in the various laboratories abroad. Under
such conditions we advance slowly and laboriously
and can necessarily take little part in the triumphs
of modern scientific research. A thorough knowl-
edge of the causes and modes of propagation of
disease, as well as the laws governing epidemics,
must be acquired before we can use with intelli-
gence whatever resources which may be placed at
our disposal. We can now boast of six or seven
private bacteriological laboratories, and there is
reason to suppose that, if properly equipped and
supported, the)- will do good and efficient work ;
yet, to meet the many and varied requirements of
our Government, something more is needed. Our
National health officials should be enabled to
carr\- on the many kinds of investigations needed
without assistance from foreign or outside sources,
and such experiments should not be allowed to
languish or fail through lack of time on the part
of the officers or the need of funds to meet cur-
rent expenses. In no other way can such sanitary '
work be prosecuted with success, than bj' the es-
tablishment of a bacteriological laboratory', form-
ing an adjuvant to the Bureau of Health — liber- 1
ally maintained by the Government and wholly ^
■devoted to the needs and demands of the latter.
Many countries have set the example. We have
onh- to commend a measure whose feasibilit)' has :
been so fully established.

There could be no Association whose interests
we hold so greatly at heart, as the one with which
we are so intiraateh- connected. Its triumphs and
successes are no less our own, while for anj' fail-
ures or shortcomings it might manifest, we should
hold ourselves in part responsible. We may then
rightfully interest ourselves in those measures by

which the aims of the American Medical Associ-
ation are defined and furthered, and b}' which its
honors and benefits are rendered free to the pro-
fession at large. As the official organ of the As-
sociation The Journal should obtain certain
special features. We see too many elaborate and
scientific articles, and those which are both uuiu-
teresting and far from practical. We are too often
obliged to spend too much time in eliminating the
great mass of verbiage and dry details with which
a few plain facts are surrounded. A journal de-
signed for the general medical reader has no right
to fill its columns with articles upon optics, or
cerebral localization, or pathological anatomy.
Contributions which have their own proper place,
should not be inflicted on the general practitioner
to be read during the limited time at his disposal.
The reports of medical societies may be placed in
the same category. If they contain anything of
special value let it be summarized and allowed no
more space than it deserves. The Association does
not require a journal which deals with special
branches and investigations, but rather one which
will give a comprehensive digest of medical prog-
ress and medical news, and at the same time pos-
sess such features as will render it popular and
attractive.

The editor of such a publication should not be
chosen without due care and deliberation, as the
office is a most important and responsible one. It
follows that, in addition to his other qualifications,
he should be a man of liberal education, elevated
thought and considerable executive abilitj'. He
should be able and willing to devote to the office
the care and attention which it demands, without
incurring the suspicion of having used it for the
purpose of furthering his own private and per-
sonal interests. What applies to medical journal-
ism as a whole, may be said to represent the needs
and requirements of the official organ of the As-
sociation, and the realization of projects for its
growth and improvement is, no doubt, a source of
care and solicitude to all of us. In this, as in all
matters which concern the future growth and pros-
perity of the American Medical Association, our
support and loN'alty are pledged. It is within our
power to add materialh- to its usefulness and suc-
cess, while at the same time we endeavor, bj- all
possible means, to improve the present condition
of the medical profession by elevating its stand-
ards and placing it upon a firmer moral and intel-
lectual basis.

I have endeavored briefl)- to direct your atten-
tion to some of the more striking evils which now
exist, and the measures which might be employed
to overcome them. We have, at the present time,
an important mission to perform, yet no one who
fully appreciates the influence and the capabilities
of this Society of Medical Editors, can justly de-
: spair of final success. We feel to a certain degree
I satisfied with the work which has already been

14

ADDRESS OF WELCOME.

[July 6,

accomplished by our Association, and desire to
show our appreciation of the evidences of esteem
and encouragement which have been extended,
yet no thought is more gratifying to us than the
conviction that, in years to come, we shall have
been found to have added our full quota to the tri-
umphs and achievements enjoyed by the medical
profession of America.

ADDRESS OF WELCOME.
BY J. H. ELDRIDGE, M.D.,

OF EAST GREENWICH, R. I..

The Oldest Member of the Rhode Island jVedical Society.

Having reached that bad eminence — the oldest
in fellowship of our State Society — an honor
w^hich I share with my friend Dr. Turner, who
will address you this evening, the Chairman of
our Committee of Arrangements has assigned to
me the very" pleasant duty of greeting you, gen-
tlemen of the American Medical Association, and
giving you a cordial welcome in behalf of the
profession of Rhode Island on this. Fortieth An-
nual Meeting, which you have done us the honor
to hold in this State.

It goes without saying, that this is a very small
State in point of territory. The most extrava-
gant diminutive can hardly convey an idea of its
proportions to those of you who come from with-
out the limits of the New England States. We
must also admit that the soil in many parts is
barren, rough and unfit for cultivation, and in an
agricultural point of view worthless. Nearly half
its surface of one thousand square miles is in its
primitive state of forest or brush- wood ; and an-
other large portion is covered by the waters of
the bay.

With all this, which we ourselves see and must
of necessity admit, and which must be apparent
to the casual visitor, we have much in which we
take a laudable pride. What nature has denied
to us in some ways she has been lavish of in
others. We are proud of the illustrious founder
of our State and the inheritance of civil and re-
ligious liberty which we have received from him.
We are proud of our historic record from the first
settlement of the State, through all the wars,
down to the present time, and of the heroic names
which are associated with us and which belong to
us, We are proud of this lovely city by the sea,
of which so much will be told you by the gentle-
men associated with me. We are especially proud
of our Bay with its numerous indentations, islands,
and headlands sloping everj-where green and fresh
to the water's edge. We value very highly the
great extent of shore bordering our tide-waters,
measured by hundreds of miles, upon which we,
the present natives, taught by the aborigines,
have learned to depend for our chief supply of
food, never failing, all seasons alike, the delicious
bivalve of every kind everywhere abounding.

No visitor is permitted to leave this State until he
shall have tasted this healthful, delicious food
prepared in the primitive Indian wa\-.

This shore privilege, as it is called, is an im-
portant feature in our Bill of Rights. All below
high-water is public property. If in your efforts
to reach this public domain by the nearest route,
j-ou should commit a trespass by crossing some
private grounds, you ma}' be assured you will
only be mulcted in nominal damages — if the trial
is before a jun,-, especially a Kent County jurj-.

We take an especial pride in our institutions of
learning. Our Brown University, our Free Pub-
lic School system, our Free Public Libraries, in
ever}' town — recognized and partlj- supported bj'
the State, and everj-where doing a good work —
continuing and completing what the free school
has begun. Nowhere can all this be seen in better
condition, more successful operation, than in this
good town of Newport.

In our industrial enterprises, to which we are
indebted for our prosperity and wealth, our cot-
ton mills, our foundries and machine shops,
where you can see the natural fibre — wool or cot-
ton— wrought into the finished fabric ; where you
can see the construction of the most powerful
stationarj- or locomotive engines and machinen,-
of every kind.

Notwithstanding the poverty of the soil and
the rough, rocky surface which so generally pre-
vails, we have some specimens of fancy farming
and fancy breeding ; and also planting of forest
and fruit trees, which plainly show what we might
have done if we had earlier turned our attention
to these important matters.

All this, and more which I might speak of, is
so convenient, so accessible by land or water on
either side of the bay, that, in the horcB subscciva: ,
from the more important aSairs for which you are
assembled here, you will find abundant opportu-
nity- to visit and examine for yourselves.

Among the original settlers and founders of
this State were a goodly number of physicians, or
chirurgeons, as they were then more commonly
called. Dr. Turner will give you a vers- full his-
toric sketch of the most prominent of these men
in the Rhode Island settlement. Other men of
the same stamp, maintaining the same position
in the Providence plantations, were associated
with them. The respect and consideration which
these good men could claim, and which was
everj-where granted to them, has been transmit-
ted through many generations of worth}- succes-
sors, until we of this day are enjoying the goodly
fruits thereof.

You have then but to announce yourselves as
physicians, as members of this convention, as
visitors, delegates from other States or other
countries, to find everything opened for your in-
spection, and to be received everj-where with a
cordial welcome.

1889.]

ADDRESS ON SURGERY.

15

ADDRESS ON SURGERY.

Delivered at the Fortieth Annual Meeting of the Anterican Medical
Association, Xt'wport, R. I., June 3-, iSSq.

BY PHINEAS S. CONNER, M.D., I

OF CINCINXATI, O.

The surgery of the centurj- has been of three
periods : the preansesthetic, the anaesthetic and
the modern one. Operative brillianc}- character-
ized the first. The suffering inseparably connect-
ed with the use of the knife and the ner\'0us de-
pression resulting therefrom was to be limited i
chiefly by celerity of execution ; hence, the swift [
moving hand was an essential part of the equip-
ment of the fittest surgeon.

When, in the amphitheatre of the Massachusetts
General Hospital, ' ' the problem of surgical anaes-
thesia was definitively solved," a new period
began. Pain was no more, and it was permitted
to examine earlier and more thoroughlj-, to re-
move more extensively, and to operate success-
full)' in regions previously altogether, or in great
measure, beyond the reach of art. For twenty
years or more, progress was in the line of diagno-
sis, of development of new and better methods of
operating, of extension of the range of surgical
interference. Time was no longer an element of
prime importance, and the work was regarded as
quickly enough done when well and thoroughly
done — too much so, in fact, for not seldom the
best interests of the patient have been jeopardized
by unnecessarj- delaj- in execution, that would not
have occurred but for the existing profound insen-
sibility. But though operations in this anaesthetic
period were without much of the terrors of the
olden time, thej- 3-et fell far short of producing
the wished for result in preser\-ation of life and
early restoration to health. Wound complications
were still as ever the bane of surger>% and too
often the wisest planned and best executed oper-
ation resulted in failure because of the super\'en-
tion of one form or other of septic infection.

It is scarcely twentj- 3-ears since patient investi-
gation, careful experimentation and practical test-
ing began to throw strong clear light upon that
most obscure of the subjects of medical studj', the
causes of disease. As never before in the histor}- of
medicine, truly scientific methods of research have
been adopted and pursued b\- a multitude of trained
observers in all civilized countries, and surgen,'
has entered upon its scientific period, in which
operator and patient are profiting by the labors of
the chemist, the botanist, the physiologist, the
physician, equally with those of the practical
and experimental surgeon. It seems but yes-
terday when Lister's early papers startled the
world. It is but twenty-two years since the
first one was published, yet what enormous ad-
vances since then in knowledge, in treatment,
and in the field of operative interference. A
new department of science, surgical bacteriology-,
has been created (for what was done prior to

1867 may for practical purposes be left out of
consideration), and in its development has been
worked out the mycotic origin of all those patho-
logical processes looked upon as inseparable from
traumatisms, or almost uecessarilj' associated with
them if severe. Suppurations, gangrene, septic
infection, er>'sipelas, tetanus, we know to depend
upon the presence or the action of one or other of
definite organisms that may be isolated, cultivated
and inoculated. Recognizing the cause, it has
been comparatively' easy to devise methods, more
or less perfect in action, to prevent the develop-
ment or neutralize the influence of it, and there
has been worked out an antiseptic and aseptic
wound treatment, the results of which are simplj'
mar\-elous. Butjustherel must protest against
the wisdom or the justice of the sweeping declar-
ations of a few enthusiasts, who see in other than
speed}' recovery after injurj' or operation eviden-
ces of what they are pleased to consider criminal
ignorance or neglect.

The existing strong probability that in any
given case septic infection might be prevented,
has given v%'arrant for the performance of opera-
tions that in preaseptic days were not to be
thought of.

Abdominal surgerj', that so short a time ago
meant scarcelj- more than the removal of an ova-
rian tumor too often carried until death was evi-
dently fast approaching, now includes operations
upon almost everj' part of each hollow and solid
viscus, and laparotomy has taken its place as a
safe, proper, and often indispensable prerequisite
to the determination of obscure diseases. Pene-
trating and perforating gunshot wounds, so gen-
erally fatal when treated by rest and opium, have
in at least forty cases been recovered from after
section and suture, and there are now but few
surgeons still unconvinced of the wisdom of earlj*
active interference. At our last meeting Senn's
carefully elaborated and beautiful demonstrations
set forth a means of determining the existence
and location of intestinal wounds that if safe, as
it has thus far seemed to be, will remove the
greatest objection to laparotomy in these cases,
the uncertainty in the earlier hours of bowel per-
foration— and prevent what otherwise will occur,
the overlooking of one or more lesions. It is not
to be expected that all or any close approximation
to all of these verj- dangerous wounds will be
saved by earl)' operation, for great injurj' will or-
dinarily be produced by the bullet, be it large or
small ; but every case that recovers after section
and suture may fairly be considered as rescued
from an otherwise almost inevitable death. Un-
questionably the laj'ing open of the peritoneum
and operating upon an abdominal organ has at
times been carried too far. Useless work has
been performed, and life has been sacrificed, for it
is not true (so far certainlj' as operators in general
are concerned) that abdominal section is in itself

i6

ADDRESS ON SURGERY.

[July 6,

without danger, doing no harm if it accomplishes
no good. But not a day goes b}- that somewhere
or other life is not prolonged and comfort secured
by an intraperitoneal ligation, suture, anastomo-
sis or excision, rendered proper, may we not say
possible, only by the aseptic results of scientific
discoverj' and experimentation.

So, too, the diseases and injuries of the other
great cavities are being attacked by the surgeon's
knife guided by the diagnostic knowledge, the
localizing exactness and the technical skill of the
physician, the physiologist and the vivisector.

There has been but a beginning of intrathoracic
surgen,-, though for years empyemas have been
treated by free incisions, supplemented not seldom
bj' extensive excisions of portions of the chest
wall, and even in preaseptic days deeply lodged j
foreign bodies were removed. Only verj' recently
has the lung been cut into for the evacuation of
abscesses and the treatment of gangrenous areas,
such pneumonotomies resulting favorably in one-
half of the reported cases ; and as yet but few
subpleural tumors have been attacked. There is
ever}' reason for believing that in the near future
surgerj' will be able to render great ser\'ice to the
subjects of not a few forms of thoracic disease
now regarded as beyond the reach of art.

The most recent and the most brilliant triumphs
have been in the treatment of diseases and injuries
of the brain and cord. Nowhere else have our
art and science so joined hands in affording relief
as here. Tumors removed, foreign bodies taken
away and their tracks drained, convulsion-centres
excised, serous effusions tapped, life preser\-ed and
comfort secured ; so reads the record. Much re-
mains to be done in the determination of the
trouble, the exact localization of the mischief, the
perfection of technique. Not seldom mistakes
will be made, errors committed ; but it will be
more and more demonstrated that the trained
mind and the skilful hand, working together, can
recognize and successfuUj- treat otherwise irre-
mediable affections within the skull and the
spinal column.

As the operative procedures necessary for the
exposure and removal of the spinous processes
and laminae of the vertebrae are but little danger-
ous, and as septic meningitis can almost certainly
be prevented, a change may reasonably be looked
for in the treatment of vertebral fractures, espe-
cially those in the lower half of the column. Up
to this time the cases in which active interference
has been made have almost always been those of
long duration, in which existing inflammator\-
changes in the cord, if nothing worse, could not
but prevent any favorable result; but even in
these, of late, the patient has been none the worse
for the operation. Without doubt, early removal
of pressure, whether made by bone or blood it
matters not, would save many an one from a.\\
those deplorable conditions consequent upon my-

elitis with which we are unfortunatel}' too familiar.

Is there any good reason why spine fractures
should not be treated as skull fractures? and who
would now for a moment think of rest and posi-
tion as the routine treatment of the latter injuries?

But in this scientific period there "has been
much more accomplished than extension of the
range of operative interference, great and impor-
tant as this has been. As never before it has been
possible to preser\'e damaged parts and to retain
important functions, to replace completely de-
tached pieces of bone and secure adhesion as per-
fect as of the fragments in a simple fracture, to
transfer large areas of integument and ingraft
pieces of bone, to supply deficiencies in soft or
hard parts bj- skin or bone from dog, rabbit,
chicken or frog. Even,' department of conser\'a-
tive surgery has been and will yet more be bene-
fited by the preventing of the evils consequent
upon the action of minute organisms.

The two diseases that produce the widest de-
struction to part and to life are tuberculosis and
cancer. The former, that xintil the discovery of
its causative bacillus was regarded as of rare oc-
currence in parts belonging to the domain of sur-
ger>', is now known to be the producer of the vast
proportion of the diseases of bones and joints, and
of many of those attacking the skin and more ex-
ternal organs.

Primarily and often for a long time local, if
allowed to go on unchecked, it effects other and
remote regions, perhaps rapidly becoming gener-
alized. But what has been learned respecting it
— that it may attack any part the blood circula-
tion in which is disturbed by general enfeeble-
ment or local injur\' of ordinarily not severe
character ; that the bacilli may be destroyed or
become encapsulated ; that the softened tissues
may, in like manner, be taken up and carried off
or shut in temporarily or permanently ; that if the
diseased focus be completely removed, as it often
may, the part and the whole are as if it had never
existed, except so far as function is disturbed by
the loss of what has been taken away, and by the
scar tissue resulting ? How has treatment been
affected by this knowledge ? It is of prime im-
portance that early diagnosis be made. Located
in bone or joint and detected while yet limited,
prolonged rest, as absolute as possible, will in the
majority of cases, certainly in young subjects,
secure destruction, absorption or encapsulation of
organisms or affected cells with resulting restora-
tion to health. Advanced to the stage of casea-
tion and liquefaction, rest may yet be followed by
recovery, though ordinarily free drainage, with or
without as.sociated removal of the infected tissue,
will be of great advantage. Injection of agents
such as iodofonu or the acid phosphate of lime,
that will destroy the bacilli and the tuberculous
masses, may produce the wished for cure. But
ordinarily it will be better, indeed generally

1889.]

ADDRESS ON SURGERY.

17

necessar3% to remove the affected area either bj'
formal or informal excision or by amputation.
Whether diseased joints are best treated by ar-
threctomies or by typical excisions is one of the
questions still sub judice, though in the last three
j-ears, as never before, it has been shown that
formal removals of the larger articulations can, in
a large proportion of cases, be followed by early
repair and solidification without suppuration or
constitutional disturbance ; even at times with re-
coverj- of original function. Though it is not
likeh' that it can ever be said with truth that the
daj-s of the lame and the hump- backed have gone
b3% because of neglect, delaj', or generalization
of the pathological process, j-et we have good rea-
son to believe that further advances in knowledge
of the development and extension of the tubercu-
lous disease will enable the surgeons of the future
to so limit, ameliorate and cure the surgical
tuberculous affections, as that they will no longer
constitute one of the most important and destruc-
tive of the external diseases.

Of cancer it may with truth be said we know
very little ; j'et of nothing do we more need
knowledge. Much less often met with than
tuberculous disease, it is yet of not infrequent oc-
currence. In our eight largest cities (Boston,
New York, Brookh-n, Philadelphia, Baltimore,
Chicago, St. Louis, and Cincinnati) during the
five years ending Dec. 31, 18S8, of 599,684 deaths
from all causes 13,094 were from cancer, 2.18 per
cent., and as we all know the disease is not pecul-
iarlj' an urban one. In five of the eight cities.
New York, Chicago, Cincinnati, Brooklyn and
St. Louis, the death rate was much the same, be-
ing in the order given 2.1, 2, 2, 1.94, 1.93 per
cent. In Boston it was highest, being 2. 98 per
cent; in Baltimore it was 2.4 per cent., and in
Philadelphia 2. 28 per cent. In Cincinnati in the
last year the percentage reached 2.6 per cent.,
while in 186S it was but 0.55 ; an altogether ex-
ceptional rate, however, as only once since has it
fallen below i per cent., in 1S70, when it was 0.8.
For these figures I am indebted to the health
officer, Dr. Stanton. One in fifty then of the
deaths in an aggregate city population of over
five millions is due to this disease, and if we have
regard only to the mortality of those within the
cancer age, i.e., more than 35 years old, about
one in twenty of the deaths is thus produced.
Even among the carefully selected adult indi-
viduals carrying life insurance, who are free or
are supposed to be, from family predisposition to
cancer, from 2.5 to 3.5 per cent, of the mortality
is from this disease The statistics just mentioned
and, particularh- the marked contrast between the
high death rate in Boston and the low one in St.
Louis, gave but little support to the theorj^ of
Haviland, that low lying lands subject to fre-
quent overflows are those in which the disease is
most prevalent.

In preparing the mortality statistics of the
census of 1880, Dr. Billings found that the disease
was most prevalent in New England and Southern
California, and least so in the South and upon
the Mississippi. It is to be hoped that in the
preparation of the vital statistics of the next
census such attention may be given to this sub-
ject of occurrence and distribution, and such full
and complete reports secured as will add materi-
alh' to our knowledge, and go far towards de-
termining to the correctness or incorrectness of
the views of the English writer named. Care
should be taken to separate, if possible, cases of
sarcoma from those of cancer.

Hirsch to the contrar\- notwithstanding, this
affection is becoming more common throughout
the civilized world, certainlj- is so in our own
country and in Great Britain. Increased ac-
curacy of diagnosis will not account for a doubl-
ing in twenty years of its mortality rate in Massa-
chusetts or in Cincinnati, or in less than twice
twent}^ years in England. Frequently, if not
usually, attacking individuals in good general
health (though oftentimes appearing soon after a
period of marked mental anxiety and depression),
it has regard neither to social conditions nor
hygienic surroundings. L'nlike consumption,
which is often of limited duration ending in re-
cover}- and at the worst, ordinarily bringing death
gently, cancer left to itself very rarely is spon-
taneously' eliminated, is almost inevitably de-
structive to part and to life, and is often attended
with severe physical and mental suffering.

What is its starting point. An unused long-
dormant embrj-onic cell, at length aroused to ac-
tivity by local irritation, general enfeeblement or
ner\-ous exhaustion ? In all probabilitj', no.
An abnormal epithelial development, abnormal
because unconfined within its normal limits ? But
why unconfined. An epithelial cell undergoing
proper 'degenerative changes, but arrested at some
point short of its complete alteration ? What
stops its retrograde movement. Is it of mj'cotic
origin ? That it should be so would hardlj' be
more strauge than that lupus or lepra should be.
That it is so has not yet been proved. The many
investigations that have been made, some of them
for a time apparently fruitful, have thus far
failed to discover a causative bacillus, unless
further and extended cultivations and inocula-
tions shall prove that Kubasoff has actually found
it. Experimental inoculations have again and
again produced no specific result, but Lampiasi has
claimed that by using a bacillus culture from the
blood he succeeded in causing in a healthy part
of the patient's skin the growth of a nodule
having " an alveolar stroma with wide meshes,
which contained manj' epithelial cells of different
form and sizes ;" and Hanan has twice success-
fully transplanted from rat to rat.

No more inviting field is open to the bacteri-

i8

ADDRESS ON SURGERY.

[July 6,

ologists and experimenters of our country (and
we have a number of them, as also well equipped
laboratories), than this verj- one of cancer. Cases
are numerous, specimens are being daily secured,
and there is no reason why America should not
now do full part in settling the vexed questions
of nature and origin. The imperative necessities
of a struggle for existence, and the intense
practicality of a new and developing country-
have heretofore prevented anj- but the verj- few
filled with enthusiasm or independent of fortune
from engaging in purely scientific studies involv-
ing minute investigation and patient labor with
often no apparent practical outcome. But the
times are changing, and the profession of our
country may, and doubtless will ere long be as
well and favorably known in biological research
as it has been, and is in relation to ovariotomy,
to ether, to the hip, to the treatment of stone, to
the surgical diseases of women, to abdominal
section, to a multitude of affections, and the
means of treating them.

As we see it in lip or breast, or uterus or stom-
ach, or it matters not what part or organ, is cancer
a local disease, or but a local manifestation of a
constitutional state? The question is still an open
one, though the great majority of pathologists
and clinicians are now agreed that wherever
seated it is primarily, and for a time purely local,
whatever may be the general conditions inherited
or acquired that permit or favor its development.
If not of limited area and capable of complete
removal, operative interference can be justified
only on the ground of affording temporar}- relief
— unfortunateh- all that is accomplished in the
majoritj' of cases submitted to the knife. But
there is great encouragement in the knowledge
that a certain percentage of patients operated
upon do recover ; that is remain free from recur-
rence for three or more 3-ears ; and that this per-
centage is larger or smaller, according as the dis-
ease is so situated as to be early detected and
thoroughly' removed, or the contrary. Located I
in the lower lip or the cervix uteri, for example,
two out of five patients operated upon get well,
in the breast one in eight. Wh}^ this great differ-
ence. Because, we may believe, of the site itself
and of the degree and rapidity of extension, in
parts immediately adjacent and of glandular in-
volvement; in other words, of the likelihood of
early and the possibilit\- of complete extirpation,
or the opposite. How are to be regarded those
cases in which after five, ten or twenty j-eafs of'
apparently perfect health, the disease again shows
itself and destroys life? As of long quiescence
of infected and infecting cells or of a new and in-
dependent affection. The latter explanation
certainh' makes a far less demand upon our
credulity, and it is no more strange that there
should he a second than a first attack in a person
and tissues possessing and undetermined and

unknown receptivity, and such there certainly
must be that cancer may be developed at all

Of nothing are we more certain than of the
immense advantage there is in early recognition
and speedy removal ; and, on the other hand, of
the utter uselessuess, so far at least as the ulti-
mate result is concerned, of any surgical interfer-
ence after a wide extension has taken place.

In perfecting, therefore, the means of establish-
ing diagnosis at an early da}- lies an important
work in the future. Though consideration of age,
of location, of pre-existing long-continued irrita-
tion, go far towards settling the nature of a given
tumor, and upon such estimation of probabilities
action may generally be safely taken, yet, as a
rule, certainty of the character of the growth can
onl\- be had after scientific determination of its
anatomical constitution. Whatever then makes
it possible to safelj-, easily and without pain re-
move for microscopic examination, a sufficiently-
extensive piece of the mass to show its deep as
well as superficial structure is of much practical
value. A convenient and promising little instru-
ment has lately been given to the profession bj'
Dr. Collins Warren, of Boston.

Physiological and chemical investigations have
furnished us with early and reliable evidence of
the existence of cancer of the stomach in absence
of the hydrochloric acid from the secretions of
that viscus ; may not kindred investigations give
us like aid when other organs are aflfected ?

The modern and scientific wound treatment
now enables the surgeon to remove more ex-
tensiveh- and at the same time safelj-, so that ac-
tive interference may reasonably be expected to
be, and is attended with much better results,
than could be looked for a few years ago. Much
of the work, though that in the last decade has
been done upon internal cancers, has been of
questionable utility' ; chiefly because of its late
performance.

What will the future reveal respecting the non-
operative treatment ? Will a drug or drugs be
found to secure destruction and removal of the
morbid mass ? Ma}- the moderate continued
electric current or powerful interrupted currents
" flashed through " prove to produce as has been
claimed for them, entire disappearance of the dis-
eased cells ? Can some pathogenic organism be
inoculated that without killing the patient will
break down the malignant growth? \Ve all know
what has been done with the micrococcus of ery-
sipelas.

In nothing could this Association do more than
in determining by collective investigation and
thorough committee work the frequency of occur-
rence of carcinoma in the country as a whole, and
in its several States, the relation borne (if any) to
geological formation, the age of appearance, the
relative affection of parts and organs, the influ-
ence of therapeutic treatment, and the duration of

1889.]

ADDRESS ON MEDICINE.

19

life with and without operation. Five years of
.such work would suffice to accumulate a mass of
statistics of verj' great value, the study of which
could not but advance the best interests of patients
and practitioners : and in this, as in ever>-thing
else "many hands make light work." To phy-
sicians, surgeons and therapeutists, the subject is
one of prime importance, and only by combined
scientific and practical work can it be determined
what excites and produces the disease, and what
can secure its relief.

As we survey the advances, etiological, diag-
nostic and therapeutic, made in the few years just
past, that are of the scientific period, and con-
sider, even in the most hurried way, the problems
that are yet awaiting solution, problems relating
to nature, origin and treatment of the diseases and
injuries of parts within the domain of surgery,
what may we not reasonably anticipate as the fu-
ture of our science and art. Accidents must oc-
cur, diseases will prevail, no matter how great the
triumphs of preventive medicine. Surgical pa-
thology is but in its infancy. Years ago it was
declared that operative surgerj' had reached its
climax. Yet, since then, operations have over
and again been done within abdomen, chest, and
skull, upon the larj-nx, throat and spinal cord
that in boldness of conception and brilliancy of
execution have no parallel in the history of medi-
cine. The end is not yet, nor will it be while,
the world over, there are active minds and cun-
ning hands busied with the determination of the
existence and extent of surgical affections, and
ready and able to remove them, aided more and
more by the labors of investigators in many de-
partments of science, general as well as medical.
Year by year, he who may deliver the Address on
Surgerj' will be able to report doubts removed,
discoveries made, remedies employed and opera-
tions done.

ADDRESS OF THE CHAIRMAN OF THE

SECTION ON THE PRACTICE OF

MEDICINE, MATERIA MED-

ICA AND PHYSIOLOGY.

Velivei ed at the Fortieth Annual Meeting of tht- A met ican
Medical Association, June 2S, fSSg.

BY FREDERICK C. SHATTUCK, M.D.,

OF BOSTON.

In obedience to the rule of the Association that
the Chairman of each Section shall review the
progress which the year has brought in those
subjects which immediately concern his Section,
I ask your attention to a very brief consideration
of a few of the large number of topics which
might worthily find notice here.

The practice of medicine, materia medica and
physiology include so much, the workers are so
many, and the fruits of their labors are so varied

and abundant that the difficult}- of selection is
itself an embarrassment.

The grass had scarcely grown on the grave of
the treatment of pulmonary tuberculosis bj- gase-
ous enemata before another curative method was
advocated by Weigert', Halter', and Krull ;'
a method which would seem at first sight to
have claims to be called curative in that it is de-
signed to remove the cause of the disease by de-
stroying the bacilli ni silii. We know that the
development of this particular microbe is arrested
at a temperature of 107° F.; and if, then, the
intra-pulmonarj- temperature can be raised to or
above this point and there maintained for a time
the happiest results must follow. I can confirm
the statements of the originators of this method
as to the ability of patients to breathe with im-
punity air at a surprisingly high temperature. I
have myself inhaled it at 320° F., and seen pa-
tients inhale it at 428° F., without notable incon-
venience. Nearly six months ago Dr. G. G.
Sears, of Boston, began to practice inhalations of
hot air on some of my patients in the House of
the Good Samaritan. His results are now ready
for publication, and it will suffice to say here that
an apparatus was used devised bj' Mr. G. L.
Kingsley, of the Har\'ard Medical School, an ap-
paratus which can be made bj' any coppersmith
for $5 — that patented by Weigert costs in this
country $75 — and that we are satisfied that the
problem of intra-pulmonary direct germicidal
action is still unsolved.

The pancreas, an organ the diseases of which
have been until recently of pathological rather
than clinical interest, is being dragged from ob-
scurity. Senn's work on cj'sts of the pancreas is
followed up by Fitz,' who has collected 70 cases
of the several forms of acute inflammation of the
organ and subjected them to a rigid analysis,
which j-ields a notable increase to our knowledge.
A frequent cause of acute pancreatitis seems to
be the extension of an inflammation from the
duodenum into the pancreatic duct and thence to
the interstitial tissue of the organ ; which tissue
stands in such relation to the peritoneum, the
retroperitoneal and retropancreatic fat tissues, as
to permit the ready passage of bacteria, and thus
account for the peritonitis and disseminated fat
necrosis so often resulting from pancreatic inflam-
mation. Inflammation of this organ is doubtless
much more common than has hitherto been gen-
erally supposed, and is not impossible of diagnosis.
The affections with which it is most likely to be
confounded, are, irritant poisoning, perforating
gastric or duodenal ulcer, perforation from gall-
stones, and acute intestinal obstruction. The first
three can be excluded by the history of the case

I N. Y. Med. Record, lS•^S, ii. p. 693.
= Berl. Klin. Wochenschrift, iSSS. Xos. 36-38.
'Berl. Klin. Wocheiischrift, iSSS, Xo. 39.

*The Middleton Goldsmith Lecture for 1889. Boston Med. .lud
Surg. Journal, rSSg, pp. iSl, 205 and 229.

20

ADDRESS ON MEDICINE.

[JtJLY 6,

and the associated symptoms ; the last by deter-
mining the potency of the large intestine through
injection, by the seat of pain and tenderness of
the upper abdomen, and by the absence of marked
tympanites. I trust that I ma)- be pardoned here
for bringing in mj' own personal experience,
which I do with the less hesitation, inasmuch as
it is not especially to my credit. It was my lot
during the past winter to be one of six physicians
and surgeons at a consultation ; four of us con-
sidered the case as probably acute intestinal ob-
struction, one inclined to perforation, while Dr.
Fitz alone held that it was acute pancreatitis, and
advised against operation. .Laparotomy was done,
no obstruction was found, and multiple fat necro-
sis was seen in the omentum, and the autopsj^
revealed acute hEemorrhagic pancreatitis.

Frerichs' long ago noticed the frequency of
atrophy of the pancreas in diabetes mellitus ; and
Lancreaux in a recent and important paper calls
attention to the relation between these conditions,
based on 20 cases which he has seen, with post-
mortem verification in 14 of these. Pancreatic
diabetes, in contradistinction from the other forms
of the affection, is characterized by sudden onset,
rapid course, and severity of the symptoms, with
great emaciation. In two of the cases, by the
waj% epigastric colic lead to the diagnosis of
pancreatic calculus, and the autopsies brought
justification.

Here we may allude to the experiments of
PavloflF and Smirnoff,' which show that in rabbits,
whose pancreatic ducts have been ligated, regen-
eration of the gland maj' take place after a new
and spontaneous communication with the intestine
has been formed.

The much vexed question as to the nature of
diabetic coma, with the indications for the liability
of its occurrence in any particular case, and the
means for its relief are ably considered by Kir-
stein," who details the steps through which our
present knowledge has been attained. In certain
cases of diabetes the organism seems to have lost
the power of burning the fatty acids, largely
/3-ox5^-butyric acid, to their normal end products.
These cases are characterized bj' a large increase
in the amount of ammonia in the urine, rather
than by any striking symptoms or complex of
symptoms, and these are the cases in which coma
is to be dreaded ; this form of coma being the re-
sult of the formation of larger amounts of free
acid than can be neutralized by the ammonia
which the organism is capable of supplying, the
con.sequent abstraction from the blood of the fixed
alkalies, and thus toxaemia.

The quantitative estimation of ammonia in the
urine of diabetics is consequently of great impor-
tance therapeutically as well as for prognosis ; but

M)ull. de r.\cfld. de .Medccine, iSSS, Tom. xix, 3 Sir. p. 568'.

' Lancet. ]>S8, i, p. 999.

7DcHtsch. Med. Wochenschrift. April 11. 1SS9.

unfortunately a method for this estimation readily
applicable to clinical purposes, is still lacking.
When this large excess of ammonia is found the
indications are to restrict the acid — rather than
the sugar-forming foods, meats for instance — and
to give alkalies freely. On the advent of the pe-
culiar dyspncea, which is apt to be the first symp-
tom of coma, alkaline intravenous injection is to
be practiced, as has already been done in a small
number of cases, Minkowski alone having saved
his patient.

The diseases of the blood have been studied by
Graeber, Hunter, and others. According to
Graeber- anaemia, chlorosis and pernicious anaemia
are distinguishable from one another bj' a count
of the red corpuscles and a haemoglobin estima-
tion. Hunter' argues to show that pernicious
anaemia is an entity, pathological and clinical ;
depends on increased blood destruction, probably
in the liver ; and is to be differentiated from all
grave anaemias, as, for instance, those of cancer
and intestinal parasites, as well as from all other
primary anaemias, by the greatlj' increased amount
of blood pigment, responding to the micro-chem-
ical tests for iron, found in the liver in this affec-
tion. The spleen contains no such excess of iron
as does the liver ; and, in the latter organ, the
seat of the pigment is chiefij' the outer portions
and cells of the lobules, not the capillaries, a fact
which goes to show that the blood destruction
takes place in the liver itself, the pigment enter-
ing the cells in soluble form — haemoglobin — and
there undergoing conversion into albuminate of
iron. In all cases where the blood destruction
takes place elsewhere than in the liver, and pig-
ment is deposited in that organ, it accumulates in
and about the capillaries.

A paper of MacMunn,'" of Wolverhampton, on
Addison's disease is noteworthy. He has studied
the adrenals and urine of patients with this dis-
ease, spectroscopically ; and, reviewing our knowl-
edge of the subject, concludes that the function
of the adrenal bodies is the removal from the cir-
culation of worn-out pigments and their accom^
panying proteids. " When the adrenals are dis-
eased these effete pigments and effete proteids
circulate in the blood ; the former, or their incom-
plete metabolites, producing pigmentation of the
skin and mucous membrane, and appearing often
in the urine as urohjematoporphyrin ; the latter
producing tonic effects, and leading to further
deterioration of the blood with its consequences."

At our meeting in Cincinnati, last year, a dis-
cussion took place on the modern method of diag-
nosis of diseases of the stomach ; and high hopes
were expressed that by the examination of the
gastric contents, an ease and certaintj- of diagnosis
in these affections is almost within our reach

^Fortschrift der inedicin, July i,^, i5^SJ^.

sPractitiouer, .\ug., iSSS, and l,aucet, iSSS, Sept. 2;. 29 and
Oct. 6

'o British Med. Journal, Feb. 4. iSSS.

1889.]

ADDRESS ON MEDICINE.

comparable to that which urinary analysis yields
in renal diseases. The more carefulh- the ques-
tion is studied, the greater is the demand for yet
further study, and the more clearly does the neces-
sity appear for the exercise of great caution in the
formation of definite conclusions at present. In
the first place, it is now seen that the only single
test for free hydrochloric acid which has a real
clinical value, is the phloroglucin-vanillin ; the
tropseolin, congo red, methyl violet, and other
tests, either reacting to other acids or acid salts,
or being often prevented from reacting by albu-
minoids, even when free hydrochloric acid is pres-
ent. Secondl}-, it gradually' appears that it is not
safe to base a diagnosis of gastric cancer on even
the persistent absence of this acid from the gastric
contents withdrawn an hour after a test meal.
Such absence is indicative of notable impairment
of the functional activity of the mucous mem-
brane, as from a severe catarrhal condition ; or of
extensive destruction of the secretorj' glands of
the stomach, largely irrespective of the cause of
the destruction. Thus, in a case of cancer sharply
localized and unaccompanied by catarrh to any
marked degree, free hydrochloric acid may be
found in sufficient amount until the cachexia is
well advanced. On the other hand, in severe but
simple catarrh, especially if attended by the for-
mation of much mucus ; in atrophy of the gastric
tubules ; in amyloid disease of the organ ; after
strong caustics have done their work ; even in
certain cases of impaired innervation ; no free
h3-drochloric acid may be detected, though sought
for repeatedly with the utmost skill and the aid of
every appliance and reagent.

It also appears that hyperacidity though a
frequent, is by no means a constant accompani-
ment of peptic ulcer.

Indeed it is impressed upon us that the pathol-
ogy of an organ which varies so widelj' physio-
logically in the same individual within such short
periods of time is a verj^ complicated thing and
the lesson is again enforced that it is not in pathog-
nomonic signs, but in careful weighing of each
piece of evidence and in the painstaking colloca-
tion of them all that accurate diagnosis is to be
attained. Before leaving this subject I must say
a word in praise of Ewald's remarkable work on
Diseases of the Stomach," and of the balance
which he preserves while enthusiastically pursu-
ing his subject.

During the past year the internal antipyretics
have continued to seek their level. It is seen that
they exert no curative influence on specific febrile
processes ; and, as we recognize more and more
clearly that even continued fever is not productive
of the changes in the parenchymatous organs
with which we credited it of late years, but that
the danger in these processes lies rather in the
effects of toxic alkaloids on the nervous centers

" Klinik der VerdanuDgskrankheiten, Ed. ii. Berlin, iSSS.

than in temperature elevation, as we recognize
this fact, we appreciate how irrational it is to ad-
dress our therapeusis chiefly to pyrexia. When
the fever is in itself productive of discomfort to
the patient the internal antipyretics are useful ;
but the indications seem to me, at least, strong
that the antineuralgic and analgesic will survive
the antipyretic application of this class of drugs.

On the other hand, it seems probable that the
cold-bath treatment, if continued, and especially
of typhoid fever, must be adopted and conscien-
tiously carried out in this country. As the prin-
ciples of Brand's methods gain headway in France,
a country not prejudiced in favor of German lead-
ership, as Brand's results are confirmed by other
observers, and in other countries, and in the face
of such statistics as are put into our language by
H. C. Wood," Wilson," and Baruch," it is diffi-
cult to see how a people who prides itself on its
wealth, general intelligence and practical quali-
ties can be longer deterred by skepticism, or
motives of convenience and economy, from the
adoption of a method of treatment which reduces
the mortality of typhoid fever to 3 per cent.

The hypnotics, sulphonal and amylene hydrate,
have come into more general use, and prove
themselves to be valuable additions to our list of
remedies of this class. Unpleasant effects seem
rare, while the slow absorption of the one, and
the rapid action of the other give each a place.

The treatment of locomotor ataxia by suspen-
sion [accidentally hit upon by Motchonkowsky,
of Odessa, who was struck by the benefit derived
by a tabetic patient, also suS"ering from spinal
cur\'ature, after the suspension required in apply-
ing a plaster jacket] has spread with great rapid-
ity, and is being thoroughly tested in this as well
as in other countries: It is still too early to de-
termine how useful it will prove to an unfortunate
class of patients.

Morton Prince'^ was led by his duties as exam-
iner of applicants for the Boston Fire Department,
and by the frequency with which he heard tem-
porary murmurs in vigorous men, to a study of
their mode of origin. It has been believed for
some years that in debilitated .states leakage may
take place through the mitral valve, the curtains
of which are not tightly clo.sed by reason of the
insufficient force of the ventricular contraction.
It will be at once appreciated that Prince's cases
were the reverse of debilitated ; and his ingenious
explanation of the murmurs heard in them is that
under conditions of great excitement, such as
many of the applicants presented, the valve may
be forced b}^ ventricular contractions of a power
disproportioned to the resistance of the valve.
It is not easy to detect a flaw in his argument,

'-Therapeutics, Its Priuciples aud Practice. Seventh Ed., i£88,
p. 5S, et seq.

■^.-inniial of the Med. Sciences, 1SS9, Vol. i.

•4N. Y. Medical Record. 18S9, i, p. 434.

'5N. Y. Med. Record, 1S89, i, p. 421. 'Boston Med. and Surg. Jour-
nal, 18S9, p. J09, et seq.

22

DISLOCATION OF THE CLAVICLE.

[July 6,

and it seems as if he had made an important ad-
dition to our knowledge.

There are many other subjects of which I
should like to speak did time permit and were the
programme less attractive. Ver\- likely another
in my place would have selected quite a different
series of topics. The highty-important and inter-
esting subject of cerebral localization, for instance,
has not been mentioned. But the work which
has been done in that direction the past 3-ear has
been rather in popularizing previous studies, and
in the application of their results to practical sur-
gery, than in new discover}-.

Prudden's'" studies of diphtheria and the con-
stancy with which he finds a streptococcus in
diphtheritic lesions deser\-es more than passing
mention. So also, Hare's'" Fothergillian Prize
Essay on ' ' Mediastinal Diseases. ' '

To sum up the results of the year, it maj' be
stated that it has been one of real, though not of
brilliant progress. Knowledge has been advanced
almost all along the line, more in some parts than
in others ; bacteriologj' in its broad sense, in-
cluding the chemical poisons generated by or ac-
companying the microbes, as well as the identifi-
cation and life history- of the organisms, offering
an enormous field for patient research.

One fact seems to me to stand out in strong re-
lief, namely, that our countr\-men are on the high-
road leading to the attainment of a reputation for
scientific research equal to that which the}' have
long enjoyed in the more immediately practical
branches of medicine and surgerj-.

The future glows with a promise which the
achievements of the past assure us will be real-
ized, and it is the part of each one of us, if he
cannot discover, at least to do all that in him lies
to make the highest and best use of the discoveries
of others more gifted than himself

ORIGINAL ARTICLES.

TWO CASES OF UPWARD DISLOCATION

OF THE STERNAL END OF THE

CLAVICLE.

BY S. T. ARMSTRONG, M.D.. Ph.D.,

PASSED ASSISTANT SVRGEON V. S. MARINE-HOSPITAL SERVICE.

The comparative rarity of this dislocation,
Hamilton' mentioning but eleven cases, may
justify the publication of the following cases :

Case /. — Jas. Davidson, set. 41, a native of
Scotland, was admitted to the U. S. Marine Hos-
pital, New York, on October 16, iSSS, for necrosis
of the frontal bone. In examining the patient it
was found that he had an old upward dislocation

"'.^m. Jour Meil. Science, March and April, 1SS9.

T Philadelphia. Bl.Tkistou, 1SS9.

' Fr.nctures and Dislocations. 1SS4. Page 671.

of the sternal end of the clavicle. The patient
stated that in 1881 he fell from a wagon, striking
the wheel with his right shoulder in falling.
Though severely jarred for a few moments, he
felt no severe pain in the shoulder or sternal
region, and was not obliged to consult a phy-
sician. A machinist h\ trade ; in resuming his
occupation the day after his fall, he noticed that
in hammering with his right arm he would often
miss hitting his chisel fairly. So aggravated did
this condition become that he was discharged as
incompetent.

Thinking that the accident might have caused his
trouble, he consulted a physician some two weeks
after the fall, and was informed that the collar
bone was dislocated, but that it was too late to do
anything to benefit him. As his right arm was
apparentlj' as strong as the left he secured em-
ployment on a v^essel.

The arm has always been servicable. Exam-
ination of the chest showed a slight prominence
of the sternal end of the right clavicle, that was
increased when the arm was extended above the
head. If the arm was extended posteriori}' there
was a slight projection of the bone forward. If
the arm was extended anteriorlj- there was a
marked projection of the extremit}- of the bone,
and a knotting of the pectoral muscles beneath it.
Moving the arm to the opposite shoulder, the
bone glided along the iipper margin of the
sternum, and could be made to almost touch the
opposite clavicle. No movement of the head
affected the position of the bone. As the motion
in hammering, with the machinist, is largeh' from
the shoulder, there was constant motion of the
dislocated extremity ; and failure of the pectoralis
to have a proper base of support, made the con-
traction of that muscle in depressing the arm ir-
regular, and hence the failure to strike a true blow
with the tool.

The extreme mobility of the sternal extremity
leads to the belief that there was originally a lac-
eration of all the surrounding ligaments. There
maj' be partial reformation of the costo-clavicular
ligament, but it seems probable that the bone is
now held iti situ bj' the subclavius muscle.

Case 2. — O. Anderson, aet. 39 years, a native ot
Sweden, was admitted to the hospital April 10,
1889. During a storm at sea, on April 7, a heavy
wave struck the vessel he was employed on, and
he was thrown against a bulwark ; he was un-
conscious for some time, and on regaining his
senses felt a severe pain in his right shoulder and
arm, and spit up blood. When admitted to the
hospital, a fracture of the right ulna was found.
There was emphysema of the right chest, axilla,
and shoulder. The right post clavicular fossa
was obliterated, and crepitation occurred on pres-
-sure here, as well as to the external to the scapula.
From this and the pulinonar}' hcemorrhage a
fracture of the ribs posteriorly was diagnosticated,

1889.]

MEDICAI. PROGRESS.

23

though the site could not be determined as it was
covered by the scapula. The sternal extremity of
the right clavicle was dislocated upward, and
rested on the upper margin of the manubrium
sterni ; by pressure it could be reduced, but it
would gradually slip upward and forward again.

The condition of the patient was such that any
attempt at fixation of the dislocated bone was
precluded. The patient was kept on his back for
two weeks, the fracture of the forearm securing
immobilization of the arm. When allowed to sit
up the arm was placed in a handkerchief sling,
and on May 6, he was discharged recovered.

The sternal end of the clavicle projected, but
there seemed to have been a partial reformation
of the ligaments, and the range of mobility, of
the dislocation was slight. Of course, with con-
stant use, it is possible that the dislocation may
be aggravated, but it is improbable that the use
of the arm will be interfered with.

These cases simply verify the reported cases :
that retention of the dislocation is practically im-
possible, and that in no case did it impair the use-
fulness of the arm. Each of the cases were veri-
fied by the staff of the hospital.

MEDICAL PROGRESS.

Bacteria in Green Sputa. — The occurrence
of green sputa is a well-known fact. Formerly
all such cases were described by the same name,
the green coloring substance was declared to be
biliverdin, and in all cases where green sputum
was observed, "bilious pneumonia" was diag-
nosed. At Traube's instigation Nothnagel inves-
tigated this symptom in the sixties. He arrived
■ at the conclusion that green sputa might originate
either from actual admixture of bile coloring sub-
stance into the sputa — and this occurs every time
when an affection of the respiratory apparatus ac-
companied by spitting exists with icterus, irre-
spective of the cause for the latter, consequentlj'
not only in pneumonia but also in common bron-
chitis— or from transformation of a blood coloring
matter into a green coloring substance. Nothna-
gel, who declares that the rust-color of the pneu-
monic sputa is an early stage of this transformation
process, found the last stage, the green color, when
the sputum was allowed to remain stagnant for
awhile ; for instance, in pneumonia terminating
in abscess of the lungs, and in subacute catarrhal
pneumonia. Later Elliot and Janssen observed a
green sputum evidently belonging to this second
category in a case of sarcoma of the lungs.

Attention has repeatedly been called to the fact
that there are sputa which immediately after ex-
pectoration do not show any traces of green color,
but which in a few days assume a beautiful green

color. Escherich, Curschmann and Rosenbach
have described such sputa. A similar process, iu
which, however, a yellow color takes the place of
the green, was described by Lower and Traube.
The fact that such coloring occurred chiefly in
summer, generally wandering in hospital wards
from one cuspidor to another, suggested the action
of microorganisms as a cause. Especially Rosen-
bach claimed bacteriological origin for it. Lender
the microscope he found in his sputa numerous
ovoid bodies, small and glittering, which he re-
garded as bacteria spores. These he thought were
the causes, and at the same time the carriers of
the coloring substance.

Curschmann, who also investigated the subject,
found no trace of bacteria. Nor has thorough
examination of this subject, on the basis of our
present attainments in bacteriolog>% ever been
made.

Dr. Fricke finally availed himself of an oppor-
tunity to do so during an epidemic of green sputa
which occurred in the Canton Hospital in Zurich
in the spring of 1S88. The sputum of a patient
with chronic bronchitis had been taken from the
medical male ward to the laboratory for the pur-
pose of microscopical investigation. In three days
it had assumed a bright green color. Later the
sputum of the same patient became green once
more, this time in the ward. A few weeks after-
wards the patient had to be transferred to the
surgical male ward because of hernia, and a few
days afterwards the green sputum of a tuberculous
patient who had been operated on in the same
ward for empyema was shown to Dr. Fricke. It
is just possible that there was an etiological con-
nection between the two cases, although the two
patients were not in the same room. At about
the same time a green sputum from an incipient
case of phthisis in the female ward was submitted.
The sputa of this last patient for six weeks be-
came green every time that it was left standing
for a few days ; afterwards the phenomenon sud-
denly disappeared. Finally one more sample of
a sporadic case of green sputum was sent to Dr.
Fricke.

At first Dr. Fricke made attempts at vaccina-
tion. Into the sputa of various diseases he intro-
duced traces of green sputa, and in two or three
days obtained a green color in the former, it mak-
ing little difierence in what disease they origi-
nated. Pneumonia sputa turned almost without
exception a dark olive-green, sputa of bronchitis
assumed a grassj' color. Waterj' or foamy sputa
colored badlj', and sputa from cavities colored the
worst of all. In short, the tendency to change
appeared to depend principally upon the physical
qualities.

These experiments already proved almost with
certainty that microorganisms were the cause of
the color. Dr. Fricke now examined all these
sputa by means of Koch's plate cultures, and

24

MEDICAL PROGRESS.

[July 6,

found in all of them, without exception (besides
diverse bacteria which did not produce any color-
ing matter, and to which he consequently paid no
further attention), the same bacillus which upon
artificial soil produced a shining green coloring
substance, and which, transferred from the pure
culture to sputa, produced in them the green color
as regularly as the original sputa. Fricke consid-
ers, therefore, this bacillus as the only cause of
the green coloring substance.

For the non-success in vaccinating certain sputa
physical, chemical or bacteriological causes may
be held responsible. By the latter Fricke refers
to priman,- occurrence of such bacteria in sputum
which do' not harmonize with the coloring bacil-
lus, which are antagonistic to the latter. He ex-
amined the conduct of the tubercle bacilli in this
respect, and found that sputa containing the tu-
bercle bacilli turn green the same as others. He
therefore ascribes no clinical significance to the
occurrence of the green coloring, as it depends
solely upon qualities of the sputa wholly unim-
portant clinically, and upon the purely accidental
entrance of the bacillus. The latter is about the
form and size of the typhus bacillus, and having
the same brisk motion. It is strictly aerobic. It
has no pathogenic qualities.

The coloring substance is not in the bacilli
proper, but in the culture media in their vicinity.
The production of the coloring matter is not a
vital function of the bacillus. Dr. Fricke. being
able to raise rather a luxuriant growth of them
on artificial soil without their producing the col-
oring substance. It is difficult. to obtain the color-
ing matter in large quantities and still more diffi-
cult to produce it in its pure state, as it is insoluble
in alcohol, ether, chloroform, etc., but dissolves
easily in water and alkali, and is therefore not
easy to separate from salts. For this reason an
analysis could not be made.

Supplementarj' to this question Fricke studied
all bacilli producing green color which he could
obtain. He had cultures sent him from the insti-
tutions in Gottingen and Berlin, and thus was
able to cultivate be.side one another seven differ-
ent bacilli, six of which produce, when fresh, a
shining grassy-green coloring matter ; when old,
a dirty yellowish-brown color substance which,
however, always retains a beautiful green fluores-
cence, whilst the color substance of the seventh,
the bar. pyocyancus ft of Ernst, is at first similar
to the other, but through shaking with oxygen or
through standing for a long time in the air, be-
comes dark green and finally almost black . The
two coloring substances also differ in their rela-
tions to acids. The /:* substance turns red like
litmus, the ex matter is completely deprived of
color. Alkalies restore to both the original green
color.

Three of the seven bacilli dissolve gelatine ;
they are all known : Dae. pyocyancus a, fi, and

B. fli/orcscens liqiiefaciens. Four leave the gela-
tine lanchanged ; of these two are movable, two
immovable. These differ again in the form of
the colonies on the different media. Of the ba-
cilli not dissolving gelatine two are identical with
descriptions in the literature : that out of sputa
with Bac. fiuoresccns putidtts and. (Fliigge), an-
other with Bac. fiuoresccns auct. (Eisenberg) ; two
others have not yet been described. There is also
in literature the description of a Bac. crylhrosporus
which likewise produces a green coloring sub-
stance, and which distinguishes itself by the for-
mation of large, dirty-red spores. None of the
seven kinds above mentioned agreeing with this
description, there are consequently eight kinds.
Fricke vaccinated all seven upon sputa, and in
all except Bac. pyocyancus li green coloring of the
sputa resulted. Consequently one or another of
these bacilli might be found in other cases of
green sputum. — Comspondcnz-Blatt fur Sclncei-
zer Aerste, No. 9, 1SS9.

Pathogeny of the Round Ulcer of the
Stomach. — There are numerous theories on this
subject. According to that most generally ac-
cepted there are two factors active in the de\-elop-
ment of the simple ulcer : a dyscrasic influence,
a modification of crasia, such as is found in cer-
tain forms of ansemia and in chlorosis, and acci-
dental local influences which produce haemor-
rhagic or other ulcerations in the superficial layers
of the inner surface of the stomach.

Ingesta may act in both forms, as modifiers of
the blood crasia, or- as local irritants. It would
be interesting to know the relations existing be-
tween the different regimens and the occurrence
of round ulcer. M. vox Sohlerx has made an
investigation in this direction, having sent inqui-
ries to a number of Russian physicians and pa-
thologists to ascertain whether there is any truth ,
in the claim that round ulcer is very rare in a
certain part of Russia. The answers received all
agree in confirming that statement. As an illus-
tration some statistics furnished by Mr. Winogra-
noff, prosector at the Obuchow Hospital in St.
Petersburg, are given here. In about 900 autop-
sies which are made every year in this hospital,
only one or two cases of round ulcer are found.
M. Petersen, prosector at the Alexander Hospital,
found only three cases of round ulcer in about
6,000 autopsies.

Information gathered by the author from phy-
sicians practicing in the Rhon and the Bavarian
Alps, two districts in Bavaria, establishes also
with surprising certainty the extreme rarity of
round ulcer in these two regions. In Russia as
well as the two Bavarian districts, the food of the
inhabitants is almost exclusively of a vegetable
character ; meat is consumed only in exceptional
cases. The climatic conditions in the two coun-
tries differ greatly, the food, too, is quite unlike.

1889.]

MEDICAL PROGRESS.

25

There is only one thing common to the countries
where round ulcer is rarely found, and that is the
great proportion of potash in the food. To this
circumstance the inhabitants of those countries
would seem to be indebted for their immunity from
round ulcer. — Gazette Mcdicak dc Paris, No. 18,
1889.

Inh.\lation of Chloroform in Diseases of

THE HE.A,RT and of THE LUNGS. — -PrOF. RoSEN-

B.\CH recommends warmly i^four. dc med. de Paris)
inhalations of chloroform in all those cases of lung
or heart disease where the other narcotics, as, for
instance, morphia, chloral, etc., act too slowly,
or where their use is followed by disagreeable sec-
ondary symptoms. The method employed by him
is as follows. From 5 to 15 gr. of chloroform
are put on wadding placed in a funnel, and the
patient slowlj- inhales the vapors from the funnel,
which is held at a certain distance from the mouth
and nose. As the chloroform is mixed with air
there is no danger to be apprehended. The pa-
tient at first experiences a disagreeable sensation
in the pharjnix, but this soon passes off, the pa-
tient makes several deep inhalations which pro-
duce a feeling of well-being, and sometimes even
produce sleep. The author never observed anj'
harmful secondary- symptoms ascribable to this
treatment.

Chloroform inhalations are indicated in all at-
tacks of dyspncea of cardiac or pulmonan.- origin,
but especially in emphysema, cardiac asthma, and
in heart disease. Good results have also been ob-
tained where they were employed for the attacks
so common with phthisical patients. People who
previously had been passing their nights abso-
lutely sleepless, slept quite well after resort to the
inhalations. Satisfactory results are also obtained
in hiccough and in acute cardialgic attacks ; in
these latter cases, however, morphia is prefera-
ble. It deserves to be mentioned that the author
succeeded sometimes in breaking up attacks of
pulmonarj- cedema. He also thinks it useful to
bathe the tuberculous ulcers of the larynx with a
watery solution of chloroform, the improvement
ensuing being due, in his opinion, partly to the
^analgesic and greatly to the antiparasitic action
of the chloroform. — Reviic Mcdicalc de I' Est. No.
9, 1889.

Aortic Insufficiency. — Timofejew ex-
presses his opinion on this subject {Bo/. Klin.
Wochcnschrift, June 11, 1 888) as follows : i. The
diastolic murmur of aortic insufficiencj- can com-
pletely disappear and be replaced bj- the second
normal tone. 2. The intensitj- of the diastolic
murmur depends entirely (a) upon the degree of
insufficienc)', (U) upon the blood pressure in the
aorta. 3. The blood pressure diminishes con-
siderably in the course of valvular affections of
the heart. 4. The second tone in the carotid of

dogs in which an aortic insuflScienc^' has been
produced, often disappears after a longer or short-
er period. 5. The second murmur, which is
heard sometimes on a level with the carotid in pa-
tients afflicted with aortic insufficiency, is a
symptom of purely local origin, and not the con-
tinuation of a murmur from the base of the heart.
6. The first murmur which is heard sometimes in
aortic insufficienc}- on a level with the carotid
may have a purely local origin.

Rosenbach, however, arri\-ed at contrary' con-
clusions {Bcrl. Klin. W'och., Sept. 17, 18S8). He
says: i. The conditions causing the murmur
after artificial destruction of the aortic valve differ
essentially in the dog and the rabbit. In the for-
mer the murmur is irregular, and may be
lacking or disappear in the course of observation,
whilst in the latter it is constant and intense. 2.
This difference is due to the circumstance that
there never occurs precipitation of fibrin upon the
injured organs in rabbits, whilst in dogs fibrin-
deposits are numerous enough to make up tem-
porarily for the loss of valvular substance. 3.
Intra-arterial pressure has no noticeable influence
on the intensitj' of the diastolic murmur, which is
chiefly produced by the aspiration of the ventri-
cle dilated by the diastole. 4. The production of
the systolic murmur in aortic insufficiency must
be ascribed to the backward flow caused, at the be-
giiming of the aorta, b}- the aspiration of the left
ventricle, which current must be overcome by the
ventricular contents liberated in the moment of
systole. — Revue des Sciences A/edicales, No. 66,
1889.

On Dorsal Tabes and Exophthalmic
Goitre — Barih reports the history' of a patient
who was affected with various troubles : on the
one hand the symptoms of tabes, lightning pains,
Romberg's symptom, cessation of the patellar
reflex, plantar anaesthesia, incoordination of
movements, vertigo, gastric crises ; on the other
hand the symptoms of Basedow's disease ; pro-
trusion of the eye, tachycardia, hypertrophj' of the
heart, swelling of the thyroid, trembling, poh--
uria, etc. From this complex of symptoms he
concluded that in the course of tabes the classical
symptoms of exophthalmic goitre may appear,
that these phenomena are the expression not of a
disease developing parallel but of a pathological
complexus lying in the centers of the medulla ; he
compares exophthalmic goitre in tabes to the
bulbar troubles described bj' Pierret and Joffroy ;
he admits that goitre may be a symptom not of
the highest stage but of the beginning of tabes
which is doubtless related to a simple congestive
hypersemia, and will yield to the use of ergot and
faradisation. {Soc. Med. des Hop., Dec. 14, i8-88).
Joffroy reports in brief the cases of seven women
afflicted with tabes, all of whom showed tachj--
cardia, whilst six had ocular protrusion, and two

26

MEDICAL PROGRESS.

[July 6,

thyroid tumor. He does not share the opinion of
Barie, but thinks that the diseases of Basedow
and Duchenne may be seen combined in the same
individual ; he admits, however, that ataxy may
sometimes give way to tachycardia, and perhaps
to a shght protrusion of the eye. — Revue des
Scie7ues Medicaks, No. 66, 1SS9.

Muscular Atrophy in Ataxia. — Dejerine
found in 106 ataxic patients in his practice in
Bicetre, 11 presenting progressive muscular
atrophy. He reports 5 clinical cases with au-
topsy and histological investigation. He con-
cludes that in most cases muscular atrophy in pa-
tients with tabes results from neuritis of the
peripheral motor- nert'es : there exist consequently,
besides the cutaneous sensitive neuritis already
described by him in 1882, motor-neuritis having
much in common with the former ; both of them
are the more pronounced the farther away from
the centres thetranks of the nerves are examined ;
both of them are also of a peripheral character,
for, in the cutaneous neuritis, the spinal gang-
lions are not affected the same as the interior
horns, which are intact in the motor neuritis.
The latter should therefore be considered hence-
forth as belonging to posterior sclerosis, the
symptomatology of which the}- may change in
certain cases. (C. R. Sec. Biol., February- 25,
1888}. Apropos of the investigations of Dejerine
regarding the peripheral nature of muscular atro-
phy in tabes, Joffroy cites several cases of Char-
cot, Pierret, Londoleon, and of his own practice,
in which this atrophy was accompanied either
bj' a lesion in one spot or by a lesion spread out
over the motor nerve cells of the anterior horns.
Dejerine is of the opinion that in these cases
there existed coincidently an acute tephro-
myelitis, sub-acute or chronic, with ataxy, but
not a genuine muscular atrophj- in tabes, which
can only result from a neuritis of the peripheral
motor-nerves. — Revue des Sciences Medicaks, No.
66, 1889.

Normal and Pathological Conditions of
G.A.NGL10NS in the Human Heart. — Adolph
Ott in the "Prager Zeitschrift fiir Heilkunde,"
Bd. ix., p. 271, says that ganglion cells are most
frequently found in the septum atriorum, that is
in its front or rear section, where it is thickest, its
thinner middle portion scarcely containing any at
all. But also in the circumference of the ventri-
cles, especially in the rear portion, and preferably
in that portion of the right ventricle located be-
tween the aortic and the pulmonary arteries, the
ventricles do not contain auj- ganglions. The
ganglion cells lie principally in the subpericar-
dial connective tissue, but occur also scattered
through the muscles. An examination of thirtj-
hearts for pathological changes of the ganglion
cells showed that they occur in two types : i. As
a progressive change-growth of connective tissue

between the cells and the nuclei of the Sheath of
Schwana with formation of a tissue at first
granular subsequently coarsely fibrous ; besides in
the advanced stages of this process fatty degener-
ation and compression of the ganglion cells ; and
secondly, as an acute parenchymatous degenera-
tion of these cells. The former change is found
in those cases which lead to stoppage and changes
in size in the heart, the latter in complete quali-
tative alteration of the blood (uraemia, sepsis, etc.)
Definite relations between changes of the gang-
lions and degeneration of the heart muscles can-
not be proven. A causal connection between the
changes in the heart, microscopically perceivable,
and those of the ganglions exist only inasmuch as
the stoppage of the blood causing hyperplasia of
all tissues in the heart seems to favor also the
growth of connective-tissue substances in the
ganglions and its consequences. For clinical pur-
poses the result of the investigation do not fur-
nish any material which would allow of drawing
a conclusion from the heart action as observed
during life upon the pathological conditions of the
ganglions of the heart, or which permit an influ-
ence upon the action of the heart, /. c, its fre-
quency or rhythm on the part of the changed
ganglions to be recognized. — Ccntralblatt fi'ir
Klinische Medicin, No. 15, 18S9.

Poisoning by Ptomaines. — M. Merveille
reports a case where a famih' was poisoned by
eating bouillon which was onl^' one day old, but
had been kept in a bedroom and had not been
boiled over. The symptoms of the patients were
verj- similar to those of cholera : incessant vomit-
ing, abundant rice-like stools, cramps in the limbs,
cyanosis, etc. The condition of the patients was
very serious, but all recovered. This was evi-
dently a case of poisoning by ptomaines which
had formed in bouillon made of sound meat, large
quantities of the soup having been eaten on the
first day without causing any trouble whatever.
— Gazette Mcdicak, No. 32, 1889.

On Tuberculosis of the Lungs in Sug.\r-
Di.\BETES. — A. B.\gou shows that phthisis in
diabetic patients is alwaj-s of a tubercular char-
acter, whatever its clinical form maj' be.
Whether acute or chronic, or pneumonic or ulcer-
ative; it always has the bacillus for an anatomical
substratum which invades the organism all the
more easily as it finds it debilitated with the im-
pregnation with sugar. The immediate cause for
tuberculosis in diabetes is the diminution of re-
sistance of the organism. Clinically it is specially
characteristic of this kind of phthisis to appear
insidiously to cause but little haemoptysis, little
febrile reaction, hardly any perspiration. But
from a prognostic standpoint it is of the most ma-
lignant type as it never improves. — Revue des
Sciences S/edicaks, No. 66, 1SS9.

iSSg.]

EDITORIAL.

Journal of the American Medical Association

PUBLISHED WEEKLY.

Subscription Price, Including Postage.

Per A^rnuM, in Advance $5.00

Single Copies 10 cents.

Subscription may begin at any time. The safest mode of remit-
tance is by bank check or postal money order, drawn to the order
of The JomNAL. When neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
letters.

Address

Journal of the American Medical Association,

No, 6S Wabash A\'e,,

Chicago, Illixois.
All members of the Association should send their Annual Vugs
to the Treasurer, Richard J, Dunglison, M.D., Lock Box 1274, Phila
delphia. Pa,

London Office, 57 and 59 Ludgate Hill.

SATURDAY, JULY 6. 1SS9,

FORTIETH ANNUAL MEETING OF THE AMERI-
CAN MEDICAL ASSOCIATION.

The first General Session of the Association as-
sembled in the Music Hall at the hour named
upon the programme. The meeting was called
to order bj' the Chairman of the Committee of
Arrangements, Dr. H. R. Storer, of Newport, who
presented the President of the Association, Dr.
"\'\'. W. Dawson, After pra^'er bj- the venerable
Dr. Thayer, the senior clerg5^man of Newport,
letters of regret were read from the following :
Vice-President L. P. Morton ; Hon. J. W.
Noble, Secretary- of the Interior ; Hon. B. F.
Tracy, Secretary of War ; Hon. John Wana-
niaker, Postmaster-General : Hon. W. Windom,
Secretary of the Treasurj- ; Drs. Stille, E. H.
Gregory, Ex- Presidents of the Association ; Dr.
H. I. Bowditch, of Boston ; Dr. \V. B. Geikie,
Dean of Trinity Medical College, Toronto ; Dr.
Montizambert, Medical Superintendent at Grosse
Isle, Quebec; Sir James Grant, M.D., Ottawa,
Can. ; Sir Charles Tupper, M.D., Minister of
Marine and Fisheries, Can. ; Dr. P. H. Bn^ce,
Provincial Board of Health, Ontario ; Professor
James C, Cameron, Montreal ; and others.

Various letters of invitation were then read, one
of the most important being that from the Fac-
ulty of Harvard Universit}' inviting the members
of the Association to visit the College on their
return home.

The Hon. H. \V. Ladd, Governor of Rhode
Island, addressed the Association in terms of wel-
come. He said that Rhode Island was noted for

its hospitality, and that the Association would
find that its reputation would be maintained in
that instance.

The Hon. Jas. H. Eldridge, M.D., of East
Greenwich, welcomed the Association in the
name of the profession of the State of Rhode Is-
land (See p. 14),

The Presidential Address, a full report of
which may be found in the fore part of this issue
of The Journal, was read by Dr. J. A. Larra-
bee, of Louisville. Dr. Dawson, the President,
though present, found himself unequal to the
task of delivering it on account of ill-health.

The proceedings of the second day were opened
with prayer by the Rt, Rev. T. M. Clark, Bishop
of Rhode Island. After the reading of announce-
ments and the report of elections to the Nomina-
ting Committee, an Address on Medicine was de-
livered by Dr. Wm. Pepper, Provost of the Uni-
versity of Pennsylvania.

Dr. Pepper's address consisted of an interesting
account of the life and labors of Dr. Benj. Rush,
together with an eulogj- of his character. The
address was a most eloquent tribute to the mem-
ory of the first of our great American physicians.
Dr. Pepper reviewed his life in considerable detail,
but dwelt more upon his personal characteristics
and the part he played in the contemporaneous
historj' of his times, pointing out the manifold
character of his work as a statesman, a literateur,
a reformer and, most of all, a physician. As a
medical officer of the Arm}-, as the projector of
the Philadelphia Dispensar}-, as a political, social,
and medical reformer, his work was of the high-
est character. His essay on ' ' The Physical In-
fluence on the Moral Faculty " occupies a classical
position in the literature of medicine. His efforts
in opposition to capital punishment, slavery, in-
temperance, and the use of tobacco were of the
most earnest and effective nature. He drew much
of his inspiration from his friend, Franklin, as well
as from his great teacher, Sydenham. He was
not only a master of literary style but a most elo-
quent and effective speaker. He was an active
and progressive educator. Through all his writ-
ings there runs a vein of piet}' free from sectari-
anism. After 1789 the greater part of his work
was medical, while the most interesting part of
his life was that subsequent to his election to the
Universitv of Pennsvlvania, From this date,

28

FORTIETH ANNUAL MEETING.

TJuLY 6,

17S9, to the date of his death, 1813, the history
of his life is the history of American medicine —
the ' ' Era of Rush. ' ' As a medical teacher he was
unrivaled for simplicity. His historj' of the epi-
demic of 1793 is one of the very best ever pub-
lished. Dr. Pepper fears that in these days re-
finement in diagnosis and the study of disease
often leads to the loss of valuable time, and that
Sydenham's belief that the prompt treatment of
disease in its incipiency is one of the most impor-
tant elements in our success as phj'sicians, as it
was in the case of his pupil Rush. Our own re-
sources are much greater now than were theirs in
the last century. We are often in danger from
too great refinement. They had few and trusted
remedies. We have many remedies for every
symptom and do not thoroughlj' learn the use of
any of them.

Dr. Gihon, U. S. N., Chairman of the Rush
Monument Committee, then presented his annual
report. He regretted that the Committee could
not report progress, and feared that the members
would not live to see the fruition of hopes in-
dulged five years ago when the Committee was
appointed. The treasurer had only received
$1,000. After a most energetic appeal to the
whole profession for aid in this important move-
ment, he announced that the dollar limit had been
abandoned and that sums of any amount would
be received. In the midst of much enthusiasm
the sum of $264.50 was soon added to the fund.

The debate on adoption of amendments to Con-
stitution then followed.

The amendment to strike out the last clause of
Sec. VII, relating to individually afiixing names
to the Constitution and regulations of this Asso-
ciation, was adopted.

The amendment proposed by Dr. Moyer, refer-
ring to changes in the Constitution of the Sec-
tions, was indefinitely postponed.

After a lively debate the resolution affecting
the personal duties of the General Committee was
lost.

The proceedings of the third day were opened
with prayer by the Rev. James Coyle, (R. C.) of
Newport.

The Address on General Surgery was then
given by Dr. Phineas S. Conner, of Cincinnati,
and will be found reported in full in this issue of
The JoIjrnal.

Dr. R. J. Dunglison, of Philadelphia, presented
his annual report as Treasurer which showed the
Association to be in satisfactory financial con-
dition.

The Nominating Committee then made their
report, after which it was decided to hold the
next meeting at Nashville, Tenn., on the third
Tuesday in May, 1890.

The following officers were elected : President,
E. M. Moore, of New York ; First Vice-President,
J. W. Jackson, of Missouri ; Second Vice-Presi-
dent, W. W. Kimball, of Minnesota ; Third Vice-
President, J. H. Warren, of Massachusetts;
Fourth Vice-President, T. B. Evans, of Maryland ;
Treasurer, R. J. Dunglison, of Pennsylvania ;
Permanent Secretary, W. B. Atkinson, of Penn-
sylvania ; Librarian, C. H. A. Kleinschmidt,
D. C. To deliver Address on General Medicine :
Dr. N. S. Davis, of Illinois ; General Surgery,
Hunter McGuire, of Virginia ; State Medicine,
Alfred L. Carroll, of New York.

The Hon. Geo. Bancroft, and Sir James Grant,
of Ottawa, were then presented to the Association,
the latter making a few remarks in which he
dwelt upon the advances made during the past
half century in the treatment of insanitj', and re-
ferred to the advances made in the surgerj- of the
thorax. The subjects of medical education and
examination were touched upon, and he recom-
mended that the best waj' to weed out irregular
practitioners is to require "a rigid preliminary
training."

The fourth day's proceedings were opened with
prayer by the Rev. D. A. Jordan, (M.E.), after
which Dr. W. H. Welch, of Baltimore, delivered
the Address on State Medicine, a full report of
which will be published in a future issue of The

JOURN.^L.

Dr. J. M. Toner, Chairman of the Committee
on Necrology, presented his annual report.

The full Official Report of the Proceedings of
the Fortieth Annual Meeting of the Association
will be published in The JofRNAL as soon as re-
ceived from the Permanent Secretary, Dr. W. K.
Atkinson, of Philadelphia.

The Weekly Medical Review, of St. Louis,
will be enlarged to the size of the New York
Medical Journal.

iSSg.]

EDITORIAL NOTES.

29

EDITORIAL XOTES.
HOME.
University of Pennsylvania. — The Asso-
ciate professorships of Obstetrics in tfie Medical
Department of the Universit}' will be consolidated
and Dr. Barton C. Hirst elected as Professor of
Obstetrics. Dr. William Goodell will continue
his duties as Professor of Gjmecology.

The Medical Society of the State of
West Virginia will hold its twenty-second an-
nual meeting at White Sulphur Springs from
July 17-19, 1889. Full particulars as to railroad
arrangements, etc., may be learned on applica-
tion to the Secretary, Dr. J. L. Fullerton, Charles-
ton, W. Va.

The Chicago Policlinic is now an assured
success. The enterprising Faculty have com-
menced the erection of a handsome four-story
structure on Chicago avenue, west of Wells street.
The exterior will be constructed of brick and
stone, and the interior finished in hardwood and
heated by steam. It will cost $25,000 and will
be completed in about four weeks.

The Ohio State Medical Society. — ^At
the forty-fourth annual session of this Society,
recently held in Youngstown, O., the following
gentlemen were elected officers : President, Dr.
John McCurdy, of Youngstown ; Vice-Presidents,
Drs. J, W. Conklin, of Dayton ; A. W. Ridenour,
of Massillon ; C. W. Tangermaii, of Cincinnati ;
J. E. Woodbridge, of Youngstown ; Secretary',
Dr. G. A. Collamore, of Toledo ; Assistant Sec-
retarj', Dr. E. C. Brush, of Zanesville ; Treasurer
and Librarian, Dr. T. W. Jones, of Columbus.
The next meeting will be held at Columbus, the
first Wednesday in June, 1890.

foreign.

Dr. Quain, F.R.S., has received the appoint-
ment of physician-extraordinary to Queen Vic-
toria.

Prof. Lowenthal has received a special mis-
sion from the French Government to proceed to
Tonquin to study the eS'ects of salol on cholera
patients.

The- Tenth International Medical Con-
gress.— Professors Virchow, von Bergmann, and
Waldeyer have charge of the preliminary^ work
for the next Congress, and are actively engaged

in maturing plans to make it a great success.
There will be a conference of delegates from all
the medical bodies in Germany at Heidelberg in
September, It is likely the Congress will com-
mence its proceedings on August 6, 1890.

In France death by electricity has fascinated
the French. The Parisians have petitioned the
Municipal Council of Paris to substitute the
electric current for the guillotine as a more merci-
ful method of capital punishment. The meteor-
logical obser\-ator3' on the Eiffel Tower is now at
work. The direction and force of the wind, the
moisture and drj-ness of the atmosphere, the
variations of temperature, cloud observations and
weather forecasts will be minutely recorded, and
the reports placarded in the Exhibition buildings
proper.

In Italy Prof. Taurini recently successfully
performed total extirpation of the clavicle for
myxo-sarcoma. Several prominent members of
the medical profession have recently died : Enrico
Albanese, professor of clinical surgerj^ in the Uni-
versity of Palermo, died of Addison's disease on
April 8 ; Dr. Davis Maragliano, professor of psy-
chiatrics in the University of Genoa; Dr. Luigi
Barzano, a pioneer of electro-therapeutics in Italy;
Dr. E. Bonamici, lecturer on materia medica and
toxicology at Florence ; and Dr. A. De Marchi
Gherini, the leading surgeon in Milan.

In Egypt the epidemic of typhus fever has
almost entirely yielded to energetic measures.
Small-pox is prevalent. Dr. Hassan Pacha Mah-
moud claims to be the discoverer of an affection
which he names bouton d' Egypte. He states that
the bouton is peculiar to Egypt, is non-contagious,
contains no trace of microbe, differs from an ordi-
nary' furuncle, is superficial, leaves no traces on.
the skin, may last from twelve to fourteen years,
and owes its origin to the action of the air and
sun. Rabies is present in Egypt. In Cairo and
Helouan 13,326 dogs have been poisoned within
fifteen months.

In India the Government is taking stringent

1 precautions against the spread of leprosy, and it

I is proposed to empower the district magistrates to

! arrest any leper found wandering about without

means of subsistence. These may be detained in

a retreat for life. Every retreat is to provide for

the complete separation of the sexes. Great dis-

DOMESTIC CORRESPONDENCE.

[July 6,

tress prevails in some districts. In Ganjam,
•where the situation is worst, no drinking water
remains in the tanks, and cholera is epidemic
throughout the district.

SOCIETY PROCEEDINGS.

Ameriran Medical 'Editors' Association.

Annual Meeting, held at Newport, R. /. ,
Jn7ie 23, iS8g.

W. C. Wile, M.D., President, in the
Chair.

The American Medical Editors' Association
met at 8:30 p.m. The meeting was called to
order bj- the President, Dr. \Vm. C. Wile.

Dr. Wm. Brodie, .of Detroit, was invited to
occupy the Chair during the reading of the Presi-
dential Address.

(See page 10.)

In the discussion which ensued Dr. Brodie, of
Detroit, said he thought there were too many
journals and too few good journalists. There is
too much work done with the scissors. I\Ianj-
good papers are lost by being published in short-
lived journals. He believed that The Journal
of the Association should be conducted on a
thoroughly impersonal plan, in which the identitj-
of the editor is wholly lost to view. The Journal
had done much good work in killing off other
journals of little value.

Dr. Dulles, of Philadelphia, said he believed
it the dut)' of medical editors to foster good jour-
nals and kill the bad ones. He emphasized the
necessity of maintaining a high ethical and liter-
arj- standard and of promoting brotherhood in the
profession.

Dr. Leartus Connor, of Detroit, believed that
idealism in medical journalism does not pay. Some
of the most wretched journals pay the best. He
was reminded of the tobacco manufacturer who
said that if one would be rich he should pander
to the vices of the people.

Dr. I. N. Love, of St. Louis, did not take the
same pessimistic views that some of the other
speakers had expressed. He believed that Dar-
win's law holds good in journalism as in animal
life.

Dr. N. S. Davis, of Chicago, in his most vig-
orous manner rebuked the patronizing of foreign
schools to the neglect of our own, and asserted
that one-fourth of the money expended by our
students in foreign countries would ser\-e to per-
fect our own valuable institutions.

Dr. T. D. Crothers, of Hartford, read a paper

the influence of medical journalism
ox the march of science.

He believed that the influence of the medical
journal cd^ild scarcely be overestimated. Medical
journals may be divided into three classes : the
general, the special, and the encyclopaedic, each
of which has its own value. Quarterlies are
doomed, while the others are constantly increasing
their usefulness. At present the weekh- journal
is the type, but in the near future we may look
for the medical daily.

Dr. Pancoast, of Philadelphia, said he de-
plored the failure to report the daih- work of the
clinics. The weekly journal should be a mirror
of the medical and surgical work done in the
clinics of each community-. We look to the jour-
nal for the knowledge we need in our daily work.
He does not share in the pessimistic views ex-
pressed b}- some of the journalists present but on
the other hand had much reason to praise our
own journals and criticise those of foreign lands.

Dr. Connor dwelt on the necessity of putting
well-digested materials before the readers, but
warned his hearers against the danger of emascu-
lating good articles by cutting them down.

Dr. Waugh, of Philadelphia, found little in
what had been said during the discussion with
which he could agree. What is ideal reading for
one cannot be ideal for all. As for special jour-
nals, there are not specialists enough to support
them, whereas culled special matter may well
enliven the columns of a general journal.

Dr. Storer, of Newport, found much satisfac-
tion in the thought that the plan which he in-
dorsed eighteen j-ears ago, of founding a weekly
journal as the organ of the American Medical
Association had met with such sreat success.

DOMESTIC CORRESPONDENCE.

LETTER FROM XEAV YORK.

CFROM orR OWN* CORRESPOXDENT.)

The Academy of Medicine; Dr. P. A. Morrow
relates some Personal Observations of Leprosy —
Discussion on the Danger of the spread of Leprosy.

At the last scientific meeting of the Academy
of Medicine for the present season Dr. P. A. Mor-
row gave some interesting personal observations
of leprosy- , recently made in Mexico and the Sand-
wich Islands, with magic lantern illustrations of
typical cases. He said that leprosy was too often
looked upon as posses.sing only a historic interest,
like the plague and other disea.ses of former times.
It would not do, however, to so regard it. Un-
fortunately, it was a living reality, and a map
representing the geographical distribution of the
disease would show that it extended over full}-

1889.]

DOMESTIC CORRESPONDENCE.

31

one-third the surface of the globe. This general
distribution, he believed, had a very important
bearing upon its etiolog}'. It was impossible to
give the exact number of lepers at present in the
world, but in India alone there were certainlj' not
less than 150,000.

The importation of leprosy from a country
where the disease was endemic to one where it
had been previously unknown, he said, could al-
ways be traced to the agency of personal contact.
In our own countrj' the cases of the disease could
be traced to three or four distinct sources. In
Louisiana it had been introduced by the Acadians
when they settled there in 1758. In Iowa, Wis-
consin, Minnesota and Illinois it had been intro-
duced b}^ Scandinavian immigrants ; and in Cali-
fornia and Oregon by the Chinese. He had re-
cently become aware of the hitherto unknown
existence of the disease in Great Salt Lake City,
where it had been brought by natives of the Sand-
wich Islands.

Dr. Morrow's personal obser\'ations began in
New Orleans, where Dr. Blanc reported the ex-
istence of fortv-two cases last year ; these beingf
entirely independent of the lepers of the Teche
River district of Louisiana. In Mexico leprosy
had existed ever since the time of Cortez, who es-
tablished a lazaretto which continued in use until
about thirtj' \-ears ago. Since that time lepers
had been cared for in the general hospitals, and
numbers of these people might be met with in the
streets of Mexico at any time. At San Francisco
he saw quite a number of cases; six of them being
in the pest-house there. The Sandwich Islands,
he thought, offered probably the best field in the
world for the study of leprosy, on account of the
comparatively recent origin and great prevalence
of the disease there. Segregation had been se-
cured by the establishment of an isolated leper
settlement, and there were now more than 11,000
cases at it.

It was only within the last twenty-five years, he
went on to say, that the true character of leprosy
has been ascertained. We now know that it is a
parasitic disease; and the bacillus lepra discovered
b}- Han.sen presents certain analogies to the tuber-
cle bacillus. This is particularly true as regards
its remarkable vital tenacity. Like all specific
microbes, it has an elective affinity for certain
fluids and tissues of the body. As regards the
origin of leprosy, he said it could be stated posi-
tively that the disease never originated spontane-
ously. It does not attach to the soil, water or
food, but is always communicated from an indi-
vidual, and can always be traced to personal con-
tact. Its period of incubation is a long one. This
is variously stated at from three to five years, but
in certain instances seems to be from ten to fifteen
years. It is a verj- difficult matter to arrive at the
exact period of incubation, because there is no
initial lesion, and the prodromal symptoms are

verj' indefinite. The progress of the disease is
slow, but it almost invariably terminates fatally.
There are several moot points in regard to the
disease, and the first of these is as to its conta-
giousness. This has never been at all questioned
until comparatively recent times; but about thirty
years ago it began to be doubted. It is worthy of
note. Dr. Morrow thought, that the leading der-
matologists of New York have never accepted the
heresy of the non-contagiousness of leprosy. The
; history of the disease in the Sandwich Islands af-
forded the most conclusive proof of its contagious-
ness. In no other way could its rapid spread
throughout the race be accounted for; at the pres-
ent day from 5 to 10 per cent, of the native pop-
ulation being lepers. In investigating the disease
one can get a history of personal exposure in al-
most every instance. At the leper settlement
many of the patients are incapacitated from tak-
ing care of themselves, and are obliged to have
relatives or friends to look after them, who are
presumably free from the disease when thej- go
there. It has been observed that a verj- large
number of these attendants after a time contract
the disease ; and it is also a well-known fact that
a considerable number of foreigners living in the
Sandwich Islands have become victims to lepros}-.
As to the modes of infection, our knowledge is
not positive ; but in a large proportion of cases
this is probably by sexual intercourse. It seems
probable that the disease may be contracted
through abrasions of the mucous membrane or
skin, and also by means of animal parasites or
the bites of mosquitoes and other insects. Vac-
cination has undoubtedly been one of the causes
of the spread of leprosy, humanized virus being
used, and no distinction being made between
healthy and unhealthy subjects in procuring the
virus. Inoculation of leprosy has been success-
fully carried out in one instance, the subject being
a condemned criminal. Dr. Morrow said he had
seen one case in which the patient claimed to have
contracted the disease from the bite of a leper,
and another in which the patient stated that it
came from the prick of a pin with which a leprous
boy had amused himself by sticking it into his
body.

Another moot point is that of heredity. For-
merlj- this was regarded as positively established,
and in all ages it has been looked upou as the
principal cause of the disease. In his personal
obser\'ations, however, he said he found no proof
whatever to support the view of heredity. A
predisposition to leprosy might be transmitted, as
in the case of tuberculosis; but he did not believe
that the actual germs were ever so transmitted.
There is not a single case of congenital leprosj'
on record. In instances of suspected heredity the
child never shows evidences of the disease under
the age of 3 years, and usually not until puberty.
In general, the disease develops only in those

32

DOMESTIC CORRESPONDENCE.

[July 6,

from 30 to 50 3-ears old. Leprosy, then, is either
analogous to late syphilis or else it is not trans-
mitted at all to offspring. Observation shows
that the children of lepers do not become infected
unless they are kept in close contact with their
parents. Verj' few living children are born in
the leper settlement. For seven years there were
only two ; and later, of twenty-six infants that
lived, nine presented evidences of the disea.se be-
tween the ages of 3 and 14, while the remainder
escaped infection entirely, It is altogether prob-
able, therefore, that in all ca.ses of suspected hered-
ity the disease is really due to post-natal contagion.

Among the photographic slides thrown upon
the screen was one of the late heroic Father Da-
mien, taken only six weeks before his death, and
also one of the convict upon whom inoculation
■was successfully practiced, the only case on record.
This man, who had been condemned to death,
was fiven his choice between execution and im-
prisonment for life with inoculation with leprosy;
and the inoculation was made by Dr. Arning in
September, 1884. Bacilli were found in numbers
about the inoculated spot until March, 1885, after
which they gradually diminished in number. Eor
several years the result was regarded as negative,
but more recently evidences of infection have de-
veloped, and at the present day there can be no
question of his having well-marked leprosy.

A discussion then followed in regard to the dan-
ger of the spread of leprosy in this country-. It
was opened by Dr. Morrow, who expressed the
opinion that such a danger actually exists, and
said that the disease in its present state here might
be compared to a conflagration, which could easily
be extinguished at first, but which, left to itself
until it had gained a certain headway, could not
be subdued until all the material it had to feed
upon had become exhausted In the Sandwich
Islands in 1848 there were but few cases of lep-
rosy, and for twenty years the Government paid
no attention to the disease. By that time there
were about 250 cases, and the authorities, becom-
ing alarmed, took stringent measures for its sup-
pression. A .s.vstem of .segregation was adopted,
but, unfortunately, the danger was appreciated
too late. He did not believe that such a fate as
that of the Sandwich Islands was in store for the
United States ; but, at the same time, he thought
there was a sufficiency of leprous seed here to
stock this or any other country. The only ques-
tion was, whether the soil was favorable for the
development of the disease. Any one who be-
lieved in the contagiousness of leprosy, must as-
sume either that a great danger menaces us, or
else that the conditions of our civilization are not
favorable for the spread of leprosy.

He went on to say that, in his opinion, the
danger was not such as seriously menaced the
public health, as the disease would spread very
slowly, if at all. At the same time it should be

borne in mind that lepros\- is a disease in which
the resources of medical science are futile, and
measures should therefore be taken to stamp it
out. It is probable that there are more cases in
this country' now than ever before. The report
of forty-two cases in New Orleans last j'ear was a
surprise to every one, and the proprietj- of legis-
lative enactment for the suppression of the disease
is unquestionable.

Dr. C. W. Allen said that his convictions on
this subject were very decided. Two years ago,
in a paper read before the Medical Society of the
County of New York, he had contended that lep-
ers should not be admitted to this country, and
that those already here should be segregated.
Two years ago he had placed the number of cases
in the United States. This number, he had reason
to believe, was too small at that time, and he
thought there could be no doubt that there had
been a considerable increase since then. When
we considered the number of cases alreadj- exist-
ing, and the increased likelihood of the spread of
the disease from the increasing facilities of modern
travel, etc., this question became one that we
could no longer shut our eyes to. Of the forty-
two cases reported in New Orleans, where no lep-
rosy was supposed to exist, twenty-nine were
natives of Louisiana, and twentj'-two of the city
of New Orleans. One of these had been a
nurse in a hospital where a leper was under treat-
! ment. The evidences of the contagiousness of
the disease were positive, and as long as a single
leper existed anywhere he would constitute a
source of danger to those about him.
' Dr. L. D. Bulkley said he regarded this subject
] as one of the most important ever brought before
the Academy. No one could fail to see, he
thought, that whenever leprosy has been allowed
free scope it has spread; while, on the other hand.
'. whenever proper measures have been taken in
i time against its spread, it has been exterminated.
[ There seemed to him a propriety in having the
I matter agitated, and he thought the least the
i health authorities could do would be to ascertain
the number and condition of the lepers now in
this countn,-. For the last twenty years he had
seen two or three cases every year in New York.
! One case he had met with in a patient who had
never traveled many miles from Poughkeepsie,
! where he lived, and another in one who had never
! been far from New York. Precisely how they
contracted the disease he did not know, but there
! could be no question that they had derived it from
! antecedent cases. Leprosy always came from lep-
rosy. He differed from Dr. Morrow, however, in
the opinion that the bacillus leprae does not exist
in the soil, water, etc., and believed that it may
be left there like other germs. In concluding he
said he thought it would be well to appoint a
I committee to report on the question under discus-
1 sion at some future time.

1889.]

DOMESTIC CORRESPONDENCE.

33

Dr. George H. Fox said that the exciting of I
alarm seemed to him objectionable on account of
the false assumption that there has been a spread
of leprosy in this country-. The cases met with
here were nearlj' all imported, and in spite of the
fact that there was no law prohibiting the en-
trance of lepers, and that no segregation was prac-
ticed, he believed that the number at present was
smaller than at former periods. Some of the cases
former!}' here had died, and others had left the
country. He also knew of one case at least in
which the patient considered himself cured ; no
signs of the disease having appeared for six years.
He admitted that there was a slight danger from
the lepers still remaining ; but so there was, he
said, from hydrophobia. As a rule, the whites
of the Sandwich Islands were free from leprosy ;
and he had yet to learn of an instance of the
spread of the disease in a white civilized countrj-.
Its prevalence among the Hawaians, he believed,
was in great part attributable to their uncleanly
habits and mode of living. The danger was of
course greater, the greater the number of lepers ;
but it was very rare for nurses, sisters of charity
and others in constant attendance upon leprous
patients to contract the disease. All lepers, he
thought, should be prevented from landing here,
as the paupers were, not so much from the likeli-
hood of their spreading the disease as because,
like paupers, they would be a burden on the com-
munity. The popular dread of this disease was
unfounded and absurd, and even physicians shud-
dered at the name of leprosy while they looked ;
with complacency upon syphilis and tuberculosis.

Dr. H. G. Piffard said that ten years ago he
had read a paper before the Academy' in which he
discussed the question now raised, and since then
his views had not altered. The points for which
he contended at that time were, first, that leprosy
is contagious ; second, that lepers should be seg-
regated ; third, that it is the inunction of the Na-
tional Government to attend to this. At this
meeting a committee was appointed from the
Academy to investigate the subject of lepro.sy in
this country, and the committee performed the
work required of it so far as it was possible to do
so. It did not succeed, however, in tracing out
more than forty or fifty cases in the United States; ]
many cases, no doubt, escaping obser\'ation. '

It was his opinion that, at the present time,
there were at least five times as many lepers in
the country as there were ten years ago. That
segregation was necessary was .shown by the fact
that wherever this has not been carried out the
disease has increased, not in arithmetical, but in
geometrical progression. To the question, whose
charge is it to attend to this segregation ? he
would answer, the National Government's. The
Government should, in the first place, prevent the
entrance of all lepers into the countrj' ; and sec-
ondly, induce, as far as possible, all lepers now

here to go to properly appointed lazarettos. It
should be the dutj- of each State to place its own
lepers in these lazarettos. Whether the present
discussion could have any practical effect he
thought was very doubtful. Not until the neces-
sity of taking active measures to prevent the
spread of leprosy forced itself upon public atten-
tion would anything be done ; but that time, he
believed, would surely come sooner or later.

Dr. F. R. Sturgis said he believed that Dr.
Morrow was right in stating that there was no
immediate danger to the public health from this
source, but that it was undoubtedly the duty of
the medical profession to call attention to the
matter. Up to the present time the evidence of
direct inoculation with leprosy had been lacking ;
but the case of the criminal referred to really
seemed to show the possibility of inoculation, and
further confirm the contagiousness of the disease.
It was probable that leprosy followed a course
similar to that of syphilis ; being more conta-
gious than in its later stages. As to the bacillus
mentioned, he did not think it has as yet been
proved to be the cause of the disease, anj- more
than was the case in regard to the so-called bacil-
lus of syphilis. ■ Dr. Fox depended on negative
evidence for the position which he assumed ; but
one positive case was of greater value than all
such negative evidence. In our crowded and
filthy lodging-houses he believed there existed
all the conditions favorable to the development of
leprosy if the contagium was once introduced.
As to the comparative risk from leprosy and syph-
ilis, he said he would rather run his chances with
the latter, as there was, so far as he knew, no cure
for leprosy. Syphilis might be ten times more
contagious than leprosy, but leprosy was ten
times as dangerous.

In closing the discussion Dr. Morrow said there
seemed to him but little doubt that the leprosy in
the case of the criminal mentioned was positively
caused by the inoculation. This was made in
1884, and the four years that elapsed before lep-
rosy made its appearance corresponded entirely
with the ordinary incubation period of the disease.
It was an important fact, he thought, that the
spread of lepro.sy in the Sandwich Islands had
occurred under conditions of high civilization: the
state of the population being greatly superior to
what it was fifty years before. Dr. Fox labored
under a misapprehension in regard to the people
there, who were in reality infinitely better off than
the majority of the poorer classes in this country.
They were accustomed to bathe four or five times
a day, and were otherwise cleanly in their habits.
Yet, notwithstanding their improved condition,
the scourge of lepros}- had attained the most fear-
ful proportions among them.

In regard to the contagiousness of the disea.se,
there was one point which offered a possible ex-
planation of the difference of opinion which had

34

MISCELLANY.

[July 6,

existed concerning it. He thought it extremely
doubtful whether the anaesthetic type of leprosy
was capable of transmitting the disease. It was
this form, rather than the tubercular, which pre-
dominated in India and Mexico to-day, and in
this the bacilli were not found in the external le-
sions. To his mind the evidences of contagious-
ness abounded and superabounded. He did not
wish to be considered an alarmist, but in regard
to this disease he believed that a wholesome dread
was better than a false security. By the adoption
of active measures he thought it could be stamped
out absolutely. At the conclusion of his remarks
Dr. Morrow exhibited under the microscope spec-
imens of the bacillus lepras which had retained
their vitality for a very long period. p. b. p.

NECROLOGY.

Dr. F. H. Reliwinkle.

We regret to announce the death of Dr. F. H.
Rehwinkle, of Chillicothe, O., who succumbed on
the yth ult. from the effects of a stroke of paraly-
sis. The stroke came to the doctor as it always
comes, suddenly, and without a moment's warn-
ing— if one overlook the haggard and broken-
down condition which had been apparent in Dr.
Rehwinkle for the past year. He had gone across
the street after supper, and consenting to take a
drive with Dr. Scearce, had gotten into the buggj'
and sat there talking and laughing with the doc-
tor's daughter, Miss Lizzie, awaiting the doctor's
readiness. When Dr. Scearce got into the buggy
and took the lines, and Dr. Rehwinkle bade Miss
Lizzie good evening, there was no indication
whatever of the terrible affliction that was about
to befall him ; but the horse had not taken
twentj' steps when, in the reply to a question
that Dr. Scearce put to his companion, he ob-
served that something was wrong. Obser\'ing
him more closely when they reached a point near
the postoflBce, he remarked, ' ' Doctor, you are
sick ! ' ' and immediately turning around drove
back to Dr. Rehwinkel's house, less than a hun-
dred yards distant, but with the wreck of the
alert, intelligent and sentient human being who
had left there but a moment before. With assist-
ance he was carried into the house, and to his
room, where an examination of the patient
showed that there was complete paralysis of the
left side. He aftem'ards sank into a half coma-
tose condition, though able to recognize his rela-
tives and friends, and in that condition had re-
mained up to the time of his death.

The most intimate friends of Dr. Rehwinkle
have known for some time past that he feared
what has now happened. It was only a short time
ago that he remarked in casual conversation with

a party of friends, " I believe that I will die of
paralysis ; and I fear at times that the stroke has
been hanging over me for months, and that it
may fall at any moment." All his friends had no-
ticed how terribly he had aged within the past
year ; how worn and haggard he had looked ; and
it has been a source of frequent, sympathetic and
regretful comment among them. He had com-
plained for some time of an unpleasant sensation
in the neighborhood of the heart, and this, and
the fancied symptoms of paralysis have been such
as to prevent him from venturing from home any
distance.

Dr. Rehwinkle has been regarded as a dental
surgeon of extraordinary science and skill ; few
or no surgeons in the state ranking higher than
he in his chosen profession. To him was accord-
ed the compliment of appointment as one of the
three American Secretaries to the International
Congress of Dental Surgeons, which assembled at
Washington D. C, in 18S7 ; and upon him fell
a large proportion of the work of preparation for
that meeting.

Dr. Rehwinkle was a member of the American
Medical Association, and Chairman of the Section
on Dental and Oral Surgerj-.

MISCELLANY.

The 75,000 Edition. — The Chicago Medical Journal
and Examiner says:

The business manager of The Journ.^i, of the Associ-
ation has issued an extra edition of seventy-five thousand
copies of The JouRN.\L, "which contains a carefully •pre-
pared report of the requirements of the various medical
colleges of the United States and Canada, compiled by
Dr. W. G. Eggleston, formerly assistant editor of The

JOURNAI,.

The additional work involved in issuing this large edi-
tion has been considerable, and it is to be hoped that it
will be the means of advancing the interests of the .■\sso-
ciation and of its official organ, and thus reward the busi-
ness manager for his faithful efforts to serve both.

Medical Society Notes. — The semi-annual meetiiag
of the Sledical Society of Fulton County, N.Y., was held
at Gloversville on the iSth ult. " Jlodern Treatment of
Wounds" was the subject of a paper read by Dr. F.
Drurv, of Broadalbin, Dr. W. C. Wood read a paper on
'■ Lazv Therapeutics. " Miss M. Helen Cullings was ad-
mitted to member.ship.

.\t the annual meeting of the Rochester Pathological
Society, held recently, the following were elected officers
for the ensuing year : President, Dr. Henjamin Wilson ;
Vice-President, Dr. E. T. Dow ; Secretary-, Dr. Ogden
Backus. Dr. E. W. JIulligan, the retiring President,
read a paper on " Microscopy in Medicine."

He.\i,TH in Michigan, JIav, 1SS9. — For the month
of Mav, 1SS9, compared with the preceding month, the
reports indicate that diarrlnea and inflammation of ki<l-
ney increased, and that influenza, remittent fever, pneu-
monia, ervsipelas and pleuritis decreased in prevalence.

Compared with the preceding month, the temperature
in the month of May, 1SS9. was higher, the absolute hu-
midity was more, the relative humidity and the day and
the night ozone were less.

1889.]

MISCELLANY.

35

Compared with the average for the month of May iu
the three years, 1SS6-S8, tonsillitis increased, and measles,
consumption of lungs, erysipelas and remittent fever were
less prevalent in May, 1889.

For the month of May, 1S89. compared with the
average of corresponding months in the three years 1886-
'88, the temperature was slightly lower, the absolute and
the relative humidity were slightly less, and the day and
the night ozone were about the same.

Including reports b\' regular observers and others, diph-
theria was reported present in Michigan in the month of
May, 1889, at 22 places, scarlet fever at 48 places, ty-
phoid fever at 10 places, measles at 23 places, and small-
pox at 2 places.

Reports from all sources show diphtheria reported at
I place less, scarlet fever at 5 places more, typhoid fever
at 5 places more, measles at 9 places more, and small-pox
at : place more in the month of May, 1889, than in the
preceding mouth.

Thirty-one Years a University Professor. — The
resignation of Dr. T. G. Richardson from the faculty of
the Tulane University, brought forth the following ex-
pression from his fellow-members of the faculty;

Medical Department,
Tulane University of Louisiana,
New Orleans, May 20, 1889.

Whereas, Prof. T. G. Richardson, who has served the
medical department thirty-one years — fourteen years as
Professor of Anatomy and seventeen as Professor of Sur-
gery', including twenty years as Dean — has urged the ac-
ceptance of his own resignation because of ill-health;
therefore be it

Resolved, That Prof Richardson's resignation is ac-
cepted with the utmost regret, this faculty being thereby
deprived of its most valued member and its wisest coun-
selor.

Resolved, That the members of this faculty can never
forget that his inflexible devotion to truth, honor and
duty furnished for their guidance the highest and noblest
standard of true manhood; that his ability and experi-
ence as a teacher placed him in the foremost rank of
medical instructors; that his wisdom as Dean successfull)'
guided the destiny of the medical department through
many years of its severest trial; and that to him, more
than to any other, is due its present prosperity.

Resolved, That while deeplj' deploring the necessity that
withdraws from active service our senior professor, vet our
hearts are revived by the hope that time and rest will re-
store him to health and give to him many happy and use-
ful years wherewith to bless his family and his friends
and to benefit all of his fellow-citizens.

Resolved, That Dr. T. G. Richardson is hereby chosen
Emeritus Professor of Surgery.

Si.gned by Stanford E. ChafUe. M.D., Dean; Ernest S.
Lewis, M.D., Jno. B. Elliott, M.D., committee in behalf
of a unanimous facult}'.

Summer DiarrhcEa. — The Medical Record says : The
period has come when the well-to-do minority of physi-
cians leaves the city, while the hard-working majority
stays in town and writes articles on summer diarrhoea
and related topics. Fortunately, something new is fur-
nished us every year on these matters. We have passed
from the stage of heat and sour milk as causative factors
of summer diarrhiea ; we are even leaving the microbe a
little behind, and are dallying now with the ptomaines.
The latest theory is one set forth by Dr. Ballard, in a re-
port to the Local Government Board of England on the
causation of the annual mortality from diarrhnea {Lancets.
Dr. Ballard states his views as follows : " That the essen-
tial cause of diarrhoea resides ordinarily in the superficial
layers of the earth, where it is intimately associated with
the life processes of some microorganism not yet de-
tected, captured, or isolated. That the vital manifesta

tions of such organism are dependent, among other
things, perhaps principalU', upon conditions of season,
aud on the presence of dead organic matter, which is its
pabulum. That, on occasion, such microorganism is
capable of getting abroad from its primary habitat, the
earth, and having become air-borne, obtains opportunity
for fastening on non-living organic material, both as
nidus and as pabulum, in undergoing various phases of
its life history. That in food, inside of, as well as outside
of the human body, such microorganism finds, especially
at certain seasons, nidus and pabulum convenient for its
development, multiplication, or evolution. That from
food, as also from the contained organic matter of par-
ticular soils, such microorganism can manufacture, by
the chemical changes wrought therein through certain of
its life processes, a substance which is a virulent chemi-
cal poison ; and that this chemical substance is in the
human bodj' the material cause of epidemic diarrha;a."

A Souvenir. — The Lambert Pharmacal Co., of St.
Louis, distributed at the Newport meeting a verj- hand-
some little souvenir containing a list of the oificers of the
Association, programme of the general sessions, list of
Presidents of the Association from 1846 to 1889, and a
number of views of Newport.

J Training Schools for Nurses. — The seventh annual
graduating exercises of the Illinois Training School was
held at the County Hospital, Chicago, on the 25th ult.
Addresses were made by Dr. J. S. Knox, Charles L.
Hutchinson, President Brand, of the County Hospital
medical staff, Franklin H. Head, Dr. Julia Holmes Smith,

I Dr. Sarah Hackett Stevenson, and Mrs. C. B. Lawrence.
Diplomas were presented by Dr. Johnson to the following

'graduates; Abbie Brotherton, Mary L. Grott, Orissa
Stanton, Lillian E. Beckley, Emma Baumbach, Ida F.
Towers, Nora Morgan, Lizzie Glennie, Sara Krueger,
Cora Overholt, Mary H. Porter, Lizzie M. Graham, May
Bixby. Salome Beardsley, Hattie Sigsbee, Ellen Strandt,
Carrie Keeler, Mary M. Roburn, Mattie Hirth. Dora Sta-
ger, Mary D. Sexton, Flora A. Reid. Anna Nicholes,
Edna Goble. Laura Happerly, Idora Rose, Lillian Gil-
more, Carrie Leoner, Nora Vase3% Emily Vasey, Emily
J. Keisz, Ella Harth, Joanna Kellogg, Victoria King.

The Commencement Exercises of the Memphis, Tenn.,
Training School for Nurses was held in that city on the
23d ult. There were four graduates ; Misses Effie Ingham,
Hattie Duulop, Lena C. Angevin, and Tillie J. Aiken.

Diphtheria and the Saloon Business. — The Pater-
son, N. J., Board of Health has distinguished itself by a
recent decision. It is to the effect that where the placing
of a green card on a house to indicate the presence of
diphtheria on the premises would interfere with the busi-
; ness of a saloon-keeper, the card may be placed on the
back door, where the general public may not see it !

PAMPHLETS RECEIVED.

Transactions of the Medical Society of the State of
New York, 1889.

Uterine Massage. By W. B. Sprague, M.D., Detroit,
Mich. (Reprint.)

Observations in Clinical Therapeutics. By J. A. Robi-
son, M.D., Chicago. ^Reprint.')

Annual Report of the Esses County Asylum for the
Insane, Newark, N. J. 1SS9.

Eighth Annual Announcement of the Woman's Medi-
cal College of Baltimore. 1889.

The Climate of Southwestern Texas and its Advan-
tages as a Health Resort. By M. K. Taylor, Major and
Surgeon, U. S. Army, retired. (Reprint.)

Puerperal Hvsterectomy or Porro's Operation. By
Edwin Ricketts', M.D., Ciiicinnati. (Reprint.)

The Radical Cure of Hernia. By Thos. W. Kay, Scran-
ton, Pa. (Reprint. I

36

MISCELLANY.

[July 6, 1889.

Ninth Annual Report of the State Board of Health of
Illinois.

Second Biennial Report of the North Carolina Board of
Health.

Sixth Report of the State Committee on Lunacy of the
Commonwealth of Penns_vlvania.

Proceedings of the Florida Medical Association. iSSg.

Annual Address of the President of the Philadelphia
Obstetrical Society. By Prof. Theophilus Parvin, M.D.
(Reprint.)

Electric Cataphoresis as a Therapeutic Measure. By
Frederick Peterson, M.D., New York, i Reprint. )

Yellow Fever. Bv Frank H. Caldwell, M.D., Sanford,
Fla.

So-called Varicocele in the Female. By Henrv C. Coe,
M.D., M.R.C.S., New York. ^Reprint.)

Fees in Hospitals. By Henry J. Bigelow.

Twenty-eighth .Annual Report of the Cincinnati Hos-
pital. I'SSg.

The Question of Relationship between Lichen Planus
(Wilson) and Lichen Ruber (Hebra). Bv A. R. Robinson,
M.B., L.R.C.P. (Reprint.)

The Rational Method of Preventing Yellow Fever on
the South Atlantic Coast. By J. C. LeHardy, M.D., Sa-
vannah, Ga. I Reprint.)

A Clinical Study on Alopecia Areata and its Treat-
ment. By L. Duncan Bulklev, A.M., M.D., New York.
(Reprint. )

Scarlatinous Otitis. By Charles H. Mav, M.D., New-
York. (Reprint.)

Hygiene versus Surgery in Gynecology. By Julia W.
Carpenter, M.D., Cincinnati, O. (Reprint.)

Warner's Therapeutic Reference Book. Bv Wm. R.
Warner, Philadelphia.

Proceedings of the Quarantine Conference held in
Montgomery, Ala., March 5-7, iSSg.

LETTERS RECEIVED.

Dr. John Marsh, Madisouville, O. ; Dr. R. J. Dungli-
son, Philadelphia; Dr. C. F. Shattuck, Boston; O. T. Phy-
thian, Cincinnati; Dr, St. V. Martinitz, Cedar Rapids,
la.; Medical Herald Co., St. Joseph, Mo.; Dr. Frank P.
Peck, Mount Pleasant, la., Allen H. Still, J. H. Bates,
New York; Dr. Geo. C. Webber, Millbury, Mass.; Dr. J.
L. Hilmantel, Milwaukee; Dr. Chas. C. Browning, Adri-
an, 111.; Johnson Eliot, Washington; Battle & Co., St.
Louis; R. L. Watkins, Prospect, O.; G. H. Whitcomb,
Greenwich, N. Y.; Medical PressCo., Philadelphia; Reed
& Carnrick, New York; Dr. W. H. Dunlop, Syracuse, N.
Y. ; Woman's Medical College of New York; Dr. H. O.
Walker, Detroit; Jas. I. Fellows, New York; Dr. W. H.
•Geddings, Aiken, S. C; Ward Bros., Jacksonville, 111.;
Dr. John G. Ames, Marblehead, Mass.; Miner & Elbreg,
Indianapolis; Dr. N. Senn, Milwaukee, Wis.; G. E. Ste-
chert. New York; Dr. John H. Chew, Chicago; R. C.
Flack, Bound Brook, N. J.; George Chaffee, Wa"rren Cen-
tre, Pa. ; Dr. W. W. Skinner, Lutz & Movius, Lehn &
Fnik, New York; Dr. Isaac Kav, Springfield, O.; Dr.
James Tyson, Philadelphia; Dr. C. R. Henderson, Yazoo
City, Miss,; Dr. C. Wilbur, National Militarv Home, O.;
Dr. P. H. Porter, New York; Dr. Florentine', East Sagi-
naw, Mich.; J. H. Chambers & Co., St. Louis; Dr. D. S.
■Campbell, Detroit; Dr. J. B. Murdoch, Pittsburgh; .Amer-
ican S: Continental Saiiitas Co.. New York; Dr. James
Tyson, Phila<lelphia; Nichols & Shepard, Three Rivers,
Mich.; Dr. J. T. Wilson, Sherman, Tex.; Dr. J. Chris.
Lange, Pittsburgh; Dr. Wm. G. Parrish, Burlington. N.
J.; Samuel G. Sloane, Chicago; Dr. G. W. Stockwell
Knoxville, Mo.; Lambert Pharmacal Co., St. Louis; Dr.
Thos. H. Manley, New York; Dr. C. W. Stevens, Charles-
town, Mass.; Cincinnati Polvclinic; Dr. E. S. King Sweet
Home, N. C; F. A. Davis, Philadelphia; Dr. J. A! South-
ard, Fort Smith, Ark.; Dr. J. R. Briggs, Dallas, Tex • Dr
Geo. P. Lee, Merced, Cal.; Thos. F. Goode, Buffalo Lithia
Springs, Va.

Official List of Changes in the Stations and Duties of
Officers Serving in the Medicat Department, U. S.
Army, from fune /j, iSSg, tofune2i. iSSg.

By direction of the acting Secretary of War, the following
changes in the stations of officers of the Medical De-
partment are ordered:

Major Albert HartsufF, Surgeon, is relieved from dutv at
Ft. Hamilton, N. Y. , and ordered to Ft. Omaha, N^eb.

Major J. M. Brown, Surgeon, relieved from dutv at Ft.
Omaha, Neb., and ordered to Ft. Meade, Dakota.

Capt. W. C. Shannon, Asst. Surgeon, relieved from Ft.
Meade, Dak., and ordered to Ft. Yates, Dak.

First Lieut. Francis J. Ives. .Asst. Surgeon, relieved from
dutv at Ft. D. A. Russell, Wvo., and ordered to Ft. L)'-
on,'Col.

Capt. J. F. Philips, Asst. Surgeon, relieved from duty at
Ft. Lyon, Col., and ordered to Ft. Crawford, Col.

First Lieut. Walter D. McCaw, Asst. Surgeon, relieved
from dutv at Ft. Crawford, Col., and ordered to Ft.
McPherson, Atlanta, Ga. Par. 9, S. O. 136, A. G. O.,
Washington, D. C, June 13, 1SS9.

Capt. Robert J. Gibson, Asst. Surgeon U. S. A. (Ft. Ti-um-
bull. Conn. 1, is designated as medical officer for the en-
campment at Fisher's Island, N. Y., and he will pro-
ceed to Fisher's Island, N. Y., August i, 1SS9, and re-
port to the commanding otBcer for duty at that post.
Par. 5, S. O. 133, Hdqrs. Div. of the Atlantic, June 13,
1S89.

Capt. Walter W. R. Fisher, Asst. Surgeon, leave of ab-
sence for one month granted by S. O. 30, c. s., Dept.
of California, and extended fifteen days by par. 3, S. O.
37 c. s., from these hdqrs., is further extended fifteen
days. Par. i. S. O. 41, Hdqrs. Div. of the Pacific, San
Francisco, Cal., June 12, 1S89.

By direction of the acting Secretary of War, the follow-
ing changes in the stations of oflScers of the Medical
Dept. are ordered:

First Lieut. Benj. L. Ten Eyck, Asst. Surgeon (recently
appointed), ordered to Ft. Leavenworth, .Kan.

Capt. Jno. de B. W. Gardiner, Asst. Surgeon, relieved
from duty at Ft. Leavenworth, Kan., and ordered to
Ft. Reno, Ind. Ter. ■

Par. 3, S. O. 132, A. G. C, June S, 1889, is amended so as
to direct First Lieut. P. G. Wales, Asst. Surgeon, to re-
port to Ft. Huachuca, Ariz., for duty in place of Presi-
dio of San Francisco, Cal.

Capt. JI. C. Wjeth, Asst. Surgeon, relieved from duty at
Ft. Huachuca, Ariz., and ordered to Ft. McDowell,
Ariz.

First Lieut. Leonard Wood, Asst. Surgeon, relieved from
duty at Ft, McDowell, Ariz., and ordered to Presidio
of San Francisco, Cal. Par. 2, S. O. 138, A. G. O.,
June 15, 1S89.

First Lieut. Henry S. T. Harris, Asst. Surgeon, granted
leave of absence for two months, by direction of the
acting Secretary of War. Par. 13, S. O. 140, A. G. 0.,
June 18, 18S9.

EXTR.\CT.

By direction of the acting Secretary of War. the follow-
ing changes in the stations of the Medical Department
are ordered:

First Lieut. Benjamin L. Ten Eyck, .Asst. Surgeon (re-
cently appointed), will proceed from New York City to
Ft. Leavenworth, Kan., and report for duty to the
commanding officer of that post. Par. 2, S. O. 138, A.
G. 0., Washington, D. C, June 15, 1889.

Official List of Chatiges in the Medical Corps of the U. S.

Navy for the Week Ending fune 22, iSSg.
Medical Inspector Grove S. Beardsley, granted a year's

leave of absence, with permission to leave the United

States.
Surgeon N. M. Ferebee, detached from special duty at

Naval Academy, ami wait orders.
Asst. Surgeon George Rothganger, ordered to the Naval

Hospital at Mare Island, Cal.

THE

J ournal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.

PUBLISHED WEEKLY.

Vol. XIII.

CHICAGO, JULY 13, 1889.

No. 2.

ADDRESSES.

SURGICAL INTERFERENCE IN FRAC-
TURES OF THE SPINE.

Delivered in the Section on Surgery and Anatomy at the Fortieth An-
nual Meeting of the A merican Medieal Association, June 2S< iS8g.

BY X. P. DAXDRIDGE. M.D.,

OF CIXCINNATI, O., CHAIRMAN" OF THE SECTION.

Mj- first duty is to express my appreciation of
the honor I have received in being selected to
preside over the meetings of this Section. This
honor brings with it, however, the embarassing
conviction that I lack many of the qualifications
necessarj- and essential for properlj- carrj-ing out
the work for which I have been chosen. The
ready co-operation that I have received in the
effort to organize the work of the Section, and the
great interest manifested in its success on all
sides have contributed to make the experience of
the past months among the pleasantest of my
life, and I only trust that in looking back upon
the completion of our meeting you may all be
able to regard it with equal satisfaction. When
I consider the characters of the papers j-ou will
listen to, and remember the prominence of their
authors, and the large amount of learning and
varied experience they represent, I may be ex-
cused for much misgiving as to my own abilitj' to
contribute anything which will be at all worthy
of your consideration, and which will not suffer
by comparison with the contribution of those
whose opportunities have been so much wider
than m3' own. Indeed, if I succeed in exciting
your interest, and holding your attention, I fear
it will be more from the importance of the subject
itself rather than from anything of value I maj'
be able to offer either in the way of original
thought or in summing up the recorded work of
others.

I have selected for my topic " Surgical Inter-
ference in Fractures of the Spine," and have been
led to its selection partly by the fact that an un-
usual number of these injuries have fallen under
my care during the last year, and will thus en-
able me from recent experience to present many
of the salient features of the subject, and also
largely from the fact that the recent achievements
of Horsley, Macewen, Abbe, and others in this

field have opened up new avenues of progress,
and have rendered it necessarj- to recast and re-
vise conchisions which seem fixed on definite and
legitimate foundations. Fresh impetus has
certainh- been given to active operati\'e interfer-
ence in all forms of spinal injur}- and disease,
and while it is certainly true that the result ot
these new surgical triumphs must necessarily and
properly enlarge our therapeutic resources in
these most trj'ing cases, it is also equally certain
that without due regard for the recorded experi-
ence of the past we are likeh- to retard true pro-
gress by rash and unreasonable interference.

Indeed, if I mistake not, the indications are al-
ready apparent that operations upon the spinal
canal will soon become popularized, and this one
of the last of the great cavities of the bod\^ to be
interfered with will become in the near future
the frequent scene of either surgical success or
failure. It is for this reason that I feel the time
is opportune for a fresh discussion of the ques-
tions involved in determining the how, and the
when, of surgical interference in fractures of the
spine. In speaking of fracture it is to be under-
stood that I make no sharp distinction between
fracture and dislocation, but consider alike all
forms of injury to the column resulting in more
or less damage to the cord. Any conclusions
which may be reached at this day must necessarily
be provisional, for the date is not yet at hand by
which we can definiteh^ settle many of the points
involved. I shall confine myself in this discus-
sion to the question of active interference in
fracture, but as the fresh impetus which has been
given to work in this subject dates back to the
successful removal of a spinal tumor bj- Horsley,
and the operations for pressure s}'mptoms in cases
of Pott's disease by Macewen, it maj' be well to
consider briefly how far these cases are analogous,
and how far the deduction from one class can be
safely applied to the other. In Horslej-'s case
there was present all the symptoms of an ad-
vanced transverse lesion of the cord by which all
power of conduction was abolished. This con-
dition was due to a tumor which had produced
an indentation, or depression, which penetrated
almost through one lateral half of the cord. It
should be recalled that this condition of the cord
was due to a slowly increasing pressure- — a

38

FRACTURES OF THE SPINE.

[July 13,

pressure which could not suddenly destroy the
conducting tracks. The removal of this tumor
was followed by a complete restoration of all the
functions which had been lost.

In considering the question of operation for
tumor, it must be remembered that removal is our
-only resource, and that we have no other method
of treatment which promises any benefit what-
ever. In cases of Pott's disease the conditions in
many respects are much the same, though they
•differ in some essentials. The narrowing of the
canal by which pressure is made on the cord is
not often due to simple changes in the bony [
walls, or to the acuteness of the angle caused by
the curvature. It is generally due to the thick-
ening of the membranes, the development ot \
^anulation tissue between the bones and dura, |
or to the accumulation of pus or other inflamma-
tory products. [

As a result of haemorrhage or the penetration ;
of the canal by an abscess pressure symptoms j
may be suddenly developed. But in all these
cases the compressing body is of such a nature
that the elements of the cord are not divided, but
theirvitality is slowly or suddenly compromised by
interference with nutrition or by secondary degen-
eration. The resulting condition may be ex-
actly the same as in the case of tumor or fracture
— paralysis below the point of pressure more or
less complete — exaggeration or loss of reflexes —
retention or incontinence of urine and fseces,
and the ready occurrence of bed sores and other
trophic changes ; but while the symptoms pres-
ent may be exactly the same as in the case of
tumor and due to a compressing body, the ques-
tion of treatment is one which occupies an en-
tirely different position. In the case of tumor
•without operation we are entirely powerless — in
Pott's disease it is otherwise, for it is a matter of
■daily experience that the most serious and threat-
ening symptoms may disappear spontaneously.
■Sensation and motion are both often rapidly re-
covered after the application of the plaster jacket,
or following the administration of the iodide ot
potash. But in certain of these cases the organi-
zation of the inflammatory products, and the
thickening of ti.ssue reaches such a degree that
they may be fairly compared to a tumor growth
and quite beyond the reach of removal except by
the knife. Charcot has demonstrated that this
condition is most apt to occur opposite the point
of greatest curvature in the spinal canal. In
such cases Macewen has first shown that operative
interference may be followed by most brilliant re-
■sults where the conditions are apparently helpless,
and where continued treatment of various kinds
has been entirely williout success.

In the second ca.se he reports after removal of
the lamina he found a connective tissue tumor so
clo.sely adherent to the dura that a part of that
membrane was removed with it. The cord was

compressed to one-half its normal size, but on
removal of pressure began to pulsate, and within
a few hours there was notable improvement in
the warmth and lividity of the limbs. This pa-
tient regained entire use of the limbs after the
existence of paralysis lasting over eight months.
It will be of interest in this connection to ex-
amine the results obtained in cases of resection
already reported. Ten cases are available for
this purpose. Unfortunately many of the cases
are so imperfectly- recorded that their value
is greatly diminished. Certain positive facts of
value can, however, be determined. Mr. Horsley
in a recent letter reports restoration of power
after complete paralysis for six or seven years.
In Macewen's first case paraplegia of two years'
standing with bed sores and incontinence was en-
tirely relieved by the removal of the arches of the
fifth, sixth and seventh dorsal vertebrae. These
cases have an important bearing on the subject
we are discussing, and are in themselves a partial
answer to the argument advanced for early oper-
ation— that delay will necessarily compromise all
chances of success. They certainly show that the
cord after long continued compression, severe
enough to abolish all conducting power may, by
relief of pressure, again recover its functions.
Trephining the spinal column in Pott's disease
does not seem to be a very serious operation.
Out of the ten cases one died in twenty- four
hours, one in a week, and one of general tubercu-
losis in seven months. It certainly promises a
field of usefulness in properly selected cases, and
will, I believe, rescue some where all other means
would prove unavailing. The danger is that
manj^ patients will be subjected to the trephine in
whom slower and less brilliant forms of treatment
would produce better results with less danger of
disastrous con.sequences. In this connection it is
a matter of interest and importance to determine
after what length of time we must give up all
hope of the disappearance of paraplegia in Pott's
disease. I desire to place on record a case bear-
ing on this point, in which after complete para-
plegia for more than three years and a half vol-
untary power returned, and six months later the
child was able to walk with a slight support.
This child, now 7 years old, has been under con-

; tinuous obser\-ation for over four years at the Chil-
dren's Hospital, Ciuciiuia-ti, with marked curva-
ture in the upper dorsal region. On admission
there was complete loss of power in both lower ex-
tremities, but neither incontinence nor bed-sores.
This condition continued without improvement
until six months ago when motion began to ap-
pear at first in the thigh nuiscles, and now he is
able to stand, and with slight aid to walk. The
improvement has been continuous and complete
restoration seems probable. For nearly two
years the treatment has been a little more than

I proper nourishment and good hygienic surround-

1889.]

FRACTURES OF THE SPINE.

39

ings. The case has made a deep impression on
my mind as showing the power of recuperation
possessed by the cord.

Let us now consider how far the lesions present
in fractures are similar to those we have just been
considering. In fractures of the bodies of the
vertebrae with displacement the anteroposterior
diameter of the canal ma}- be narrowed in any i
degree up to complete obliteration, and the cord
may be injured in any degree up to a complete
division — the membranes being either contused J
and lacerated, or entirely uninjured. It is stated
by Hutchinson that direct compression of the
cord by displaced bone is not often seen at the
autopsy in these cases. This is due to the fact ^
that the greatest amount of displacement is mo-
mentary, and that correction is effected in the
subsequent removal and handling of the patient.
In fractures involving the lamina the bone may
or may not be depressed sufficiently to make
pressure on the cord. Extra or intradural ex-
travasation of blood, or hsemorrhage into the
cord itself may occur as the immediate result of'
injury to the column without any evidence of dis-
placement being present. Within a few weeks a
case illustrating this fact has come under my
care.

Case I . — An adult fell backward from a ladder ;
a distance of five or six feet, and struck on the
back of his head ; when seen in the hospital he
was evidently much stunned though not un-
conscious. He was able to move all four extrem-
ities— the limits of sensation could not, however,
be determined. The pulse was quick and small,
the breathing hurried and shallow, and the face
somewhat flushed. Movement of the head caused
pain, particularly in flexion. No deformit}' could
be detected in the spine. When seen in the
evening the breathing was rapid, and almost en-
tirely abdominal, and the face deeply flushed ;
movement in the extremities still existed. Death
occurred eighteen hours after the accident. At
the post-mortem examination a partial dislocation
forward of the second cervical vertebra was found
with slight displacement. The spinal canal was
laid open from behind — the cervical arches were
intact, the membranes were untorn and normal,
and on laying them open no evidence of injur\^
to the cord could be seen as it lay in the spinal
canal. The cord was removed, and when laid on
the table presented no evidence of injury until by \
passing the finger along its surface a transverse 1
section of softening corresponding to the height
of the displaced vertebra was discovered. The
cord was now divided by a longitudinal antero-
posterior section. Slight softening involved the \
entire thickness of the cord, and within this area '
on either side a small clot of recently extravasated \
blood was found. These clots were found on
either side of the central canal, and were so 1
centrally situated that on the surface of the cord j

there was no evidence of their existence. The
persistence of motor power in the four ex-
tremities showed certainly that these lesions had
not entirely destroyed the conducting power of
the cord. The cause of death must have been
due to interference with the origin of the phrenic
nerve. In a less vital portion of the cord there is
no reason why such a lesion should have sud-
denly terminated life, and it seems not unreasona-
ble to suppose that complete restoration of func-
tion might have followed absorption of the clots,
and it is not improbable that in cases of recovery
after paralysis in spinal injury, such lesions may
frequently exist. Repair under such circum-
stances will certainly not be aided by airy opera-
tive interference. The changes which follow
fracture may result in thickening of the mem-
branes and the production of more or less inflam-
matorj' tissue, or pus within the spinal canal,
sufficient to cause marked pressure on the cord —
a pressure which in some cases may explain the
continuance, or reappearance, of the paralytic or
trophic symptoms. These cases then approxi-
mate the condition found in Pott's disease, suffer-
ing from pressure symptoms, plus the amount of
the original, and unrepaired damage to the cord
itself. The question of operative interference in
spinal injurj' must be considered in reference to
interference immediately after the receipt of in-
jury, and interference deferred until the amount
and character of permanent disability can be de-
termined. The solution of these questions in-
volves a consideration of the course and results of
fracture treated without recourse to operation.
It is well known that not only a considerable
number of these cases escape death, but entirely
recover all their functions, even after the existence
of paralysis, incontinence, and bed-sores existing
for a variable length of time. In a valuable
paper Burrill has investigated the results of all
the cases which ha\'e occurred in the Boston City
Hospital — eighty-two cases in all — of which
eighteen sur\'ived. Divided into regions we find
twenty-eight cases of fracture of the cervical
vertebrae gave two recoveries — twelve cases of
fracture of upper dorsal vertebra;, six recoveries
— nineteen cases of fracture of lower dorsal, one
recoven,- — twenty-three cases of fracture of lumbar
vertebrae, ten recoveries. Of the sixty-four fatal
cases thirty-five died within five days — eight in
from five to ten days, and seven in from ten days
to one month. Five of these cases were submitted
to operation — all of which were promptly fatal.
In the eighteen who survived the result was good
in nine, and in nine complete disability remained
permanent. The especial value of Burrill's paper
is that it is based on the entire number of cases
treated in a single institution, and gives, there-
fore, more reliable data for deductions, than
statistics made up of isolated cases. Favorable
results always obtain undue prominence under

40

FRACTURES OF THE SPINE.

[July 13,

such circumstances. It is apparent from the
above figures that 21 per cent, of fractures of the
spine survive, and that over 10 per cent, make a
satisfactor3- recovery.

Of the fatal cases a verj' large proportiou die
in the first few days — a fact of importance in es-
timating the danger of operation, the high mor-
tality of which in cases of recent injury can not
properly be attributed to the operation itself but
is largely due to the concomitant injury.

It is further evident that while treatment is
.successful in preserving the lives of a consider-
able number, one-half the sur^'ivors are left com-
pletel}- disabled, so that any addition to our thera-
peutic resources must be eagerly welcomed. I
can best present the points involved in the ques-
tion of treatment of spinal fracture by brieflj' re-
ferring to the more salient features of the cases
which have come under my care in the last few
months, and describing the methods adopted in
each and the results obtained.

In addition to the case of dislocation above re-
ported I have had in the time specified five cases
of fracture of the dorsal spine ; in three of these
cases the plaster jacket was applied within a short
time of the accident, and in two the result was
entirely satisfactory, but in the third only par-
tially so — in one an air-bed was used with per-
sistence of the paralysis and incontinence and the
development of extensive bed-sores. This case
at the end of five months was trephined — the loth,
nth and 12th dorsal and first lumbar arches re-
moved. The last case was treated on an ordinarj*
bed, great care being exercised to avoid pressure,
and at the end of several months had gained con-
trol of bladder and rectum, complete restoration
of sensation, and improvement of motor power.
The disabilities which remained were markedly
improved by systematic suspension several months
later.

Case 2. — An adult, as the result of forcible
bending of the body in driving under a low arch-
way, suffered a fracture of the spinous process of
the nth dorsal vertebra, which could be felt
movable and somewhat displaced under the skin.
There was no paralysis of motion or sensation or
any disturbance of the function of the bladder or
rectum. Ever)- movement of the body was pain-
ful and there was entire inability to sit up in bed.
A plaster jacket was at once applied by means of
the hammock suspension and was followed b)-
immediate relief of pain and by ability to move
about and sit up in bed. In five weeks the pa-
tient walked out of the hospital quite well.

Case :;, — A carpenter fell 25 feet from a scaffold,
striking his back ; the fall produced at once com-
plete paraplegia. He came into the hospital three
or four days later. Paralysis of motion and sen-
sation was complete nearly to a level with the
umbilicus, and there was retention of urine. The
fourth and fifth dorsal spine were slightly promi-

nent and were painful on pressure, and movement
of the body caused pain in this part of the col-
umn. The jacket was applied in the hammock
at once, and immediately gave a great deal of
comfort, enabling the patient to move in bed and
sit up without pain. For seven or eight weeks it
was necessary to use the catheter, when expul-
sive power was regained and the pus and mucus
disappeared. During the first few weeks the
bowels were only moved by injection. Sensation
began to appear in the lower extremities after
seven or eight weeks and was soon followed bj^
voluntary' motion. This improvement continued
and in eighteen weeks the man was able to walk.
Six months later there remained onlj' a slightly
ataxic gait and the man was able to resume work
as a carpenter.

In one other case the jacket was applied on the
fifth daj- after fracture in the lower dorsal region.
At this time there was paralysis in both lower ex-
tremities, retention of urine and involuntary-
escape of faeces. The jacket afforded comfortable
support. Within a few weeks a bed-sore devel-
oped over the sacrum and incontinence of urine
and cystitis followed. In four months sensation
had completely returned, the thigh muscles could
be voluntarily moved, but there still remained
paralysis of the legs, and the incontinence was as
bad as ever and has continued up to the present
time unimproved.

The application of a plaster jacket in the treat-
ment of fracture of the spine is certainly no nov-
elty, as manj^ cases have been reported and its use
has materially improved the ultimate results as
well as adding greatly to the immediate comfort
of the patient. The method of application I re-
gard as of great importance, and sufficient appre-
ciation, has not, I think, been shown to the use
of the hammock suspension, as first suggested by
Mr. Davy. An extensive experience in the use
of the hammock in the application of the plaster
jacket for Pott's disease has given me great con-
fidence in this method wherever a spinal support
is required, and in cases of fracture it presents
special advantage. In a case described by Burrill,
in which suspension was employed, the pain is
described as so agonizing that the jacket was
completed with great difficulty, and I cannot but
think that there must be at times danger where
the continuity of the column has not been im-
paired. One advantage only I can see that suspen-
sion can pos.sess over the hammock, and that is
that the weight of the body may act as an extend-
ing force in overcoming any displacement. In
Burrill's case sensation was felt in the toes the
moment the body was free from the bed. But
extension can be perfectly well practiced with the
hammock, and the further advantage of an au-
cesthetic can be obtained with safety while the
patient remains in a horizontal position.

The method of using the hammock is verv sim-

1889.]

FRACTURES OF THE SPINE.

41

pie ; a piece of strong muslin as wide as the pa- 1
tient's body and about 15 feet long is stretched
out on the bed beside him, a proper undershirt is
applied and the patient is gently rolled over until
he lies prone on the hammock. One end is now :
securely knotted to a strong hook in the wall and
the other end attached by a pulley to a fixed point
at the opposite side of the room and the patient
is then swung free from the bed. After protecting
the bony points, the plaster bandages are applied
including the hammock, and the suspension con-
tinues without an}- inconvenience to the patient
until the jacket is perfectly hard. In none of the
cases in which this method has been used has |
there been any pain complained of, and in one of
the fractures the patient compared it most favor-
ably with the di.scomfort of a former suspension.

In one case, still under obser\-ation, decided
benefit has been obtained in improving the condi- ,
tion some months after fracture by systematic sus-
pension.

Case /. — An adult, set. 30, carpenter, fell 30
feet, striking his back and producing complete j
paraplegia — motion and sensation being both
abolished. For five weeks it was necessarj- to 1
use the catheter, when expulsive power returned ;
for about the same length of time the rectum was
evacuated only bj- the use of injections. Cystitis
soon developed, bed-sores occurred on the heels
and over the right trochanter. In six months he
had so far improved that complete control of the
bladder and rectum was regained. Sensation
throughout returned and there was marked im-
provement in motion. In the right leg there was
fair control of the thigh muscles ; in the left
scarcely any voluntary' motion at all. There was
no voluntar}- motion in leg or foot muscles on
€ither side. The reflexes were greatlj' exagger-
ated and contact of feet with the floor or slight
tapping of the finger over thigh or patella pro-
duced such violent contractions of all the exten-
-sors of the leg that the knees could not be flexed
for some minutes. At this time a marked curva-
ture in the lower dorsal region, the prominence
involving several vertebraj, and in this condition
he was admitted to the Cincinnati Hospital, for
the purpose of trying suspension. He was sus-
pended twice daily, at first for five minutes at a
time, and then the time was much lengthened. |
The benefit was evident from the first. The ex- ■
aggeration of the reflexes soon showed diminution
in intensity and there was improvement in volun- j
tarj- motion.

The treatment still continues and it is too soon
to determine the ultimate result, but thus far the
patient's condition seems to show that we have in
suspension the means of further improvement
where recovery' has fallen short of complete suc-
cess. The range of its usefulness can onl)' be
determined by further trial. This method of
treatment is still so new that it is not worth while

to speculate on the manner in which suspension
acts. It may, however, be suggested that repair
in fracture of the vertebrae often falls short of
complete bony union, and in these cases a sus-
pension may possiblj' act by straightening the
canal and thus relieving pressure.

In the admirabl}' analyzed tables of fracture of
the spine in Ashurst's essay the great advantage
of immediate correction of the deformity and dis-
placement by extension and manipulation where
the cervical vertebrae are the seat of injury is
prominentlj- enforced, and later experience has
fully confirmed the conclusions of the author in
this respect, so that the benefit of this practice
may be considered so fully established that it
does not require further argument to support it.

I have had one case in which I have trephined
the spine and removed the loth, nth, and 12th
dorsal, and first lumbar arch. The operation was
undertaken five months after fracture in the dorso-
lumbar region. There was present at the time
extensive bed-sores, incontinence of faeces and
urine and complete paraplegia.

Case §. — F. H., aet. 27, entered Cincinnati Hos-
pital November i, 1888. Four days before he fell
through a hatchwaj- and found himself unable to
rise. On admission there was complete paralysis
of motion and absence of sensation as high as the
crests of ilia, and inability to void urine. Incon-
tinence developed within a few days, with invol-
untary- discharge of faeces. The patient was at
once placed on an air-bed, but in spite of the most
assiduous attention cystitis developed and exten-
sive bed-sores appeared over the sacrum and along
the posterior aspect of both legs within two or
three months. Sensation returned to the middle
of the thighs, but there was no improvement in
motion. On return to hospital service, April ist,
five months after the accident, I found no further
improvement, but on the contrary spreading bed-
sores and the cystitis, incontinence and paralysis
unchanged. The operation of exsection was ex-
plained to the patient, and the possible chance of
benefit which it offered, and after consultation
with his friends he decided to accept it. Api il
loth, with the assistance of the surgical staff of
the hospital, the spinal canal was opened. A free
incision was made over the spinous processes, the
center of which was the i ith dorsal, and the mus-
cles were rapidly dissected off, so as to fully ex-
pose the lamina on either side ; bleeding was con-
trolled by packing the wound with sponges. The
spinous process of the 12th dorsal was first cut
away with strong cutting forceps and the trephine
then applied and the canal opened. The arch of
the nth dorsal and first lumbar was similarly re-
moved. The dura thus fully exposed was covered
with a thin layer of rather closely adherent con-
nective tissue, which was scraped away with a
blunt spoon ; no pulsation was seen and the cord
appeared normal to the touch, except at the upper

42

FRACTURES OF THE SPINE.

[July 13,

part exposed, where it seemed diminished in con-
sistency, and as the membrane appeared closely
applied to the arch above this was also removed.
No condition causing compression was discovered,
and the dura was not opened. The wound was
closed throughout, except at the lower end, where
a large drainage-tube was inserted, reaching to
the bottom of the cavit}', and a voluminous dress-
ing of gauze and absorbent cotton applied. The
following day this was saturated through b}' the
discharges and was renewed ; on the fourth day
the dressing was again changed, and as the dis-
charge was small the drainage-tube was removed.
This I am now ♦satisfied was a mistake, and I
attribute the suppuration which occurred and the
delay in healing of this part of the wound to this
fact. Except about the tube the wound healed
bj' first intention. For several daj's there was
slight fever and the bed-sore over the sacrum in-
creased slightlj' from a slough. Eight weeks after
the operation the wound was entirely healed.
The general condition was certainly better, the
urine was almost perfectly clear and of acid re-
action, and some of the bedsores were entirely
healed, and all improved and contracted. Incon-
tinence still persisted, and there had been no im-
provement in either sensation or motion. So far
as the operation is concerned I consider that it
has been entirely negative, and that the improve-
ment which has ensued has been due to the assid-
uous care and attention the man has received.
This result, however, I do not feel should dis-
courage further effort under proper conditions.
Indeed, earlier operation I believe is indicated,
and sufficient success has been attained by others
to more than justify further effort in the surgical
interference in these cases.

The operation is not difficult, and is now shown
to be not very dangerous, and where continued
treatment has failed to afford relief resection
should be undertaken without very great dela5^
for even where complete success has not been at-
tained the operation appears to have a marked
influence in controlling cystitis and incontinence,
and in hastening the healing of the bed-sores, re-
sults which amply compensate for the small
amount of danger. Ashurst, in the essay referred
to, has presented the result of resection of the
spine up to that time, and asserts that there is "no
well authenticated case of cure after the operation
when undertaken for fracture." Surgical writers
previous to the reports of Horsley and Macewen
are unusually unanimous in condemning the oper-
ation. Among the latest, Page, in Heath's Dic-
tionary, says that " it is an operation not within
the range of practical surgery." To this general
pe.ssimistic view Erichson is a notable exception,
and largely on the result of Gordon's case in
Dublin advocates further trial. In this case sixty-
seven days after injury the arches of the i2th
dorsal and first lumbar vertebrae were removed for

fracture of the lamina of the latter. The opera-
tion was undertaken for the relief of incontinence
and cystitis, complete paraplegia and extensive
bed-sores, and resulted in much benefit. The
cystitis disappeared, entire control of the bladder
was regained, the bed-sores healed, sensation re-
turned, and the paralysis of motion was greatly
improved.

Since the appearance of Horsley 's paper I find
ID cases of trephining the spine for fracture.
Many of these cases are most unsatisfactorily re-
ported, but several points of importance and inter-
est may be gathered from them. Macewen reports
a case, operated on five weeks after accident, in
which the 1 2th dorsal and first lumbar arch were
removed, the former being fractured, and com-
plete success obtained. Horsley removed the
nth and 12th dorsal after the appearance of bed-
sores, with marked benefit to the patient, but
without the complete disappearance of motor
paralysis. In no case in which operation has been
performed within a few hours of injurj' have I
been able to find a complete success reported.
Most of the patients have lived, some slight im-
provement noted, but in none has there been a
disappearance of the paralyticsymptoms. In deter-
mining the propriety of immediate operation the
question may be asked whether in fracture of the
bodies of the vertebrae removal of the arches and
the severance of the ligaments must not necessarily
further weaken the column as a whole, and so
render displacement more liable to occur. Such
an objection would not exist after partial or
complete consolidation.

In all cases where decided benefit has followed
fracture of the arch only has been reported. It
has been urged that where fracture of the body is
present, with the narrowing of the canal, that
removal of the lamina will permit the cord to
expand backward. I have not been able to find
recorded any case where this has been demon-
strated.

Experience is now rapidlj' accumulating, how-
ever, in these cases, and may soon fully confirm
these suggestions. As for technique of the oper-
ation Horsley's description is so complete that
little can be added. The condition demanding
the opening of the dura requires investigation.
Such a step adds to the gravity of the operation,
but failing to do so in some cases may possibly
account for want of success. The conclusion to
which this discussion points is this : that in injury
to the spinal column with the symptoms indica-
ting damage to the cord, e.xperience has already
shown that a satisfactory result may be obtained in
a considerable proportion of cases, and that in the
majority of those that recover after the existenceof
paralysis, retention or incontinence, improvement
only begins after some weeks, or po.ssibly after
some months. Recent experience has certainly
shown that resection of the spinal arches is not so

1889.]

POPULAR PROGRESS IN STATE MEDICINE.

43

dangerous or difficult as was once supposed, and,
furthermore, that it is capable of dealing success-
fully with cases of pressure on the cord of long
duration after other methods have completely
failed. It is certain, therefore, that we have in
operation an additional resource in fractures of
the spine. I cannot but feel, however, that the
tendency at present is to push to an extreme the
analogy between tumor and Pott's disease pro-
ducing symptoms of paraplegia, and cases of frac-
ture, in determining the question of operative in-
terference where the symptoms do not yield at
once to a correction of the displacement, is likely
to result less satisfactorily than trusting to the
other methods longer in use. At the same time
a sufficient number of cases exist to show that
under certain conditions resection will save life
and remove symptoms worse than death itself.

From the above I feel justified in presenting
the following provisional conclusions from which
doubtless many will dissent :

1 . In fractures of the cervacal vertebrae there is
indicated immediate reduction of any displace-
ment by extension and manipulation under an
anaesthetic, followed bj' continuous extension and
immobilization.

2. In all fractures of the dorsal or lumbar spine
involving the bodies or the arches, with or with-
out evidence of injury to the cord, the immediate
application of the plaster jacket by the hammock
suspension preceded, if there is evident displace-
ment by an extension, under an anaesthetic.

3. When symptoms indicating injur\' to the
cord persist without improvement resection is
indicated.

4. Immediate operation would be indicated
where there is marked depression of the arches
with symptoms of paralj'sis.

5. Long continuance of the symptoms is not
in itself a contraindication to operation.

6. We have in suspension the means of allevi-
ating some of the sequelae of fracture of the
spine.

POPULAR PROGRESS IN STATE
MEDICINE.

Delivered in Section on State Medicine at the Fortieth A nnual Meeting
of the A merican Medical Association, June 25, 1889.

BY J. BERRIEN LINDSLEY, M.D.,

OF NASHVILLE. TENN., CHAIRM.\N OF THE SECTION.

The Section on State Medicine has two feet
upon which it securely stands — law and science.
My immediate predecessors as Chairman of the
Section have noted the recent progress in science
as connected with its practical work. On this
occasion I shall, with great brevity, note progress
in the other direction. As in America all law de-
pends upon the sovereign will of the people, who
are at once governors and governed, my topic is

substantially " Popular Progress in State Medi-
cine."

This progress is one of the great features of
the present century, which is as signally charac-
terized by the application of the physical forces
to the daily uses of man as was the fifteenth by
the unfolding of the globe's map. Thirty years
ago sanitary ideas, problems, reforms and work
were unknown, or at all events unmentioned.
To-day, outside of partisan politics with its per-
quisites, no topics engross so large a share of pub-
lic attention as do those belonging to practical
sanitation.

As evidence of the recent and rapid progress
State Medicine has made in the United States, the
following substantial proofs may be cited :

STATE BOARDS OF HEALTH.

The first State Board of Health created was
that of Massachusetts, at a date no longer ago
than 1869. From a table very carefully compiled
by Dr. Geo. Homan, Secretary of the State Board
of Health of Missouri, we learn that, in iSSS,
twenty-nine States maintained Boards of Health,
by an annual expenditure of more than half a
million dollars. Thus a major portion of the
American people are becoming acquainted with
the connection between law and health.

In most instances these Boards have high pow-
ers. In all cases they exercise a great educational
influence.

Voluminous reports, prepared with care, and
with special adaptation to the several localities,
are liberally distributed. At this date the series
issued by those two advanced States, Massachusetts
and Michigan, constitute a cyclopaedic collection of
treatises upon all the pressing questions of public
sanitation. The Illinois Board has exerted a last-
ing influence upon medical education b)- its persist-
ent efforts to protect the people from imposition.
Perhaps it is not beyond fact to say that a very
few years of legal effort by this single State Board
has done more to elevate medical education than
all the advisory and hortator\' resolutions of our
own great Association in forty years. Law is a
rapid and efficient educator. No less than eight
of these twenty-nine State Boards issue monthl}-
publications containing reports and information
from all localities within their bounds. These
periodicals are circulated bj- the thousand, and
tend materially to advance the work. All date
within the last four years.

CITY AND LOCAL BOARDS.

The progress, influence, powers and expendi-
tures of city Boards of Health in the recent decade
is even more remarkable than in the case of State
Boards. I have not at hand such an analysis of
their work as that furnished by Dr. Homan, above
referred to. However, a single topic under their
care reveals the wide scope of their functions and
the immense results which must in a few years

44

POPULAR PROGRESS IN STATE MEDICINE.

[Jt-'LY 13,

ensue. Healthy homes for all the people is be-
coming their watchword and the demand of their
constituencies. To exemplify this point time for-
bids. The work done by the New York, Boston
and Nashville Boards may be cited in proof.

A wonderful illustration happened in Europe
only a few days ago (June 15), when the King,
Queen and Crown Prince of Italy inaugurated the
improvement of the sanitan,- condition of Rome.
This grand work will require ten years for its
completion. Many new streets will be opened
and 17,000 houses be demolished.

The American Democracy long since voted it-
self public schools by means of which the keys
of knowledge are placed in the hands of all.
Witness Massachusetts, which for its last scho-
lastic year voted without grudging the royal sum
of $7,500,000.

The American Democracy will beyond a doubt,
long before the next centurj- becomes old, vote
that each man, woman and child of its many mil-
lions, everywhere upon its imperial domain, shall
breathe the pure air of heaven and enjoy that
bright sunshine which is the truest emblem of the
Divine Giver of all life.

Ever since my student days in that loved Alma
Mater, the glorious old University of Pennsylva-
nia, have I, as opportunity offered, inspected the
dwellings of the masses in our large cities, and
always with sadness and compassion, that so
many among them fared no better than like classes
in the Old World. Now, when these scenes meet
my eyes, it is with the comforting reflection that
such disgraces upon our vaunted civilization will
soon pass away.

VOI,UNTARY ASSOCIATIONS.

These are rapidly becoming a power. On April
18, 1872, in the rooms of the New York City
Board of Health, seven pioneers founded the Am-
erican Public Health Association, which now
counts its membership by the hundreds. This
Association has published fourteen substantial
and handsome volumes, permanent memorials of
the best thoughts of very many of the most emi-
nent practical sanitarians in America. By the
thoughtful liberality of a single member, Mr.
Henry Lomb, of Rochester, N. Y., it has sent
many thousand copies of capital essays among
classes specially needing and prizing such instruc-
tion.

The Newport Sanitarj- Protection Association
is a model in its way, which in a very few years
will be widely copied in all parts of our great
Republic.

The New York Ladies' Sanitary- Association,
recently formed, has some 350 members. It has
taken hold of such great subjects as defects in
public school buildings, the removal of garbage,
and the like. Though in its infancy, it is already
noted for good work. J

INCREASED RESPECT BY RULERS.

This is very remarkable, and has done much to
give our cause prestige with the people. The say-
ings of D' Israeli the gifted, and of other eminent
British statesmen, have become axioms. No
greater tribute, however, has ever been paid to
State preventive medicine than the idea recently
advanced by an American Secretary of State, look-
ing to the peaceable acquisition of a great island
now a plague-spot, a terror and a menace to our
people, that so it may come under the redeeming
influence of sanitarj- science,

THE BARRING OUT OF CHOLERA.

In 1884 and 1885 France, Spain and Italy were
visited by an epidemic of Asiatic cholera which
alarmed all Europe, and created great uneasiness
in our own countr3% specially in the vast Interior
Valley. In all previous visitations of this exotic
pest it was allowed free course. On this occasion,
however, it was met by the organized hosts of
I scientific physicians acting with the power of law,
and was stopped short in its career. This fact has
given the American public great respect for and
great confidence in State preventive medicine, as
I know from conversing with man}^ outside our
profession .

GRE.\T MONEYED INTERESTS AROUSED.

Yellow fever epidemics, and even yellow fever
scares, are now of National importance because
of their disastrous influence upon inter-State com-
merce. The scare of last year damaged more or
less all the railway campanies with extensive lines
in the South, probably more than the really great
epidemic of 1878, which was so fatal to life. This
because of the increase in mileage of these rail-
roads. During the continuance of this scare and
consequent embargo upon commerce, ver>- many
railroad and mercantile men studied and discussed
the perplexing topic of quarantine. These men
represented millions upon millions of capital and
multiplied thousands of employes. One sentiment
prevailed among them, respect for State Boards,
abhorrence of local shot-gun quarantines, and a
desire for a central Federal head at Washington
which should cooperate with vState Boards and
harmonize quarantine rules. There are no better
auxiliaries in public health work in the South
than our railroad officials. The depopulation of
Decatur, Ala., when yellow fever was declared
epidemic, as conducted by the management of
the Louisville and Nashville Railroad, was a
model for promptness, efficiency and humanity.

The recent astounding calamity of May 31, in
Pennsylvania, has also awakened a widespread
feeling of the necessity of a Federal hand which
in such une.xpected and destructive calamities
shall be ready to aid local authorities with that
promptness and wealth which great Governments
alone can exhibit. In such times of trouble there

1889.]

POPULAR PROGRESS IN STATE MEDICINE.

45

should be no necessity for the slow, uncertain and
costly agency of voluntary contributions from in-
dividuals among 65,000,000. Our Government
is a Commonwealth of States, and at its Capital
has all the organization for mutual insurance
against earthquakes, floods, and pan-epidemic
pestilence that can possiblj' be needed.

LIFE INSURANCE AND VITAL STATISTICS AND
SANITATION.

As it respects numbers interested and capital
involved, life insurance is second to no business
in America. Without vital statistics it walks in
darkness. With local sanitation it is intimateh'
concerned. A company at Hartford has within
ten j'ears sent an accomplished physician twice to
Tennessee on an inspecting tour, whose reports
give an admirable summarv- of the sanitarj' con-
dition of that State, though never published.
This kind of inspection is more frequent than
health officers are aware. It is impartial and
meant for business uses alone. Unhealthy coun-
tries are embargoed b^' life insurance companies,
for a single epidemic may destroy the resources
of years.

THE BUSINESS INTERESTS OF AMERICA NOW DE-
MAND THE UNITED STATES PUBLIC HEALTH
SERVICE.

This topic for twenty years past has been much
discussed in medical associations. National and
State ; also in sanitarj' conventions of all kinds.
\'arious plans have been proposed with widely
different features. At one time, 1879, a National
Board of Health was created, from which much
was expected. These expectations were disap-
pointed, and perhaps inevitabl}-, since this Board
was not in harmony with the machinery of the
United States Government. Perhaps, also, be-
cause it was mainly established under the spur of
an epidemic disease which aflfected onl}^ one sec-
tion of the Union and did not concern the people
of more than half the States.

Everj' one conversant with the development
of bureaus and departments at Washington is
aware of the fact that in each instance they are
the outgrowth of progress in the separate States,
and of the wants of large classes of people.

After many States had created agricultural bu-
reaus, boards or commissioners, and after the farm-
ers had become widelj' interested in the matter,
Congress enacted a Bureau of Agriculture. After
a while this was exalted into a Department, with-
out a seat in the President's Cabinet council. Very
recentlj^ it has made the last step in advancement,
and its head is a full Cabinet minister. Nearly
all the States had .systems of public schools before
the Bureau of Education was created, which, un-
der the long and successful administration of Com-
missioner Eaton, passed from infancy to vigorous
manhood. This Bureau works in perfect harmony
with the State Superintendents of Public Instruc-

tion. It gathers, arranges and collates a vast
amount of educational statistics and information
not coming under State purview. It represents
the vast corps of teachers in the Union at Wash-
ington, increases the self-respect of this large
body of influential citizens and, as a consequence,
grows continualh' stronger in the public esteem.

There is now at Washington nearh- all the pro-
vision or machinery of a Health Department wor-
thy this mighty people, which yet does not satisfy
the public demand for want of enlargement and
coordination. A ser\'ice nearly a centur}- old, es-
t tablished originally as an act of charit}- to a heed-
J less class, and supported by a tax upon that class,
has, by a singularly interesting process of evolu-
tion, expanded into a Bureau with four exceed-
ingly important drawers. The care of the United
States Marine Hospitals, once its sole function and
the cause of its creation, is now only one of its
duties, a great charity though it be. with a chain
of splendid buildings perfectly equipped and ably
managed. All honor to him who conceived the
idea of elevating this ser\-ice from the low estate
into which partisan administration had reduced it.
All honor to those who have changed it from sin-
ecure posts for party reward to scientific positions
for genuine merit.

Last year, in pursuance with an earnest request
from the American Medical Association, Congress
greatly enlarged the abilit}- of this Ser\-ice to take
charge of maritime quarantine, so that now this,
one of the chief functions of a National Health
Bureau, is by common consent placed in its hands,
with funds and powers amply sufficient for most
efficient work. Surely this addendum far out-
weighs in importance and esteem its moderate
hospital work.

Curiously enough, last year also a threatened
epidemic of yellow fever brought a demand upon
the central Government for assistance which could
not be refused, inasmuch as a contingent fund for
just such purposes had been placed to the order
of the President, who could find no other channel
through which to extend relief than this same old
seaman's friend. Thus inter-State quarantine and
aid fell under its wing. And though this may be
a temporary work, yet when occasion does occur
for its performance, in magnitude and importance
it dwarfs even maritime quarantine. A fourth
drawer in this nondescript 'Bureau is the direction
of investigations throwing light upon the causes
j and prevention of diseases, which has been com-
I mitted to its charge in more than one instance by
Act of Congress during the few years just passed.
; Thus it would seem that the United States
Marine Hospital Service has altogether outgrown
its name. It should be styled the United States
Public Health Service, while retaining essentially
its present organization. Maritime quarantine,
inter-State quarantine and aid, and scientific re-
searches, with its original work should constitute

46

GYNECIC USES OF BORIC ACID.

[July 13,

four separate sub-departments with ample funds I
and full clerical force. The head of the whole
should be, as now, a Supervising Surgeon-Gen-
eral. This is better than a Bureau with a politi-
cal appointee at its head. The term Service is
significant and it. is popular.

The U. S. Signal Service, Life Saving Service,
Eight Service, are doing much to render the Gov-
ernment revered as a benefactor instead of being
regarded as a harsh tax-gatherer. The small sum
expended upon lights along both banks of the
Mississippi River has done more to lighten toil,
mitigate danger and save loss of life and property,
than immense sums expended in other channels.

The United States Public Health Service thus
established, by a process not of revolution but
evolution, can be most efficienth- aided in its wide
field of action b}- three existing agencies at Wash-
ington, each of which has been long in operation
with universal favor and popular support.

First. The United States Signal Service. Cli-
matology is of late admitted by all to be a most
important branch in the study of preventive med-
icine. It will not be long before weather warn-
ings will be more in request for health purposes
than even now for commercial and agricultural
reasons. One or two clerks in the Public Health
Service can obtain and coordinate all the weather
knowledge it may need as effectually as if the two
Services were combined in one.

Second. The United States Census Bureau of
Vital Statistics. Every ten years the Govern- ,
ment, in connection with the enumeration of the
people required b}- our polity of representation,
sets to work a Supervisor of Mortality and Vital
Statistics for that special census. This office
should be permanent and the work continuous.
All admit the supreme importance of accurate
vital statistics as the ver>' basis of practical sani-
tation. The experience of over a centur}- shows
that the States and Territories will not efficiently
provide these statistics. A few large and wealthy
States may, but, judging the future from the past,
the youngest grandchild of our great-grandchil-
dren will not live to see America on a par with
Great Britain in this, the very basis of a high
civilization. This work is eminently within the
province of the Federal Government, and will
find with the people a welcome not less warm
than that extended to the postal or weather ser-
vices.

Third. The United States Coast and Geodetic
Survey. A minute topographical survey is an
essential insanitary' work. Great Britain, France,
and even Spain, a country- which we ignorantly
nuich underrate, have either perfected or are per-
fecting topographical maps on a scale of several
inches to the mile. These maps are perfect de-
lineations of the country. In America there is
not a single State thus mapped, and perhaps never
will be. It is a costly work, requiring time and

highest scientific skill. This, too, is eminently
an undertaking for the Federal Government, of
absolute necessity- from a military standpoint no
less than for public health reasons.

That a complete Weather Service in each State
under the control and support of the United
States : that the permanent collection, collation
and publication of the vital and mortuary statis-
tics of each State under the same authority ; and
that a minute topographical survey of each square
mile in the three and a half millions over which
floats our flag, is also its legitimate work, follows
logically from the fact that each and all of these
great factors in the people's progress to a civili-
zation higher than any which has yet been at-
tained by humanity, are eminently National in
their character and relations ; and also from the
further fact that their cost is far beyond the means
at the disposal of the States. Be it always re-
membered that the States have surrendered to the
Federal Gov-ernment the two lucrative sources of
revenue, customs and excise duties, and thus left
themselves poor.

Above is briefly sketched the outline of a plan
which, without jostling or jarring, but simply by
expansion and coordination, will give what the
American Medical Association has so often and
earnestly demanded — • a Public Health Service
worthy- our Continental Republic, which, though
but a century old. already- rivals in influence, fame
and future hopes the mighty Republic of antiquity
whose name is even now a sy-nonym for dominion.

0RIGIN.4L ARTICLES.

NOTE ON SOME GYNECIC USES OF
BORIC ACID.

Read in the Section on Obsteti ics and Gynecology, at the Fortieth An-
nual Meeting of the A merican Medical Association. June 2s. /88p.

BY WILLIAM WARREN POTTER, M.D.,

OF BUFF-^LO, N. V.

It is simply- proposed at this time to record
some personal experiences with boric acid in
gynecological work. This will necessitate a tol-
erably free employment of the personal pronoun,
for which I trust your pardon will be readily-
granted.

I was first led to the use of this agent in the
manner detailed, in casting about for a substitute
for iodoform. After using the latter drug twelve
vears, surgically and gynecologically, in sundry-
and divers ways, I was compelled to abandon it
by reason of a poisonous eflect it produced on my-
hands. This was a sore grievance, for it seemed
at the time as if it meant the relinquishment of
my work to a considerable extent. Whenever I
suspended the use of iodoform my hands recov-
ered, but every time I took it up again a derma-

1889.

GYNECIC USES OF BORIC ACID.

47

litis was set up, and exfoliation of the cuticle
followed.

In boxing the compass for a substitute that
should stand completely in its .stead, no Httle dif-
ficulty was experienced, for I must needs have
one that would answer both aseptic and antiseptic
indications. To be sure, I knew something about
boric acid and some of its various uses in medicine
and surgery, but it did not readily occur to me to
make such use of it as I had previously done of
iodoform — not, indeed, until I had tried .'several
other drugs that, one and all, only served me in-
differently well.

In the treatment of the various uterine and
ovarian displacements it had been my custom in
many instances, for some years, to pack the vagi-
na in one way and another with cotton, wool, and
other materials, first dusting the vaginal surfaces
with iodoform in the dr\' treatment, or saturating
the first two or three pledgets in glycerole or iodo-
form if the moist packing was employed. Expe-
rience had taught me that in this way I could
make the packing last much longer without de-
composition of the uterine and vaginal discharges
— a desideratum of no inconsiderable importance.
But without iodoform I found the time in which
decomposition would take place considerably les-
sened.

While passing through this period of trial, ex-
periment, and disappointment — speaking with
reference to the various drugs I had been substi-
tuting for iodoform — a lad)- came to me one day
with a history of dysmenorrhoea, from which she
had suffered since girlhood. She had now been
married several years without issue, and the pain
during menstruation was steadily increasing. I
found a long, narrow, and bent cervix, with ero-
sions surrounding the os uteri, and a catarrhal
exudate oozing therefrom.

This appeared to me a good case for rapid dila-
tation, and I so stated to the patient, giving mj-
reasons for the opinion. She was a woman of
culture and intelligence, and readily assented to
the proposed future operation, I agreeing that it
should be done after the next menstruation.
Meanwhile, I proposed to cure the erosions and
vaginal irritation that the acrid discharges were
causing. Having some boric acid at hand that I
had obtained for another purpose, it occurred to
me to dust the os and upper vagina well with it,
and to pack some dry cotton around the cervix to
retain the boric acid in contact with the eroded
surfaces, and particularly to keep the vaginal walls
asunder.

Three days afterward I removed the packing,
when, to my delight, the erosions were found
changed to a more natural color, while the cotton
was as sweet and inodorous as the day it was
placed. This treatment was repeated at regular
intervals, though more efficiently than at first,
until the erosions were cured ; but, alas ! the

menses did not appear at the next expected pe-
riod. The woman proved to be pregnant, and I
was thus deprived of the opportunity of making
a lucrative, and I trust successful, operation for
the cure of her dysmenorrhoea and sterility.
However, nature has done her work well, the
dysmenorrhtea is cured, a young family is grow-
ing up with rapid increase, and I have no right
to complain.

While treating this patient I had other oppor-
tunities of using this medicine daily, and I have
continued it, for one reason and another, ever
since.

The lessons this case taught me were :

1 . That boric acid was an antiseptic of no mean
value for intra-vaginal uses.

2. That it was chemically adapted to neutralize
the acridity of the uterine and vaginal discharges,
and thus contribute to the cure of sterility due to
such causes. I have since had opportunities to
verify this observ-ation.

In the treatment of uterine and ovarian displace-
ments, as I have before remarked, and in dealing
with pelvic inflammations or their residues, it has
been my custom for some years, in suitable cases,
to employ vaginal tamponnement, either as a pre-
paratory measure to other and more radical man-
agement, or as a curative agent, as the case might
indicate or demand. I have described my method
of packing the vagina for such purposes in con-
siderable detail, not only in papers read in this
Section but before other societies as well, and I
only refer to it here and again in order to eluci-
date one or two points relating to it, for this paper
may be regarded as in a measure supplementary
to the others.

When I first began the systematic employment
of vaginal tamponnement for the various condi-
tions to which it is adapted, it was not expedient
for the patients to retain the packing longer than
twenty-four to thirty-six hours. This was partly
becau.se the work was done with less mechanical
perfection, and hence the tampon would sag or
become partially dislodged ; but more especially
because the secretions and exudates, natural and
unnatural, would decompose and give off putres-
cent odors if left much longer.

Now, after twelve years or more, there has been
much improvement in this .simple but important
mode of treatment. Then glycerine, carbolic acid,
iodine, chloral, and perhaps a few other agents
were employed to render the packing a.septic, and
to promote shrinkage, absorption and osmosis.
When iodoform came into vogue for this work it
served a much better purpose, for it prevented de-
composition for a longer time, was less irritating
to the mucous membrane and, besides, possessed
some inherent advantages as a curative agent.

But it is not my purpose now to chronicle the
evolution of vaginal tamponnement for pelvic
disease, from the primitive cotton-glycerine ball

48

THE STUDY OF PNEUMONIC FEVER.

[July 13,

of the earlier days, to the multiple wool tampon
of the present. My object is more especially to
invite attention to the fact that boric acid is a
valuable drug to use in connection with this sort
of treatment ; and that, wheareas under the old
plan the tampon could not be permitted to remain
longer than two or three days at the utmost, now
I have no difRculty in packing the vagina so it
will stay for a week, and that without emitting
the slightest putrescent odor upon removal. This
is of great moment, especiallj- to patients who
must needs come from a distance, and to those
again who cannot afford more frequent visits to
their doctor. Furthermore, I believe it better in
many cases that this treatment be not repeated
oftener than once a week. It is less disturbing to
manj- women, psychically speaking, to have infre-
quent manipulations of the genital tract, no mat-
ter how delicately done ; and, again, it is even
better in many other cases not to disturb a well
placed and efficient packing too often. We insure
good pelvic rest, the elastic pressure is well main-
tained, the tampon keeps sweet. These, and many
other reasons that I need not take time now to
mention, all conspire to make it expedient — nay,
even wise — to repeat the treatment as infrequently
as possible or consistent with the welfare of the
woman. Not all patients can wear the packing
equally long; indeed, some should not be allowed
to go a full week before its renewal, while others
may carr^- it a little longer; but a week may be
given as a fair average.

The method I adopt may be briefly and con-
cisely described as follows :

First. Place the patient on her back and ad-
minister a copious hot vaginal lavement.

Second. Direct her to assume the knee-chest
posture, introduce a Sims speculum or other re-
tractor, wipe the vagina dry with absorbent cot-
ton, dust the whole surface well with boric acid
by means of a powder blower.

Third. Place two or three pledgets of cotton
around the cervix, then turn into the vagina such
a quantity of boric acid as may be desired — sa}'
a tablespoonful — and finally pack it neatly and
quickly, even firmly, with wool pledgets, distrib-
uting the pressure where most needed.

At the end of a week — sometimes more, some-
times less — this packing is removed by the threads
attached to each pledget, when the operation may
be repeated.

This tamponnement of the vagina should al-
ways be preceded by the hot douche to insure a
foundation of cleanliness, for which latter it is
quite as important as it is for the effect it has ou
the circulation of the pelvic vessels.

The knee-chest posture affords the best oppor-
tunity, as a rule, to bring the boric acid in con-
tact with every nook and cranny of the vagina,
and enables the operator to pack the cavity snugly
with less discomfort to the patient ; yet, in some

cases where this posture is inexpedient, the Sims
position ma}' be substituted.

The method of doing the packing^its tech-
nique— is of considerable importance ; for, if it
be carelessly or indiflferenth- done, its potency is
greatly diminished. A little practice will readily
suggest to the operator the proper course to pur-
sue as to the amount of pressure, quantitj' of boric
acid, and other details of the treatment. The
principal feature to be borne in mind is that the
tampon must not be uncomfortable by reason of
its size, while at the same time it must be suffi-
ciently ample in volume to be retained well in
place.

Another way in which I have used boric acid
with satisfaction must not be forgotten. After
plastic operations in the genital tract I pour a
quantit}' of it into the vagina, and then cany a
rope of boric cotton up to the os uteri, allowing
it to hang out over the perineum 2 or 3 inches.
This may remain three or four da^^s, and will pro-
tect the parts in various ways. The line of su-
tures— cervdcal, intravaginal or perineal — will be
guarded antisepticalh- with a suitable dressing,
that I cannot but regard as beneficial in promot-
ing immediate union. I formerly used iodoform
gauze in a similar way, but I like this plan much
better.

There are manj' other g>'necic uses of this drug
that could be referred to, but I fear that I have
already- gone beyond the limits of a " Note. ' '

The points upon which I wish to place empha-
sis are :

1. That boric acid is suited to manj- g^-necic
uses where antiseptics are required.

2. That it can claim superiority for vaginal
tamponnement by reason of (a) odorless, (d) col-
orless, ((■) non-irritant, chemical properties; these
admitting of its frequent, liberal, and prolonged
employment where this method of treatment is
indicated.

3. That it is a remedj^ of value in sterility' due
to acrid secretions that destroy the fecundating
power of the spermatozoa.

4. That it is one of the best powders to render
operation wounds in the genital tract aseptic.

If I have given to even one person in this as-
semblage a single hint that may hereafter prove an
aid to him, the object of this note will be ser\-ed.

2S4 Franklin St.

AN INTRODUCTION TO THE STUDY OF

PNEUMONIC FEVER.

BY EDWARD F. WELLS, M.D.

EIGHTH PAPER.

CAUSATION : PREDISPOSING INFLUENCES.

There is much which we know of the causa-
tion of pneumonic fever ; but there is vastly
more of which we are, as yet ignorant. W'ith the

1889.]

THE STUDY OF PNEUMONIC FEVER.

49

lapse of time and the progress of knowledge we
may confidently expect that the veil will be
lifted and the Egyptian darkness dispelled. In
no corner of the etiological field is there so much
room for doubt and error as in the study of the
predisposing' causes of diseases, and this is
especially true of pneumonic fever.

This malady has been so often observed to oc-
cur during, or to follow upon some peculiar state
of the general system, an injury or a disease,
with such regularity and frequency as to lead to
the inference that thej' exercise a predisposing in-
fluence over the production of the pneumonic
fever. The explanation of the fact, however, is
often, nay generally, not at hand. Yet even
under these circumstances we should never lose
sight of the fact that "every occurrence in na-
ture is the result of some previous occurrence
which we have agreed to call its cause, and which,
in turn determines some other, which we con-
sider its effect. Nothing is accomplished at any
time by a sudden act of transition," "' or by chance.

A vigorous and robust constitution, joined, as
it usually is, with active habits and a sanguine
temperament, is thought b}' many^ to predispose
to the disease, whilst others' hold opposite views.
It is probable, however, that one of the principal
reasons why the strong and healthy are so fre-
quently attacked is that they are usually more
exposed to the deleterious influence of cold and
wet, overexertion and worrj- and other predispos-
ing causes of the disease."

Of 171 cases analyzed by Chomel, 87 were
strong, 36 average and 13 weak. Of Bouillaud's
26 ca.ses, 20 were strong and 6 weak. Of Ben-
nett's 118 cases, 49 were in bad health when at-
tacked. Of 750 cases tabulated by Patton only
18 per cent, were previously healthy. Of my 498
cases 134 were strong, 267 average and 97 weak.

Some persons, without any obvious reason, are
peculiarly predisposed to, or exempt from, attacks
of pneumonic fever, and this proclivity or im-
munity may extend to entire families, tribes or
races.'' In some instances immunitj', for example,
is clearly due to exceptionally favorable hygienic,'
climatic or other external influences ; or to certain
states of the system, such as pregnancy' or

■ Predisposition is that which prepares the system for the re-
ception and entertainment of the exciting cause.

- Oliver, N. Y. Med. Record, .'Vug. 27, 1SS7, p. 243.

? Bouiilaud, Dic.de Med.: Chomel, Pneumonie, S. 31S; Copland,
Med. Die, Vol. i, p. 647 ; CuUen, Prac. Phys., Phila., 1792. Vol. i. p.
iSi : Fox. Reynolds' Syst. Med., Phila., 'iS8o, Vol. ii, p. 156; Gri-
solle. Traits <ie la Pneumonic; Hippocrates' Works, Adams' Ed.;
Huss, LungenentzUndung, 1S62, S. 9 ; Sturges, Nat. Hist. Pneumo-
nia. London, 1S76, p. 168; Ziemssen, Pleuritis u. Pneumonie, Ber-
lin, 1S62, S. 153; et. al.

4 Bennett, Restorative Treat. Pneumonia, 1866, p. 24; Juergen-
sen, Berliner Klin. Wochenschr., 1884, Nr. 17, S. 271 ; Patten, Jour.
Am. Med. Ass., Oct. 16, iS86, p. 425 ; Green, Pathology, p. 364.

5 In this connection it should be remembered that exposure
-which was yesterday borne with impunity may imperil life to-
morrow, as is often illustrated in practice.

6 See Pfeiffer. Berliner Klin. Wochenschr., 1S84. S. 198; Bagin-
sky, Pneumonie. TUb.. 1880, S. 82 : Krieger, Disposition zii Katarrh,
etc., Strassb., 1880.

7 Fox. op. cit., p. 157.

8 Juergensen, Ziemssen's Handb., Bd. v. S. 28; Pause, Lungen-
«ntziindung. 1861, S. 64.

chlorosis,' in females, or advanced emphysema,'"
etc.

The inhalation of various noxious gases, fluids
and .solids may act as a predisposing cause of the
disease. The lungs act as a filter and retain
much of the irritating substances which find ac-
cess to them," and these may light up a local in-
flammatory process'- which serv^es as a nidus for
the development of the pneumonic poison, or

; render the system less able to resist its onslaughts.

' Of such substances we may mention gasses aris-
ing from the combustion of anthracite and other
coal," natural gas," sewer-gas,'' smoke, steam and
heat, the fumes of acids" and bromine,'" vapor of
chloroform and other anaesthetics, '' cinders,
pollen, dust from hemp works, flouring and plan-
ing mills, cotton gins and cotton mills," seed and
grain threshing machines, =" needle, edged-tool and
gun-barrel grinding, button and naiP' making,
mining, '^^ quarrying'' and various other foreign
matters."

9 Fox, op. cit.. p. 157 ; Huss, op. cit., S. 9.

i^ Rokitanskv, Path. .\nat., Phila,, 1S56. Vol. iv. p. 56.

" Tyndall, Floating Matter in the .A.ir, London, 1881.

I- Lehmann. Expmt. Studien., Miinchen. 1S86.
I I-' Crawford, Diseases Wyoming Valley, Wilkesbarre, 18S1.
; "4 Corfield — N. V. Med. Rec. June, 1886, p. 665— doubts whether
1 this acts as a cause.

! "5 Corfield, London Lancet, 1884, Vol. i, p. 472 ; Bell, N. Y. Med.

Rec, Nov. 12, 1887, p. 663; Loomis, Pepper's Svst. Med., Vol. iii.
p. 31:-

if>£)yson, London Lancet, 1884, Vol. 1, p. 65.

'7 Brunton. Pharmacol., etc., Phila., 1885, p. 469.

»' Gerster, N. Y. Med. Rec, April 23, 1S87, p. 453; Wveth, Ibid,,
p. 474 ; et. al. Gerster has given a series of very luteresting cases
in which pneumonic fever followed the employment of auxsthetics.

A female, aged 43, submitted to lumbar colotomy, under ether.
On the following morning a severe chill ensued, followed by the
ordinary symptoms of pneumonic fever and death on the fourth
day. The entire right lung was solidified.

A man, aged 60. was castrated, under ether, and was attacked
with pneumonic fever two days later. The temperature rose to
106'^ F. and death speedily ensued.

A man, aged 61, underwent inguinal colotomy, under ether, and
on the next day was attacked by pneumonic fever, locally affecting
the entire right lung.

A man. aged 25. who had recently had pneumonic fever, took
ether for the extirpation of the inguinal glands. The affection re-
appeared in the same lung and proved fatal.

A woman, aged 50, was operated upon, under ether, for rup-
tured perineum. Pneumonic fever developed immediately and
terminated fatally.

A boy, aged 16. had the inguinal glands removed, under ether.
Severe pneumonic fever ensued. Recover\'.

It inaj- be that the pneumonic inflammation is due less to the
effects of the an;Esthetic than to the exposure and chilling of the
patient by the extensive uncovering and wetting of parts usualU'
clothed. Sec Wier. N. Y. Med. Rec, April 23, 18S7, p. 473 ; Abbe.
Ibid, p 474. For further information as to the effects of anassthet-
ics on the lungs see Brit Med. Jour.. Dec. 18, 1880.

•J Moen. Rpt. Health Officer, Oldham, 1S86.

-^^ I have met with an interesting series of cases of pneumonic
fever following exposure to the dust of clover-hulling machines,
of these the following are examples : A farmer, aged 42. engaged
in threshing clover, was attacked with pneumonic fever, locally af-
fecting the entire lefl lung. Three days later the base of the right
lung also became involved. Recovery was long delayed by a small
abscess in the right lung, which only began to improve after the
expectoration of a thick mass of pus iii which were imbedded some
small, dark objects, supposed to be pieces of clover-hull. A young
man, engaged in like occupation, developed pneumonic fever, the
local processes pursuing a lingering course ; improvement follow-
ing closely upon the expectoration of a small piece of clover-hull.
I Another gentleman, of middle age, likewise engaged, was attacked
' with pneumonic fever, with diffused local consolidations, which also
I pursued a lingering course.

-I Reeve, Jour. Am. Med. Ass'n. 1S85.

" Hirt, Die Staubinhalations Krankh., Breslau, 1871 ; Moll,
I Berliner Diss., 1869 ; Osterlen, Med. Statistik., S. 375.

23 Greenhow, "Trans. Path. Soc,. Vol. xviii.

-4 Zenker. Deutsche Arch. f. kliu. Med., Bd. ii ; Fox, op. cit., p.
158; Peacock, Brit, and For. Med.-Chir. Rev., Vol. xxv ; Holland,
Edinb. Med. and Surg. Jour., 1843; Grisolle, op. cit., p. 146; Ditistl.
distr. Zeitschr. f. Prak. Heilk., 1862; Bretonueau, Rech. Inflam.
Spec. Tis. Muqueaux, Paris, 1826. p. 100 ; Reitz, Sitz. k. k. Aked zu
Wien, 1867; Wyeth, op. cit.. p. 474; Veraguth. Virchow's Arch., Bd.

50

THE STUDY OF PNEUMONIC FEVER.

[July 13,

It has been doubted, and even denied, that
suspended solid matters could reach the alveoli,
but the observations of many writers disprove the
assertion."

A curious case of pneumonic fever came under
my notice several years ago : A male epileptic
imbecile, set. 22, shortly after eating, was taken
with a fit, falling to the ground with his face in a
shallow depression. Whilst in this position he
vomited freely and some of the ejecta found their
way into the lungs. The inflammation was con-
fined to the apex of the left lung, pursued an
ordinary' course and terminated in recovery.

Filling of the bronchi with water, as in sub-
mersion, is not infrequently followed by pneu-
monic fever.

The foreign matters may be of a septic nature
and cause pulmonary inflammation of a peculiar
character, besides infecting the system generally.
This is what occurs when the poisonous dust
arising from" fleeces of wool infected with anthrax
is inhaled.™

The foreign material may be a body of consider-
able size, and may remain for a long time in the
lungs without causing disease, but so long as it
or its effects remain it is an element of danger.

Hargrove" relates the following case : In the
autumn of 1866 a cockle-burr was lodged in the
right bronchus of a healthy woman of .18. After
subsidence of the first violent symptoms no seri-
ous inconvenience was encountered until Febru-
ary, 1869, when acute pneumonic inflammation
developed in the right lung. A second attack
ensued in June and the final one in July. At the
autop.sy both lungs were found inflamed, with an
abscess on the surface of the right one. The burr
was in a perfect state of preser\'ation.=*

The secretions of the respiratory tract, especi-
ally bronchial, when aspirated into the finer tubes
and alveoli act as foreign bodies, and, when not
promptly expelled, may pave the way for pneu-
monic inflammation. Collapse of lobules may

Ixxxii; Heszay, Ungar. Zcitschr., Bd. ii, 1859, S. 33 ; "Wilson, Med.
Times and Gaz., Oct. 17, 1864, p. 384 ; Robers, Phth. Carbon., Paris,
1862; Freiderich, Virchow's Arch., Bd. xxx, S. 394; Merkel, Arch.
f. klin. Med., Bd. viii, S. 206 ; Sanders, Schmidt's Jahrb,, Bd. cxxiv.
1864, S. 149 ; Beaugrand, Canstatt's Jahresb., 1865 ; Rindfleisch, Path.
Gewebl., Leipzig, 1871, S. 375; Fuchs, Henker's Zeitschr., 1837, S.
12; Vleminckx, Bull., etc., 1869, T. iii, p. 1249; Fran5ois, Bull.de
I'Acad. Beige, i8s7 ; Lewin. Inhalation Therap,, Berlin, 1865, S. 24;
Crocq, Schmidts' Jahrb., Bd. cxxvi, 1865,8.98; Beddoes, Pulmon.
Consump., London, iSor ; Kuborn, Mai. auxonvriers Mineurs, Paris,
1863; Morten, Vierteljahrschr. f. Ger. Med., Oct., i860; Brockmann,
Die Metal. Krankh., etc.. i8,!;i ; Peroud, Charb. du Poumon., 1862;
Markettor, Black Phthisis, Edinb,. 1846; Cox, Jour. Pub. Health,
March, 1857.

=5 Peacock, Lancet, N. Y., 1S61, Vol. i, p. 56 ; Greenhow, Lancet,
N. v., 1863, Vol. i, p. 306 ; Lakeman, Lancet, 1884, Vol. ii, p. 255;
Villaret, Anthrocosis. etc., Paris, 1S62 ; Maggiorani, Sulli ing della
sub. pulv. nella via della Resp. , 1858 ; Reimbault, Hyg. des ouvriers
Mineurs, Paris, 1861 ; Marshall, Lancet, 1K23 ; Schoiifcld. Employes
aux Mines de Charbon, Charleroi. 1843 ; Bartheleness, Lungen Mel-
anosis, Krlangen, 1S55 ; Fossion, Bull, de I'Acad. de Beige, 1859;
Kiipper, Rhein u. Westphal. Corresp. Bl., 1845, Nr. 17-22 ; Tardieu,
Hyg. de Mouleur, etc., Paris, 1855 ; Boens, Mai. des Houilleurs, 1S62;
Vernois, Ann.d'Hyg., 1858.

-•^See Greenfield, Loudon Lancet, N. Y., 1881, Vol. i, p. 481 ;
Bond, London Lancet, 1887, Vol. ii, p. 511.

»7 Am. Practitioner, March, 1870. p. 1.88.

28 For other cases and inforniation consult LeCount, Jour. Am.
Med. Ass'n, Sept. 17, l&87p. 371; Kinsman, Cincinnati Clitiic, Mar. 7,
1.S74, p. 113 ; McCormack, London Lancet, N. Y., 1852, Vol. i, p. 299 ;
Wells, Jour. Am. Med. Ass'n, Dec. 19, 1885, p. 675; et. al.

produce the same effects. The solid and semi-
solid secretions sometimes formed in the nares,
tonsils, pharynx, larynx, etc., may also cause
like results should they become dislodged and
find their way into the peripheral areas of the
respiratory tract.

Blood, pus and acrid, putrid or other secretions
from wounds or diseases of the respiratory tract
may pass into the finer bronchial tubes and be
followed by pneumonic fever.

This may occur in cancrum oris,^' scurvy and
other ulcerative diseases of the mouth, ^" cancer of
the tongue, pharynx or larynx and the operations
for its relief," diphtheria, tracheotomy and laryn-
geal intubation,^'' calculus of the bronchi,'^ chronic
bronchitis,"* haemoptysis,'" etc.

Disease and injury of the central nervous sys-
tem are verj^ frequently followed by pneumonic
fever.

Calmiel," in an analysis of i88 cases of organic
disease of the brain found acute inflammation of
the lungs present in nearlj' one-third of them.

A girl, aet. 5, received an injurj' of the head by
being run over by a carriage. Two or three days
afterwards feverish .symptoms set in, with stupor,
stertorous breathing, tremulous pulse, involuntary
discharge of faeces, convulsions and, finally,
death. At the autopsy no gro.ss lesion was found
within the cranium, but the right lung was found
violently inflamed and consolidated."'

A man, aet. 26, received a pistol-shot wound of
the head, from which he had partially recovered,
when, after exertion, pneumonic fever developed
and terminated fatally in ten days. At the au-
topsy the ball was found, partially encysted and
partially imbedded in the jugular fossa. The
pulmonary vessels were everywhere dilated, with

-^Baudelocque, quoted by Chomel, Pneumonic, S. 334 ; Grisolle,
op. cit.,; Fox, op. cit., p. 161.

5" Hermann, Lungenentziindung, S. 22 ; Murray, Loud. Lancet,
N. Y. 1882, Vol, ii, p. 429: Chomel, op. cit., S. 239; Fox, op. cit.,
p. 161.

3' Gould, Lancet, N. Y., 1881, Vol. i, p. 415 ; Albert, Wiener Med.
Presse, Oct. 30, 1881, S, 1373 ; McLeod, Lancet, 1S78, Vol. i, p. 750 ; Cur-
ling and Wordsworth, Lancet, N. Y., i860, Vol. i, p. 404 ; Stokes and
Baker, Ibid, 1881, Vol. ii, pp. 59-60 : Spanton, Ibid, p. 144 ; Page, Ibid,
p. 432 ; McKenzie, Illness of Frederick the Noble, London, 1S88;
Scheier, Deutsche Med. Wochenschr., June 7, 1S8S ; Seinon and
Shattuck, N. Y. Med. Record, April 28, 1888, p. 4S0 ; Mudd, St. Louis
Med. Rev., Nov. 10, 18S8.

3- Gross, Phila. Clin. News, April 9, 1S81, p. 202 ; Spencer, Lon-
don Lancet, N. Y., 1883, Vol. i, p. 463 ; Evans, London Lancet, N. Y.,
1859, Vol. ii, p. 44 : Jacobi, Diphtheria, N. Y., 18S0, p. 226 ; "Treves,
Lancet, 1884, Vol. i, p. 299 ; Gerster, Jour. Am. Med. Ass'n. May 22,
18S6, p. ji85 ; Bouchet, Paris M^d., 1SS4 ; Wier, Cincinnati Lancet
and Clinic,"^ Dec. 22, 18S3. p. 555 ; Anderson, Lancet, N. Y., 1S61. Vol.
i, p. 14S; Langenbusch, Jour. Am. Med. Ass'n, March 22, 18S4, p.
320 ; Brown, N. Y. Med. Rec, June 25 and July 23, 1SS7 ; Waxham,
Jour. .\ra. Med. Ass'n. Oct. 24, 1S85, p.469; Ripley, N. Y. Med. Jour.,
Feb. 14, 1SS5, p. 201 ; Mudd, Jour. Am. Med. Ase'n, June 25, 18S7, p.
70^; VanSantvoord, N. Y. Sled. Rec, Jan. 24, 1885, p. 107; Brothers,
N.'y. Med. Rec, Dec. 11, 1886. and June 18, 1SS7 ; Hoadley, Jour.
Am. Med. Ass'n, Mar. 26. 1SS7, p. ,^38; O'Dwyer, N. Y. Med. Rec,
June 18 and Oct. 29. 1887; Steiner. Ziemssen's Handb.; Caille, N,
Y. Med. Rec, June iR, 1SS7, p. 687; Peter. Gaz. Hebdom., iS6?, p.
689 ; Northup, N. V. Med. Rec, Dec. 11, 18S6. and June iS, 1SS7 ;'hu-
ber, N. Y. Med. Rec. June 18, 1SS7, p. 6S4.

33 Montane. N. Y. Med. Rec. July 30, 18S7, p. 146.

-34 Fox, op. cit., p. 250 : Rokitausky, Path. Anat.. Vt>l. iii, p. 50 ;
Legendre, Mai. Enfants, p. 223 ; Stukes. Dis. Chest, p. 159 ; Stewart,
Dilatation Bronchi, 1867; Biermer, Virchow's Handb.; Laennec,
op. cit.

-35 Drysdale, Med. Press, Jan. 21. 1885; Cleveland, Cincinnat.
Clinic, Sept. 1, 1877, p. 948; Fox. op. cit.. p. 158. *

36 Diet, de MM.. T. ii, p, 196, et Mai <fu Cen-eau, Paris, 1859.

37 Klein, Chir, Bemerkungeii, Stuttgart, iSoi, S. 41.

1889.]

THE STUDY OF PNEUMONIC FEVER.

51

a reticulated exudation in the alveoli and thick-
ening of the pleura.^*

That pneumonic fever often prevails in connec-
tion with cerebro-spinal fever has long been a
matter of common observation."

In these cases the pneumonic inflammation is
due either to pulmonary extravasation/" local vaso-
motor paralysis, paralysis of the vagus*' or paresis
of the respiratory muscles. '= Paralysis of the
soft palate and pharynx may be followed by the
disease.*'

When the vagus is implicated irritative matters
pass readih' into the lungs, from whence they, to-
gether with the mucus secretions, cannot be
again dislodged. Inflammation is the result.

A boy, set. 12, suffered a mild attack of diph-
theria and apparently recovered in due season.
After the lapse of three weeks there super\^ened
a gradually increasing paralysis of the palate to
such an extent that swallowing liquids was a
very difficult procedure — being invariably ac-
companied by regurgitation through the nares,
and often by coughing and choking. Ten days
later pneumonic fever was developed, ending in
recover}'. The faucial parah'sis graduallj' im-
proved, but was still present to a slight extent
eight years afterwards.

It has been believed that insanity predisposes
to pneumonic fever," but after an attentive study
of a great number of asylum reports I cannot
confirm the supposition. The influences of the
passions, hope, fear, anger etc., in this direction
are not fully known,*"

38 Fisher, N. V. Med. Jour., Aug. 25, 1SS3, p. 222.

39 Jeffe, Med. Chir. Runsdcbau. April. 1882, S. 242; Smith, Am.
Jour. Med. Sci., Oct., 1873, p. 314 ; Wilson, Fevers, N. V., 18S1, p. S7;
Warren, spotted Fever; Gallup, Epidemics of Vt., 1S16 ; Levick,
N. Y. Med. Rec. July q. 1887, p. 42 ; Bartholow, Prac. Med., N. Y.,
1S80 ; Clark, N. Y. Med. Rec, June 15, 1S72 , Carpenter, N. Y. Med.
Rec, July 16. 1S87. p. 85, et. al. Wood — N. Y. Med. Rec. May 14,
18S7, p. 557 ; Robinson. Ibid, p. 55S, and others — have not been able
to obser\'e any relation between the two diseases,

4^ Brown-Sequard, in experimenting on animals, found that if
an injury of the head was survived for a time that pneumonic in-
flammation frequently ensued. After such injuries emphysema
and numerous minute extravasations were found in the lung on
the side opposite the cerebral injurs-. See London Lancet, Jan.
7. 1S71.

These observations are confirmed by those of Fleischmann —
Centralbl. f. d. Med. Wissensch., 1871, Nr. 28 — on men. and a case
reported in the U. S. Mariue-Hospt. Rpts.. 1883, p. 262.

41 Traube, Expmt. Path.. 1846; Simon, Holmes' Syst. Surgery-.
Phila., 18S1, Vol. i, p. 89: Gartner and Amrus, Lond. Lancet, Mar,
7, 1SS5 ; Wilks, .\ss'n Med. Jour., Feb. 17. 1854, p. 145: Frey, Arch,
f. Phys., Bd. xiv, 1877; Lagout, L'Union MM., Oct. 19, 1878; Mac-
ewen, Phila. Med. News. Aug. 18, 1SS8, p. 173; Rohden, beutsche
Med. Wochenschr.. June, 1S77 : Bartholow, Med. Electricity, and
op. cit.; Fernet. La France M6d., 1S7S : Rosenbach, Berliner Klin.
Wochenschr., Oct. 14, 1S78 ; Osier, Canada Med. and Surg, Jour.,
July, 1SS7; Broadbent, Brit. Med, Jour., March. 18.87; Gaskel, Jour,
Phys.. Vol. v-vii ; Jessop. Dobell's Rpts., 1876, p. 48 ; Warner, Brit,
Med, Jour,, 18S7 ; Mills, Jour. .\uat, and Phys, Weit, Vols, xx-xxi ;
Th^se de Paris. 1S82 ; Bettleheim, in Lupine's Pneuraonie, Wien,
1883. S. 115 ; Hewan, Med. Times and Gaz., March, 1875 : Niemeyer,
Handb, d. Spec, Path, u. Therap., Berlin. 1S62 ; Bianchi, Rivista
Clin., Feb., 18S8 ; Lupine, Pneumonie, Wien, 1883,8, 29; Fabre, Gaz,
des H6p., 1878, p. 1171 ; et, al.

4- Erichsen — Concussion of the Spine, N. Y,, 18S3, p, 46 — has
shown that certain injuries or diseases of the spinal cord maybe
followed by paresis of the muscles of respiration to such an extent
as to prevent the expulsion of the bronchial secretions. Results
similar to those following paralysis of the vagus ensue. See also
Richardson, London Lancet, 18S7, Vol. ii, p, 1221,

43 Lancet, N. Y,, 1883, Vol. ii, p. 319.

44 See Mann,.N, V, Med, Jour,, Jan. 3, 1885, p. 24.

45 See LaRoche, Pneumonia, p, 427 : Doubleday, N, Y, Med,
Rec, March 28. 1885, p, 343,

Otitis media is not infrequently complicated by
pneumonic fever."

In 1880, I saw in consultation a child, aet. 3,
that had been ill for three weeks with otitis
media purulenta with perforation of the drum
membrane. Two days previously the discharge
had ceased, followed by fever, delirium, incessant
vomiting, cough and the evidences of inflamma-
tion at the ba.ses of both lungs. Icterus and
effusion into the left pleural sac ensued and he
died a week later.

A female child, i year old, was restless for a
a day, awoke from sleep with fever, retraction of
the head, a nasal discharge, a stifled cough and
a piercing crj', followed bj- moaning. Four daj-s
later there were presented the evidences of pneu-
monic consolidation at the base of both lungs and
distention of the tympanic cavit)-. The drum
membrane was punctured and exit given to a
small amount of purulency. The discharge be-
came free after a few hours, and the pulmonary
symptoms rapidly subsided.

A young lady, aet. 22, experienced for a few
da5's the ordinarj' symptoms of a " cold in the
head," notwithstanding which she exposed her-
self for several hours to intense cold. This was
followed b}- intense pain in both ears, fever epis-
taxis, delirium, dry tongue, sordes, total deafness,
cough and rusty expectoration. Examination on
the fifth day revealed hepatization of the base of
the left lung. The right ear was discharging and
the left drum membrane was punctured. Re-
covery, including hearing ensued.''

Injuries of the chest may be followed by pneu-
monic fever," although it is not a necessar>-
consequence."

A boy, set. 15, engaged in a scuffle, was sprung
upon by his antagonist, who knocked him down
and knelt upon his breast. Pain at the injured
spot was at once complained of, although there
was no outward injury to be seen. Illness came
on, with fever and the symptoms of pulmonary
inflammation. Death occurred after ten days
and the autopsy revealed consolidation of the
lung beneath the seat of injury.'"

A simple, uncomplicated, fracture of the ribs,
although seldom followed by pneumonic inflam-
mation in the young, may be so in the aged sub-
ject of chronic bronchitis. Under these circum-
stances a fracture of the first rib or clavicle is of

4^ Gull, Med, Chir. Trans., Vol. xxxviii : Hinton. Holmes' Syst.
Surg.. Vol. ii, p. 211 ; Steiner, Kinderkrankheiten.

47 For further information see Wells, Cincinnati Lancet and
Clinic. June lo, 1S82, p. 504; Hillier, Diseases of Children.

4? Richardson. Jour. Am, Med, Ass'n, July 24. 1884, p, 47 ; Swett.
Dis. of the Chest, p, 84; Hilton, Med. Times and Gaz,, 1867, Vol, i,
p, 144: Senn. Jour, Am. Med. Ass'n, Sept, 3. 1SS7, p, 317; Fox. op,
cit,. p, 158; GnsoUe. op, cit., p. 316: Wunderlich. Handb, d. Spec
Path,, Bd, iii, S. 13: Andral. Med, Clin.. Ob,sv, 7; Duchek. Prager
Vierteljahrschr,, 1853, S, 37 ; Litten. Zeitsch, f, k. Med.. Bd. v ; Thir-
iar. N. Y. Med, Rec, April 21. 1888, p, 447; Chomel. Pneumonie. S,
320 ; Boldt, N, Y, Med. Rec, Aug. 20, 18S7, p, 224 ; LaCount, op, cit,,
p, 370; Pied, Pueumonie, U, S, Marine-Hospital Rpts,, 1883, p, 245;
Lancette Francaise, 1834. p, 1S5 ; et. al,

49 Eraser. Wounds of the Chest, London, 1839 ; Flint, N, Y, Med.
Rec, July 14, 1877,

5^ Morgagni. De Sed, et. Cur, Morb,, Lib, ii, Ep, xx, S, 28,

52

THE STUDY OF PNEUMONIC FEVER.

[July 13,

serious import, inasmuch as they are the starting
point — the fulcrum, as it were — of the system of
respirator}^ muscles, and it is upon the integritj^
of this base of support that their proper function
depends/' In these cases the respiratory move-
ments and cough are restrained and impeded by
pain, and the bronchial secretions flow into the
alveoli, causing irritation and inflammation.
Not only do such results occur from the injury
alone, but in some undoubted instances the sur-
geon has unconsciously aided in bringing it about
by apph'ing bandages so tightly as to still
further impede the action of the respiratory
muscles.

Hernia of the lung and paracentesis of the
thorax"^ may be followed bj- pneumonic fever.

Pneumonic fever has frequently followed other
injuries" and operations, e.g., concussion of the
lungs," caries of the spine," resection of ribs,'*
resection of joints, '■ resection of the pylorus,"* in-
juries to nerves,"' burns and scalds,'" the bites of
rabid and other animals." the bites of venomous
snakes,'- pulmonan,' apoplexj'," etc.

It has been supposed," but most probably er-
roueousl}-,'" that overexertion of the lungs, as in
public speaking, singing, playing wind instru-
ments, etc. , predisposed to the disease. Excessive
bodily exertion, especially when accompanied bj'
anxiet}' is a factor in its causation."

Pneumonic fever may also follow or accompany
various diseases of near or distant organs or
structures, e. g., pericarditis,"" inflammation of
the respiratory tract above the air-cells," inflam-
mation of the bronchial glands," abscesses of the
thoracic walls,"" spleen,"' liver," abdomen,"' pelvis,"'

51 Hilton, London Lancet, N. Y., 1852, Vol. i, p. 262.
f: Hughes, Guy's Hospt. Rpts.. Vol. ii, p. 336 ; Van Santvoord,
N. Y. Med. Rec, March 17. 1SS3. p. 301.

53 Erichsen — Lancet, N. V., 1S55, Vol. i, p. 357 — found it present
in 28 of 64 cases of grave surgical injuries submitted to post-mortem
examination.

54 Albutt, London Lancet, April 27, 187S ; Schneorl, Deutsche
Arch, f k. Med., Bd. xlii.

55 Farre, Lancet, N. Y., 1S61, Vol. i, p. 341 : Allan. Ibid, 1S81. Vol.
ii, p. 223.

56 Kronlein, Berliner Klin. Wochenschr.. 1S84, Nr. 9.

57 Fergusson. Lancet, N. Y., 1859, Vol. i, p. 298.

58 Czerny, Wiener Med. Wochenschr., 18S4, Nr. 17. iS u. 19.

59 Bowlby, London Lancet. 1SS7, Vol. ii, p. 53.

to Wilkes. Guy's Hospital Rpts., Vol. i. p. 146; Holmes' Syst.
Surg., Vol. i, p. 414.

^'i Lutaud. Lancet, 1887, Vol. ii, p. 235.

6= Laennec. op. cit., p. 250 ; Williams, Lancet. N. Y.. 1862, Vol.
ii. p. 3; Chorael, op. cit,, S. 327. This is denied by LaRoche. op.
cit., p. 351 ; Juergensen, Ziemssen's Handb.. Bd. v, S. 35 ; et. al.

63 Eichberg, Cincinnati Lancet and Clinic, Dec. 15^ 1S83, p. 525.

^i Wunderlich. Spec. Path.; Fox. op. cit.. p. 158; Barth, quoted
by Chomel. Pneumonie. Leipzig, 1S41.

65 GrisoUe, Traits de la Pneumonie. 1864, p. 115.

^ See cases of Andral. Med. Clinic, Vol. ii. p. 114-, Williams,
London Lancet, N. V.. 1862. Vol. ii. p. 4 ; Grisolle. op. cit,. p. 316.

'7 Ralfe, Lancet, N. Y., iSSi, Vol. i, p. 52; Flora, Cincinnati
Lancet and Obser\'er, April. 1865. p, 215 ; Day, Loudon Lancet, N.
v., 1881, Vol. ii, p. 408.

^ Ripley. X. Y Med Gazette, Nov. 25, 1S82, p. 562 ; Siebert, N,
Y. Med. Rec, May 30, 1885, p, 60S.

^■9 Bolles, Boston Med. and Surg. Jour.. Feb. 3, 1881, p. 104 ; Lo-
rey, Berliner Klin. Wochenschr.. 1884. S. 32; Roosevelt, N. Y. Med.
Rec, July 21, i.SSS, p. So.

70 Johnson. London Lancet, N. Y., 1864, Vol. ii, p. 605.

7' Griffiths, London Lancet, 1887, Vol. ii, p. 68.

7? Fowler, Lancet, 18S4, Vol. i, p. ^25; Barensprung. Arch. f. k.
Chir.. Bd. xviii, S. 557, CoUes. St. Louis"Med. and Surg. Jour.. Oct.,
1878, p. 195; Clark, Lancet, 1884, Vol. i. p. 525; Chvostek, Wiener
Klinik, i88i, S. 132 ; Morchead. Diseases of India ; DeCastro, Abces
du Koie. Paris, 1870; Freriechs. Klinik d. Leberkrankh.: Larive,
Jour. Hebdom., T. iii, p. 220 ; Pcage, Am, Jour. Med. Sci., 1837 ; Rai-

spine,'° neck,'" etc., thoracic aneurism," stricture
of the oesophagus,'* pleurisy,'' chronic heart dis-
ease,'" obstruction of the bowels," acute myostitis,*^
ulcerative endocarditis,"^ pyaemia-' and other mor-
bid states of the blood,'* chronic cancerous dis-
ease,"' narcotic poisoning," acute and chronic al-
coholism," albuminuria and other renal diseases,*''
including diabetes,'" the acute exanthemata," ery-

kem, Jour. Hebdom.. T. i, p. 133; Thierfelder, Ziemssen's Handb. ^
Bd. viii. S. 123 ; Loomis. N. Y. Med. Rec. July 21. 18SS, p. 78.

73 Bristowe, London Lancet. N. Y., 1883^ Vol, ii, p, 436 ; Good-
hart, Ibid, p. 4S3.

74 Porter, Boston Med, and Surg. Jour., Sept. S, 1S81. p. 229 ;
Tessier, in Chomel's Pneumonie. S. 48 ; Silbermann. Berliner KUn-
ische Wochenschr.. 1884, S. 31 : Minot. Boston Med. and Surg. Jour.,
Sept. 8. 1S84, p. 231.

75 Sebatier, Jour. Hebdom.. 1829, T. 11, p. 90; Hamilton, Prac.
Surg.. X. v.. 1872, p. 751 : Shaw, Holmes' Syst. Surg.. Phila., iSSi,
Vol. i, p. 312.

7^ Moore, London Lancet. X. Y.. 1S64, Vol. ii. n. sSo.

"Thompson, N. Y. Med. Rec, March 31, 1886, p. 336; Gull,
Guy's Hospt. Rpts., Vol, v; Bristowe, London L-ancet, N. Y., 18S1,
Vol", i. p. 399 ; Robinson, X. Y. Med. Gaz.. Nov. 25. 1SS2, p. 562.

7^ Forster. London Lancet, N. Y., 1S63, Vol, ii, p. 723; Hoadley,
Jour. Am. Med. Ass'n, March 26. 1.S.S7. p. 33S.

7<y Peacock. Edinb. Med. and Surg. Jour., 185,=;, p. 2&1 ; Fox, op.
cit.. p. 252: Biermer. Virchow's Handb.. Bd. v. liefl i : Chambers.
Cincinnati Lancet and Obser\*er, Jan. i.'^63, p. 50 ; Heinmann, N. Y.
Med. Rec. Jan. 26. 18.^4. p. 106 : and a great many others.

The intimate relations existing between the lung and its serous
envelope sufficiently explains why it is that the one is scarcely
ever inflamed without involvement of the other. This fact has
been recognized by every observer from the most ancient to the
present time.

*^ Andral. Anat. Path.. 1S32. T. ii. p. 517; Virchow. Virchow's
Arch., Bd. i, S. 460 ; Stokes. Diseases of the Heart; Hasse. Path.
Anat., 1S46. p. 219; Walshe. Dis. Heart, Phila., p. 2S9 ; Niemeyer,
Spec. Path. u. Therap., Bd. i. S. 117 : Oppolzer, Krankh. d. Herzens,
1S69. S. 199 ; Latham. Dis. Heart. 1&47, p. 320 , Aitken, Sci. and Prac.
Med.; Fuller, Dis. Lungs. 1S62. p. 562 ; Skoda. Ausculta. u. Percuss.,
Wien. 6 te, Auflage, S, 282; Delafield, Am. Jour. Med. Sci., Jan,, 1S71,
p. 95 ; Grisolle. op. cit.; Chambers. Med. Chir. Rev.. Oct.. 1S53 ; and
others.

^' Cameron. Glasgow Med. Jour. iSSo, p. 444 ; Ogle. Lond. Lan-
cet, J8S7, Vol, ii, p. 105 ; Porter. Jour. Am. Med. Ass'n. July 28, 1SS8,.
p. 123; Liicke, Centralbl. f. Chir.. iS.SS, Nr. i.

^5 Jackson, Jour. Am. Med. Assn. Jan. 11. 1SS7, p. 663.

^' Jaccoud, Pathol. Int., T. i; Wysskowitsch, Virchow's Arch.,
Bd. cii. heft 2 ; Copland. Lancet. 1884. Vol.i.p. Soo; Shattuck. Bos-
ton Med. and Surg. Jour.. March 31, iS.8i, p. 298; Osier. Arch. Med.,
Feb.. i8Si,p. 44: Bramwell.Ara: Jour. Med. Sci., July, 18S6; Walshe,
Dis. Chest, p. 312 ; Hopkins, N. Y.' Med. Rec, Feb. 6, 1SS6, p. 159 :
McClure. London Lancet. 1SS7, Vol. ii. p. 251 ; Musser, Jour. Am.
Jled. Ass'n, May 21, 1887, p. 561 ; Pollock, London Lancet, 1S82, Vol.
ii, Dec. 9.

84 Wright. London Lancet. X. Y., I'Si. Vol. ii. p. 406; Rccolin,
M^m. de I'Acad. de Chir.. T. iv, p. 429; Tussell. London Lancet. X.
v.. 1.881, Vol ii, p. 219; Borden, Traits sur les Tissu Muqueaux ;
and others.

S5 Routh, Med. Times and Gaz., April 7. 1S55 ; LaRoche, Pneu-
monia, p. 451 ; Weinlechner. Wiener med. Wochenschrift, 18,84, S.
381; Fincham. London Lancet. N. Y.. 1858. Vol. i. p. 524; Wachs-
niuth. Die Bluterkrankh . :Magdeburg, 1849; Copland. Med. Die,
Vol. iii. p. 299; Parvin. Jour. Am. Med. Ass'n. June 20, 1885. p. 603;
Barnes, London Lanceti X. V . 1,862. Vol. i. p. 389; Chomel, op. cit.,
S. 237: Tonnell^. Arch. G^n. de MM.. T. xxii. p. 4S7 ; Fox, op. cit..
p. 161 ; Budin. Jour. Am. Med. Ass'n. Aug. 27, 1SS7, p. 2S5 ; Fleisch-
mann. N. Y. 3Ied. Rec. Mav 14. 18S7. p. 562.

8' Grisolle, Traits de la" Pneumonie. Paris, 1S64; Fox, op. cit.,
p. 162.

87 Mvgge. Nordisk. Med. Arch., iSSi ; Wilks, Ass. Med. Jour.,
Feb. i7.'i'8m. p. 14,8; Tennent. Glasgow Med. Jour., 1870, Vol. i. p.
74 ; R^ichert. Am. Jour. Jled. Sci.. Oct.. 18.81. p. 441 ; Brunton. Mat.
Med. and Pharmacology. 1SS5; Mfilier, Mfm. de I'Acad. de MM.,
T. X, p. 726.

8* Doubledav, X. Y. Med., Rec, March 28, 1.8S5, p. 343 ; Rooker.
Cincinnati Lancet and Ob5er\-er. Feb., 1862. p. 82 ; Copland, op. cit..
Vol. I. p. 7.88; Fox. op. cit.. p. 1,87; Peters. N. Y. Jour. Med., Vol.
iii. p. -i^s ; Van Bibber. Jour. .\m. Med. .4ss'n. July 28. iSSS. p. 113 ;
MartirirHuraan Body, p. 183 et p. 184; Huss, Atcoholismus Chronica,
Stockholm, i8i;2; Callender, Holmes' Svst. Surg., Vol. i, p. 54S ;
Lee, in Copland's Die. Med., Vol. i, p, 7S8 ; Flint, Prac. Med.. 1868,
p. iSo ; Francis, in Ginroel's Baccuus, p. 470 ; and many others.

89 Sturges. op. cit. .p. 82; Fox. op. cit.. p. 161 ; Bamberger. Volk-
mann's Vortriige. Xr. 173; Stewart. Bright's Disease: Becquercl,
S^m^iotiquedes urines, 1S41 ; Grisolle, op cit.; Paget, London Lan-
cet, X. Y.. 1.864. Vol. i. p. 189 ; McDowell. Ranking's .\bst., 1856. Xo.
24. p. 6^ ; Jones. Med. News, 1870, p. 113; Simon. Lancet, X, Y.,
1S51, Vol. 1, p. 174: Jaccoud. Clin. MM.. 1S67; Taylor. Med. Chir.
Trans.. 1S4';. p. s6s ; Turner. Lancet. 1S.84. Vol. i. p. S4S ; Bright.
Guy's Hospt. Rpts., 1836; Rosenstein, Path. u. Therap., Xieren-
krankh.. S. 19S ; Loomis. N. Y. Med. Jour.. Nov. 10, 1S8S.

« Elstein. Arch f k. Med., Hd. xxviii ; Freriechs. Deutsche.
■Med. Woch.. 1881, Nr. 24 ; Juergensen, op. cit., S. 28 ; Patton, Jour

1889.]

MEDICAL PROGRESS.

53

sipelas'^ and chronic skin diseases,"' cholera,-'* in-
fluenza,■*'■ glanders, ^"^ difficult dentition/'^ malarial
intoxication'" although some vehemently deny
that it bears any causative relation to the disease
in question;^" typhus, typhoid'"" and other forms of
continued fevers,'"' plague,'"- dysenter>',''' senile
gangrene,'"* rachitis,'"^ melanosis, '""'sweating feet, '"^
vesicle calculus,'"' pulmonar>^ phthisis,'"' gonor-

Am. Med. Ass'n, Oct. 10, 18S6, p. 425; DeWolf. Ibid, Vol. i, p. 582,
and Med. News, Jan. 7, 1S83. p. 8.

91 Andral, op. cit., p. 16S ; Tanner, Dis. Children, p. 160 ; Gri-
solle. op. cit.; Rpt. Bd. Health D. C. 1878, p. 115 ; Gee, Reynolds'
Syst. Med.. Vol. ii, p. 344 ; Chorael, op. cit., S. 32S ; London Lancet,
18S4, Vol. i, p. S56; Rilliet et Barthez. Mai. des Enfauts. T. iii, p.
264; Northup. N- V. Med. Rec. July 25, 1887, p. 114; Bartels. Vir-
chow's Archiv., Bd. xxi, S. 756 ; and others.

9- Billard, Mai des Enfants. Paris. 1S28. p. 113 ; Lee. op. cit., p.
956: Busk, Holmes' Svst. Surg., Vol. i. p. 531 ; Strauss, Rev. Men-
suelle, Sept., 1S79 ; Labb^. These de Paris, 1858, p. 57 ; Sutton, West.
Lancet. Nov., 1843 ; Austin. V. S. M,-H. Rpts., 1S84. p. 123 ; Stokes,
op. cit., p. 339 ; Fox. op. cit., p. 160.

93 Lancette Fran^aise, 1837, p. 243

04Gubian, Thdse de Paris, 1855; AVassige, Bull. Acad, de M6d.
de Belg-., 1S49. T. iv., p. 24 ; Moering, Hist. Choi., etc., Leip., 1830 ;
Sturges, op. cit.. p. 157.

•^5 Wilson, Fevers, N. Y. :8Si, p. 33: Sydenham, Works, by
Wallis, p. 330 ; Mussey, Clin. M^d., Paris, 1874 ; Guiteras and White,
Phila. Med. Times, April 10, 18S0 ; Peacock. Influenza, London. 184S;
Graves, Clin. Med.; Hamilton. Influenza, London, 17S6.

9f' Poland, Med. Times and Gaz., Mar,, 1869 ; Dickinson, London
Lancet. Vol. i, 1869.

I" Patton, Jour. Am. Med. Ass'n, Aug. 11, 1883. p. 140 ; Fox, op.
cit., p. 157; Ziemssen, Pleuritis u. Pneumonie, Berlin, 1862.

9* Hippocrates, op. cit., p. 195; Frank, Prax. Med., Lib. ii, p.
315: Lancisi. De Nox. Paludum Effluviis ; Sydenham, op. cit., p.
3$; Cleghorn, Dis. Minorica, p, 257; Wells. Trans. Med, Chir. Soc,
Vol. iii, p. 537 ; Jackson, Feb. Dis., London, 1820. Vol. i, p. 10 ; Bell,
Med. Phvs. Jour., Vol. ii, p. 316: Rush, Works, Vol. iii, p. g; Mac-
culloch. Malaria, p. 442; Williamson, Med. Reg., Vol. iii, p. 453:
Boat, Life of Armstrong, Vol. ii, p. 4': ; Anderson, Trans. Ala. St.
Med. Ass'n, 1854: Yates, Bilious Fever, Albany. 1S13, p. 27; Sar-
cone, Mai. de Naples, etc.; Lewis, N. O. Med. Jour., Vol. iv, p. 28;
Bizzell, Trans. Ala. Med. Ass'n. 1.S75 ; Gaines. N. O. Med. Journal,
ifi6:; Ford. St. Louis Med. and Surg. Jour., Feb.. 1878: Manson,
N. O. Med. Jour., Sept., 1857 ; Delacroix, These de Paris. 18^5 ; Sko-
da, Algem. Wiener Med. Zeit., 1862, No. 42; Ballard. N. W. M'^d.
Jour., July. 1849, P. 93: Chomel.op.cit-,S. 240; Holt, N. Y. Med. Jour.,
Feb. 21, 1S85. p. 217 ; Lescher, X. W. Med. Jour., Mar.. 1S50. p. 509 ;
Wallian, N. Y. Med. Jour., Feb. 7, 1885. p. 166: FleurT,-. Jour. Univ.,
T. liv, p. 354 ; Cazentre. Lancette Fran^aise, T. viii, p. 343; Mat-
thews, N. W. Med. Jour,, Jan., 1849, p. 3S3 ; Bell, N. Y. Med. Jour.,
Feb. 7, 1SR5, p. 165 ; Fox, op. cit., p. 157 ; Roche et Janson, Elem. de
Path., T. i, p. 582 ; Van Bibber. Jour. Am. Med. Ass'n. July 28, iSSS.
p. 1 12.

99 Loomis, N. Y. Med. Jour., Feb. 7, 1S85, p. 165 ; Sternberg, Ma-
laria, N. Y., 1884 ; Schultz, Am. Prac. Aug. and Sept.. 1879 ; Flint,
op. cit.. p. iSi ; LaRoche, op. cit.; and others.

!«' Murchison, Continued Fevers, p. 1S4 ; Tweedie. Lancet, N.
Y.. i860. Vol. ii, p. 7; Stokes, London Lancet, N. Y., 1854, Vol. ii. p.
293, and 1855, Vol. 2. p. 121 ; Wilson. On Fevers, p. 182 ; Coupland.
London Lancet, 1S84. Vol. i, p. 335 ; Schultz, Jour. Am. Med. Ass n,
July 31, 1886, p. iiQ ; Flint, op. cit., p. S20 ; Gueneau de Mussy, Gaz.
des H6p., Avr., 1S46 ; Sauvages. Syst. Nosol.. Vol. i ; Fod^r^'. Med.
Reg.. T. V, p. 351 ; Chorael. op. cit.; Bartlett, Fevers, p. 111 ; Hosack.
Med. Reg., Vol. iii, p. 449; Wood, Prac. Med., p. 39; LaRoche, op.
cit.. p. 450 ; Huxhara. Fevers, p. 59 ; Jackson,^ Boston Med. and Surg.
Jour.; Montault, M4m. de I'Acad. de IVI^d., T. vii, p. 209 ; Cotting.
Med. Addresses, 1875, p. in. Louis. Fiev, Typh., T. i, p. 360. Bar-
low, Lancet, 1884, Vol. 1, p. 745. Curtis, Boston Med. and Surg, Jour.,
May II, 1876. p. 551. Trousseau, Clin. Med.. Phila., 1873, Vol. ii, p.
260. U. S. Marine-Hospt. Rpts,, 1883, p. igo. Harley. St. Thomas"
Hospt. Rpts,, 1873. Diomantopulos. Tvphus of Smyrna, Wien. 188S.

i_.i Veale. British Armv Rpts,, 1879. Wernich, Zeitsch. f. Klin.
Med-, Bd. iv, S. 385. Deslais, These de Paris, 1S77. Wilson, op. cit..
p. ]S2. Parr>', Am. Jour. Med. Sci., Oct., 1870, p. 356. Barrella,
Bull, de I'Acad. de M^d. de Belg., 1S77, p. 124. Dublin Jour. Med.
Sci., Vol. \'iii, p. 334.

>'^'- Rivierius, De Feb. Pest., L. ii, p. 95.

I*'? LaRoche, op. cit.. p. 451.

>p4 Coote. Holmes' Syst. Surg., Phila., 1881, Vol. i, p. 363.

"'5 Parr>*, Am. Jour. Med. Sci., Jan., 1872, p. 23. Fox, op. cit..
p. 156.

"^ Stein, N.'Y. Med. Rec, May 21, 1887, p. 517. Todd, Jour. Am.
Med. Ass'n, July 14, 18RS, p. 53.

i"7 Jour. I'Experience, T. 1, p. 488.

'^ Roberts, London Lancet. N. Y., 1859, Vol, i, p. 128.

>'^ Watson, Prac. Phys., 1845, p. 581. Chomel, op. cit., S. 83.
Moxon. Med. Times and Gaz., Jan. 21, 1S71. Copland, op. cit., vol.
iii, p. 1215. Sturges, op. cit,, p. 96. Louis, On Phthisis, p. 38. For-
mad. Jour. Am. Med. Ass'n, vol. ii, p. 144. Gerhard. Dis. Chest,
1S60. p. 24S. Andrew, Lancet. 1884, vol. i, p. 786. Leudet, Arch. G^n.
de M^d., May. 18R5. Williams, London Lancet. N. Y.. 1862, vol. ii,
p. 7. Wendt. N. Y. Med. Rec, Oct., 1S84. p. 430. Sarater. Berliner
Klin, Wochenschr June 2^. 18S4, Kinnicut. N. Y. Med. Rec, Oct.
u. 1S84, p. 399. Se6, Le Prog. M^d., Dec. 8. 1883 ; and many others.

rhoea and other venereal diseases,"^ rheumatism,"'
pertussis,"' mumps, "^ etc.

Not only may various diseased states"' be ac-
companied' by pneumonic fever, but the malady
may follow the cure of some others, e. ^., chronic
ulcers,"^ chronic agues, ""^ rectal sinuses"" haemor-
rhoids, etc.

A gentleman, set. 50, for twenty years a martyr
to bleeding piles, was operated upon by the in-
jection of a glycerinated solution of carbolic acid.
The operation was successful, but was soon
followed by pneumonic fever, locally affecting the
base of the right lung. Great relief followed the
application of a blister to the affected side, a
seaton to the inside of one thigh and of leeches
around the anus. Recover\^ ensued.
{To be coficluded.)

MEDICAL PROGRESS.

On Diabetes Mellitus. — Seegen {Zeitsch,
fur Klin. Med. XIII., p. 267) regards the mild
form of diabetes — diabetes of the fleshy — as pure-
ly of a hepatic origin. The cells of the liver alone
are affected ; in consequence of an anatomical or
chemical change as yet unknown they have lost
their glycogenic power. A large portion of the
sugar introduced by the food is thus no longer
utilized but carried off in the urine. In this form
of diabetes diet has great therapeutic effect. The
severe form of diabetes, diabetes of the lean, is
due on the other hand to a change of all the cells
of the organism which have lost their power of
utilizing the sugar furnished by the blood. Diet
in these cases will merely have a pallia-

i"^ Biblioth. Med., T. xii. p. 117. Lancet. N. Y., 1859. vol. ii, p. 437.

m Lupine, Pneumonie, Wien. 1S83, S. S9. Fuller. On Gout, etc,
p. 385. Taylor. Med. Chir. Trans.. 1845. p. 565. Schcenlein. Klin.
Med. Rev., 1845. Trousseau. L'Union Med. 1S55. Grisolle, op. cit.,
p. 173. Aran. Gaz. des Hop., i860. Lithgow, Lancet, N. Y.. 1SS4,
vol. i, p. 101. Yaillard, Provence M^d.. No. 28. Eberle, Prac. Med.,
1&32, vol. i. p. 293. Sieveking, Brit. Med. Jour., Feb. 2, 1&6S. Ball.
These d' Aggregation. 1S66. Juergensen. op. cit., S. 144. Black,
Lancet, N. Y., 1883, vol. ii, p. 458. Fernet, These de Paris, 1S65.
Andral. op. cit., p. iiS. Latham. Clin. Med., vol. i. Burrows, Lan-
cet, July 2K>, 1S45. Loomis. Phvs. Diag., p. 60. Lemoine, These de
Paris, 1869. Monly. Th^se de'Montfell, 1S76. Chomel. op. cit., S.
32q. Davis. Prac. Aled.. 1SS4. Nicot. These de Paris, 1829. Roupell,
Lancet, N. Y., 1S51, vol. ii, p. 218. Vasquez. These de Paris. 1S7S,
Peacock. Lancet, N. Y.. 1821, vol. ii, p. 259. Sturges. op. cit.. p. 70.
Marmonnier, I.vou M^d., 1873. Humblet. ,\rch. M^d. de Beiges, 1SS8.

"= Radclifle" Lancet, N. Y., 1S56, vol. ii, p. 279. Rpt. Ed. Health
D. C, 1878. Copland, op. cit.. vol. ii. p. 276. Hewitt, Whooping-
Cou^h, London. 1S55. Tanner, op. cit.. 290. Trousseau, Clin. Med.,
vol. 1. p. 131. Laeiuiec, op. cit.. p. 102. Smith, Med. Chir. Trans.,
1854. Vogel, N. Y. Med. Rec, May 14, 1887. p. S53. Marshall, Rpt.
Me. Bd. Health, 18S5.

"3 Haldcrman, Jour. Ain. Med.. Ass'n, May 14. 1887, p. 544. In
March, 1876. I saw a man, aged 35. who had been, six days before,
attacked by mumps. There had been but little inconvenience un-
til the day previously, when he had a profound chill followed by
swelling of the right testicle and inflammation of the base of the
right lung. Recovcn.- ensued after ten days.

"1 For further information and cases consult I'. S. Mar. -Hospt.
Rpts., 1887, pp. 169, 206, 217, 222, 230, 205. Rpt. Roosevelt Hospital,
1S75. PP- 24-25, and for 1874. p. 25. Low, Am. Med. and Phil. Reg.,
vol. iv, p. 31. Ingals. Jour. Am. Med. Ass'n, Dec 17, 1887. p. 788.
Hulke, London Lancet, 18S7. vol. ii, p. 1064. SaK-ia. L'Ospedale
Lina, Rend. Statis, 1881-86, Naples, 18S7. Hulbert. Rpt. Health Com.
St. Louis, 1SS6. p. 276. Hirsch, Hist. Geog. Path., Bd. ii, p. 37.
Crothers. London Lancet, 1887. vol. ii, p. 1010. Hawkes. Ibid.p. 1271.

"5 Bouresche, These de Paris, 1S24.

'I** Andral. op. cit., p. 159. Broussais, Chron. Phlegmas.

"" Allingham, Diseases Rectum, Phila., 1S83, p. iS.

54

MEDICAL PROGRESS.

[July 13,

tive effect. In patients with diabetes, besides tu-
berculosis, a special fibrous pneumonia (already
described by Riegel ) is often observed. Fink re-
ports a new case (A'/iaich. Med. Jloc/i., No. 37,
1887) in a man 32 years old, who had been
afflicted for three years with sugar-diabetes, and
in whom three months before death an indurative
sclerosis of the right lung, with dilatation and
purulent secretion of the bronchii, had been diag-
nosed. Tubercle-bacilli were never found in the
sputa. The autops\- confirmed the diagnosis, but
did not show in the sclerosed tissue any bacilli
nor tubercular nodules, — Revue des Sciences Medi-
cates, No. 66, 1889.

GoNOCocci IN A Discharge from the Ure-
thra WITHOUT Sexual Intercourse. — Prof.
Straus reports {Arch, dc medicine experimentale.
No, 3, 1889) the case of a youth 16 years old who
had practiced masturbation for four years and who,
a week before applying to the physician, M. Mau-
riac, had practiced the vice more actively than
usual. Two days afterwards pains while urina-
ting, and shortly after well-defined symptoms of
gonorrhoea, were noticed. Patient absolutely de-
nied that he had had any intercourse with women,
and M. Mauriac was inclined to give credence to
his assurance. The discharge contained the typi-
cal gonococci of Neisser, and it was impossible to
distinguish them from those found in the dis-
charge of a patient afflicted with common gonor-
rhoea.

If the assertion of the young man was truthful
a great deal of importance attaches to this case,
as it goes to show that the gonococcus of Neisser
may exist as an inoffensive lodger and simple
saprophyte in the healthy urethra, and that under
the influence of harmful irritation it may invade
the epithelium and cause the characteristic ca-
tarrh.— Revue Medicate del Est, No. 9, 1889.

On the Development of Malaria Parasites
IN Febris Tertiana. — The causal relations be-
tween the peculiar plasmodii occurring in malaria
inside of the red blood- corpuscles and the origin
of the disease are almost universally recognized
by the investigators of the present time. Most of
them, as for instance Laveran, Marchiafava and
Celli, Councilman, etc., do not hesitate to ascribe
diagnostic significance to the proof of the exis-
tence of these formations in the individual case.
Golgi goes a step farther. Already in earlier
works he had attempted to show that the malaria
parasites in the blood of patients go through a
regular course of development, the various stages
of which are closely related with the recurring
fever attacks.

Inside of the red blood-cells pigmented forma-
tions are said to grow from theuncolored amoeboid,
incipient forms of the plasmodii which constantly'
grow in size by absorbing the substance of the

blood-corpuscles, and finally begins to divide, a
process which coincides precisely with the begin-
ning of the fever, or precedes it directlj'. The
result of the division is the birth of new genera-
tions of microorganisms which gain an entrance
into other red blood-corpuscles and there continue
the process, i. e., cause new attacks of fever,
whilst the remaining melanin which originated at
the destruction of the haemoglobin and had been
freed bj' the process of division, is absorbed
through phagocytosis bj- the leucocytes in the
circulating blood or inside the organs.

It is claimed that the presence of the perfectly
developed bodies and of the immature ones indi-
cates the impending outbreak of an attack, that
by accurate observation of the various stages of
development of the parasite the beginning of an
attack can be foretold one or two days previously,
and finally that it can be shown whether the con-
ditions exist for a single attack {febris quartana),
or for two attacks {Aovl\A& febris quartana), or for
three attacks (Xx\{o\A. febris qua>-ta?ia, i. e., forms
of the febris quotidiana ) , according to whetlier one
generation or several successive generations of the
plasmodii appear. All these facts had been estab-
lished only for the febris quartana with its
varieties just mentioned, whilst according to
Golgi 's opinion the parasite causing the malarial
infection in febris tertiana must have a different
course of development.

To prove in detail this latter statement is the
purpose of an article by Golgi in Fortscli d. 3 fed. ,
1889, No. 3, according to which the essential
points of difference between the tertian and quar-
tian species of the plasmodii are as follows : The
amoeboid forms, not pigmented, which represent
the incipient stage in the development of the micro-
organism and always lie inside of the red blood-
corpuscles, show much more lively movements in
febris tertiana than in quartana : they are, fur-
thermore, capable of destr03nng and absorbing
the haemoglobin of the blood-corpuscles with
especial rapidity, so that in febris tertiana the
infected blood-cells appear as colorless formations
in the first hours of the day between the two at-
tacks, whilst m febris quartana their characteristic
yellowish-green coloring is preserved to the end.
The protoplams of the tertiana plasmodii has a
more delicate look than that of the quartana ;
the former deposit the pigment within themselves
in a much finer, small granular mass than the
latter ; but above all the process of division occurs
in the two in an essentially different manner. In
the^ tertiana each plasmodiura is divided into 15-20
new elements, in the quartana into 6-12, which
are correspondingly larger than the former. In
the interior of the globules thus formed, i.e., of
the parasites, in the quartana a glittering little
body is seen, a sort of nucleus, which is missing
in the tertiana, etc.

" These points of difference enable us, by means

).]

MEDICAL PROGRESS.

55

of a simple examination of the blood to recognize
febris tertiana and to make its differential diag-
nosis from other varieties oi febris inlennittens.
The relations between the various stages of de-
velopment of plasmodii and the stages of the dis-
ease are the same in febris tertiana as in febris
qiiartanay

In view of the importance which these observa-
tions of Golgi, if proven correct, have for our
knowledge of the character of malaria, it is desir-
able that at least the principal types of the most
important and most characteristic forms here de-
scribed be made more genreally known by photo-
graphy.— Centralblatt fiir Bakteriologie und Paja-
sitenkunde, No. i8, 1889.

On Cardiac Contractions. — Von Ziemssen
studied, by the aid of tracings, the successive
phases of the cardiac revolution. Between the
moment of complete relaxation and of the first
valvular tone, the contraction is represented by a
rather quickly ascending curve followed by a line
still ascending approaching the straight, but a
little longer and approaching more the hori-
zontal. Between the first and second murmurs
the cardiac sketch presents an ascending, almost
vertical line, terminating in a rounded bend the
summit of which corresponds to the most active
phase of contraction. Then the curve descends
again about as rapidly to a level a little above
that which corresponds to the beginning of this
second phase. The curve ascends again twice,
but feebly, Of these two summits, which are
much lower than the first and correspond to a
normal dicrotism, the last one is the lower and
coincides with the second murmur. Thereupon
the curve descends again a little less abruptly to
the lower level of the trace, the whole of which
thus represents the totality of a cardiac revolution.
The experiments made with alcohol and digitalis
prove that, with the latter, the duration of the
phase intervening between complete relaxation
and the first valvular murmur is alone influenced;
it is shortened with the former and prolonged with
the latter. This duration was from 0.18 to 0.46,
the normal duration being 0.25. In the same ex-
periments the remainder of the trace and the re-
spective duration of the other phases did not dif-
fer from the normal. — La Semaitie Medicate, No.
17, 1889.

Experimental Production of Renal Cal-
culi.— Ebstein, of Gottingen, has made, to-
gether with NicOLAiER, experiments on dogs and
rabbits, and succeeded in producing in these ani-
mals, by introducing oxamide into their food,
renal concretions, the most voluminous of which
was found in the pelvis of the kidne3% whilst the
gravel or grit of the oxamide was found in all
parts of the urinary apparatus. Although the
oxamide injected was white, the renal concretions

were of a greyish yellow. The largest of them
showed on their surface wrinkles and roughness.
The calculi are quite hard and, on polishing them,
one finds upon the surface thus obtained circles or
parts of concentric circles, between which concen-
tric layers can be seen presenting radiating stria-
tions. These concretions are composed of oxamide
and an organic skeleton showing the reaction of an
albuminoid substance. By treating these calculi
with hot water of 80° to 90°, the oxamide dis-
solves and leaves a bare organic skeleton, the
sections of which show an aspect similar to that
of the ground surfaces ; onl}' the suppression of
the radiations reveals the relation existing be-
tween these starred fibres and the presence of ox-
amide.— La Semaine Medicate, No. 17, 1889.

On THE Utility of Specific Gravity and
THE Quantity of Albumen in Pathological
Transudates and Exudates for their Clin-
ical Determination. — Dr. E. Neuenkircher,
of Riga, gives as the result of a series of calcula-
tions the following ; Pleural and peritoneal tran-
sudates and exudates are characterized according
to their genesis by various specific gravities. The
average figures of the specific gravity are lowest
in pleural and peritoneal transudates caused by
morbus Brightii ; a higher specific gravity is
shown by peritoneal liquids in cirrhosis hepatis,
then follow the pleural and peritoneal transudates
in general venous stasis, the ascites in carcinoma
hepatis, the pleural and peritoneal exudates in
carcinoma peritonei and pleurae, the exudates in
idiopathic and tubercular pleuritis, and the high-
est specific gravity is shown by exudates in puru-
lent pleuritis. For prognostic purposes of an in-
dividual case the changes of the specific weight in
repeated punctures can be utilized only with great
care. As a general rule, the falling off of the
specific gravity in such cases denotes a deteriora-
tion of the general condition of the patient and
presents an evil prognostic symptom. — St. Peters-
burger Medicinische Wochensclirift, No. 13, 1889.

A Case of Alopecia Areata after Oper-
ating ON THE Neck. — Pontoppidan has made
an observation in a man {Mo?iatssch.f. prakt. Do-
mat., viii, 2, S. 51), which is closely related to
the examinations made by Joseph (Berlin) of the
second cervical nerve of the cat. A girl 10 j^ears
of age was operated upon for a glandular swelling
the size of a pigeon'.s-egg in the left carotid region.
That portion of the glandular growth imbedded
deeply was adherent to the external jugular vein,
and during the loosening of it a rather violent
bleeding from a rent in the vein occurred. The
haemorrhage was stopped by tampon with iodo-
form gauze saturated with sublimate solution and
compression with bandage. After removing the
latter on the twenty-first day two S5'mmetrically
bald spots, circular, about of the size of a dollar.

56

MEDICAL PROGRESS.

[July 13,

were discovered ou the back of the neck. Micro- !
organistas could not be found. The spots rapidly
grew in size; new ones appeared toward the mid-
dle of the head and behind the ears, and ran to-
gether. After about seven weeks the height of
development was reached, and then the extent of
symmetrical baldness corresponded to the area
supplied by the N. occipit. maj. and minor and
the rear branch of the N. auricularis magnus.
The skin was smooth and normal, sensibility not
disturbed. Five weeks later the entire portion
was covered quite thicklj' and uniformly with new
lanugo-like hairs.

Here is an illustration of an alopecia areata oc-
curring after a lesion of the upper cervical nerves.
The most probable explanation is that a neuritis
was caused by the tampon and the compression
of the origines of the cervical nerves. The sym-
metrical spreading of the baldness toward the side
not operated upon is remarkable. Pontoppidan
considers an invasion of the corresponding nerve
area of the other side, perhaps by a neuritis cen-
tripetally transmitted, as possible. — Centralblatt
fi'/r Physiologic, No. 2, i88q.

On the Treatment of the Painful Symp- !
TOMS OF Phthisis of the Larynx. — It is
especially in cases where the lesions predominate
on the level of the upper orifice of the larynx that
intense pain is experienced at every movement of
deglutition, preventing the most indispensable
functions for strengthening the organism — those
of alimentation. Previous to the discovery of
cocaine opiates constituted the most efficacious
means for relieving the sufferings of the patient.
The muriate of morphine may be mixed either
with an inert powder (powdered sugar), or with
an antiseptic or modifying powder, in the follow-
ing proportions :

Powdered sugar lo gr.

Powder of muriate of morphia i gr. or 0.50 gr.
or

Iodoform (pulverized) 10 gr-

Powder of muriate of morphia i gr. or 0.50 gr.

A pinch of one of these powders is put into an
insufflator bent for the purpose, and, with the aid
of a mirror, applied to the ulcerated parts. This
little operation maj' be done preferably in the
evening, so as to serve the two-fold purpose of
rendering alimentation and sleep possible. As
stated above, the discovery of cocaine has fur-
nished us with a means of much greater efficacj'
for local anaesthesia. This drug appears to best
advantage in the treatment of phthisis of the
larynx. The muriate of cocaine can be applied
by insufflation the same as morphia, in one of the
following proportions :

Powdered sugar or iodoform 10 gr.

Muriate of morphia i gr. oro.50 gr.

Muriate of cocaine i gr- oro.50 gr.

But its efifect is greater in solution, in water mixed

with glycerine, so as to enable the liquid to better
adhere to the tissues.

Water 5 gr.

Glycerine 2 gr.

Muriate of cocaine i gr. or 0.50 gr.

By means of pincers or bent wadding-carriers,
and with the aid of a mirror, the epiglottic and
aryteno-epiglottic region is washed with this solu-
tion and thus within a few minutes an anaesthesia
is obtained sufficient to allow the patient to take
his meal without great stiifering, — Journal de
Medicine de Paris, Vol. xvi. No. 16, 1889.

A Case of T.enia in a Baby id Weeks Old.
— A baby 10 weeks old was brought to Dr. Men-
siNG.\, of Flensburg, the father of the child hav-
ing previously shown to him a sort of worm said
to have come from the anus of the patient. With
the child the parents brought, in alcohol, about
twenty links of a taenia. The baby had just had
a stool. The faeces in the diapers were quite com-
pact and full of moving proglottides which, chang-
ing peristaltically their forms, completely per-
vaded the faeces.

It was discovered that the man had killed a pig
when the child was two weeks old and, on finding
that it was measly, sold it in the citj'. Peculiar
circumstances must have combined to introduce
the germ of the taenia into the baby. Nourish-
ment— milk not boiled — being given to the latter
with the bottle, the dishes had probably been
used for the milk as well as for the pig-killing,
and not being cleansed thoroughh-, having thus
carried the affection to the child. — Internationale
Klinisehc Rundschau, No. 17, 1889.

Calculation of Small Quantities of Sug.vr
IN the Urine. — To ascertain the quantity of su-
gar in the urine when less than 0.2 per cent, is
difficult but useful. Some individuals have but
a small quantity of sugar in the urine when they
have taken a great deal of hydrocarbons, and in
the lighter cases of diabetes it is this kind of food
which causes glycosuria.

POLLATSCHEK {Deutsche Med. Wochenschrift,
No. 18, p. 354, 188S) advises to treat the urine
with carbon before reducing the copper. A small
quantity of charcoal is put into the test-tube, the
mass is stirred up and filtered ; the urine is tlien
clear and freed from substances which might ren-
der the analysis uncertain. In another test-tube
equal proportions of solution of sulphate of cop-
per, Rochelle salts and .soda are mixed and heated.
If the mixture remains clear the filtered urine is
added and heated again ; the precipitate is yellow,
rarely red. For control subnitrate of bismuth,
hydrochlorate of phenyl-hydracine, which Jaksch
recommends, is used. — Revue des Sciences Mcdi-
cales, No. 66, 1889.

1889.] EDITORIAL. 57

Sttbscription Price, iNCLuon^G Postage.

Per Anitom, in advance $5.00

Single Copies 10 cents.

■""'^^ 1 that the phj'sician's duty in cases of infectious

Journal of the American Medical Association disease is but half fulfilled in his most solicitous

PUBLISHED WEEKLY. ^^^^ ^^^ ^j^^ patient's individual welfare. To pre-

vent the extension of the malady from the sick-
room to the household — from the household to
the communit}-, is an even more important obli-

Subscription may begin at anytime. The safest mode of remit-
tance is by bank check or postal money order, drawn to the order ^jatlOn.

of The Journal. When neither is accessible, remittances may be Although the mysteiy' of the ZCrU COntagia is

made at the risk of the publishers, by fonvarding in Registered ... , , . ^ ■ 1.1 ■ *,- c -l

™^^^ V • - '^ Still unsolved m a strictly scientific sense, enough

Address js known of the ordinary conditions of their evo-

JouRNAi, OF THE AMERICAN MEDICAL ASSOCIATION, j^^j^^^ ^^^ transmissiou in manv instances to

No. 6S Wabash Ave.,

Chicago, Illinois, facilitate the application of what we may venture

All members of the Association should send their Annual Due^ ^^ ^^jj . . ^^l jjjj(,al hygiene. ' ' Aside frOm all thcO-
to the r)(rojM«r, Richard J. Dunglison, M.D., Lock Box 1274, Phila ■' '^ .

deiphia. Pa. ' retical controversies concerning the part played

London Office, 57 and 59 Ludgate Hill.
SATURDAY, JULY 13, 1889.

by microorganisms — as causes, carriers, or merely
ferments operative onl}' in suitable media — we
know that a morbific something is extruded from
the sick ; in the cases most commonly brought
under our attention we know the channels of ex-
trusion ; and with this knowledge we can reason-
ably, if empirically, adopt appropriate preventive

THE ANNUAL MEETING AT NEWPORT.
The Fortieth Annual Meeting of the Associa-
tion was in every respect a success. The Com-
mittee of Arrangements had so perfectly accom- measures.

plished its work that ample provision was made, For example : In the specific diarrhceal dis-
not only for the General Sessions, but for each of orders of which typhoid fever may be taken as a

the Sections as well.

The Association was particularly fortunate in

tj'pe, it is generally agreed that the infective
tnateries morbi lies in the intestinal excreta, and

the selection of its officers. The programme for , that even in these, when fre.shly voided, we have
each Section gave evidence of thorough and an inter\'al of comparative innocuousness during

judicious preliminary work.

which precautions may be safely exercised. If

The profession of the entire countn,- was repre- ! action be promptly taken at this time, we may
sented in the preparation and discussion of papers. ' spare ourselves the perplexing consideration of
Ever}' hour assigned to Section-work was fully the relative dangers of contamination of water,
occupied, and in several instances two, and even soil, air, or food ; but if such action be tardy or
three extra sessions were required to complete the unintelligent, the widespread resultant mischief
programme. may long baffle the wisest resources of public

Attractive as were the social features arranged sanitation. Assuming Eberth's bacillus to be at
for each day, still it was a noticeable fact that but , least the specific ferment whereon depends the
few of the members could be diverted from the j evolution of the virus of enteric fever, it seems
real purposes of their assemblage, and from first to ' proven that this microzyme can sustain itself, for
last each Section was ably represented by a full some days, at all events, under a temperature ex-
corps of earnest workers, ceeding 112° Fahr,, or below the freezing point ;

Many papers of unusual value were presented, ! that it sporulates in the range between 66° and
and their careful perusal, as they shall appear in 104°; that it multiplies even more vigorously in
The Journal, will reward the reading. comparatively pure than in very impure water ;

=^ that it finds a congenial habitat in damp soil,

BEDSIDE HYGIENE IN TYPHOID FEVER. and yet resists desiccation for an undetermined

The instructive Address on State Medicine i period. It is destroyed by boiling, by even
given by Dr. W. H. Welch, of Baltimore, at the weak solutions of mercuric bichloride, by chloride
recent meeting of the Association, should empha- of lime and some other chlorides, and its growth
size anew in the mind of everj' general practi- is retarded by acids. The safest disinfectant to
tioner the oft taught, but oft neglected, lesson, 1 be intrusted to unskilled hands is fresh chloride

58

INDIVIDUAL EFFORT.

[July 13,

of lime, or the official solution of chlorinated
soda. For the excreta, the former of these may
be used in saturated solution, or the latter undi-
luted, and they should be employed immediately;
for textile fabrics which have been soiled b}- the
discharges, and which it is undesirable to burn,
boiling will be effective, but it should be done as
soon as possible after the soiling. Disinfection
by steam of bedding and other articles which
cannot be thus treated is hardly practicable until,
if ever, public provision shall be made for it.
With proper care in nursing, however, such
things may be easily protected from infection.
Even during convalescence, vigilance with regard
to the dejecta should not be relaxed, as in excep-
tional cases bacilli have been found in the stools
a fortnight after the reduction of the temperature
to the normal line.

The task of bedside sanitation thus outlined is
neither a difficult nor an exacting one, and if the
famili' physician bear it always in mind he will
forestall the far less hopeful labor of the health
officer.

AN INTERESTING CASE OF ASTHMA.

In the Berl. Klin. Wochenschr. of December 10,
1888, there was reported by P.\winski a case of
asthma which presented a remarkable condition
of auto-intoxication, apparently, as shown by the
urine. Large amounts of aceton were discovered
in this secretion upon the occurrence of each at-
tack of asthma, while during the intervals it could
be found only in traces. The patient, a young
woman, was seized by the asthma after having
been at a dance the previous night. When seen
by Pawinski she presented the customarj- phe-
nomena of such an attack, together with demon-
strable enlargement of the heart. The case was
under observation for some time and always pre-
sented acetonuria. It subsequentlj' terminated
fatally.

This case is of special interest for two reasons:
I. Because it indicates that acetone, which is
known to be linked to an increased decomposition
of the tissues, as in fever, carcinoma, diabetes,
starvation and the like, may be produced In- con-
ditions in which so disastrous a breaking up of
tis.sue is not apparent and might, therefore, be
overlooked, and that the accumulation of this
substance in large amounts acts as a profound
poison to the central nervous system. 2. Because

systematic examinations of the urine, in cases of
asthma, may lead to the detection of many con-
ditions not now recognized as predisposing causes
of asthma.

" A word to the wise is sufficient," and hence,
if one will profit by the lesson taught by this
case, he will not neglect the examination of the
urine in each case of asthma whose etiology is at
all obscure.

THE RENOV.\TION OF NAPLES.

At last wise counsels have gained the ear and
the confidence of the Italian Government. The
phrase " See Naples and die," had come to have
a fearful and literal significance, and the Neapol-
itan fever was the dread of all foreign travelers.
But the day of its renovation has come to the
beautiful c\\.y of Naples.

What Italy does, it does thoroughly, and this
is no ordinary movement which the Government
is making. It means the demolition of seventeen
thousand houses and of sixtj'-two churches in the
verj- heart of the city. It means the expenditure
of over forty millions of dollars in one stupendous
sanitarj' work, the cost to be borne mainly by the
Italian Government. But let the health and
prosperity of Naples be once more assured and
the returns, even for this large expenditure, will
be tenfold. The impetus thus given to the subject
of sanitarj- science is to be world-wide in its
results. Other cities have like needs. Other
governments should follow this example.

INDIVIDUAL EFFORT.

It would .seem a small matter that during the
ensuing j-ear each member of the Association
should secure for The Journ-VL one additional
subscriber. The doubling of the subscription list
would warrant such an outlay for the improve-
ment of The Jourx.\i. as would well repay the
effort. The Association would at once command
a wider influence and the profession at large secure
to themselves a benefit too valuable to be lost.
Will those members of the Association who have
its welfare and the best interests of the profession
at heart give us a helping hand, while we labor
earnestly to increase the value and usefulness of
The Journal ?

Will each member secure one new subscriber f

1889.]

EDITORIAL NOTES.

59

EDITORIAL NOTES.
HOME.

McGiLL University. — Dr. George Ross has
been appointed Professor of the Practice of Medi-
cine, and Dr. Richard Z, McDonnell Professor of
Clinical Medicine in the Medical Faculty of the
University.

Dr. \Vm. W. Keen succeeds the late Dr. S. W.
Gross as Professor of Surgery in Jefferson Medical
College, Philadelphia.

Detroit Board of Health.— At the annual
meeting of the Board of Health of the city of
Detroit Dr. Wm. Brodie was elected President.
The members of the Board are, Dr. Brodie, Dr.
Chapaton, His Honor, the Mayor, the President
of the Police Commission, the Comptroller and
Dr. Klein.

The authorities of Harvard University have
invited Sir Edwin Arnold to deliver a course of
lectures to the students on subjects of his own
selection.

The Mississippi Valley Medical Associa-
tion will meet at Evansville, Ind., September 24,
25 and 26, 1889.

The American Pharmaceutical Associa-
tion held a very successful convention at San
Francisco from the 24 to the 29th ult. The fol-
lowing officers were elected : President, Emlen
Painter, New York ; First Vice-President, Karl
Simmons, St. Paul ; Second Vice-President, W.
M. Searbj-, San Francisco ; Third Vice-President,
J. W. Eckford, Aberdeen, Miss.; Treasurer, S. A.
D. Sheppard, Boston ; Permanent Secretary, J. M.
Maisch ; Reporter on Progress of Pharmacy', C.
Louis Diehl, Louisville, Ky. ; for Members of the
Council to ser\'e three years, Loe Eliel, South Bend,
Ind.; W. S. Thompson, Washington; John H.
Dawson, of San Francisco. The next meeting
will be held at Old Point Comfort, Va., the second
Monday in September, 1890.

The Presbyterian Hospital at Philadelphia
is the recipient of $100,000 donated by Lady
Courtright and to be used to found a Convales-
cent's Retreat. She has also given $50,000 to the
Hospital to build a male .surgical ward and to
endow two free beds.

Explanatory. — It is due to the readers of
The Journal to state that while the President's

Address and other matter pertaining to the meet-
ing at Newport was in type, it was deemed advis-
able not to present them in the last issue of a
closing volume, and thus separate them from all
that was to follow in the new volume which was
to commence with the next issue. It seemed
better to issue the first number of the new vol-
ume three days in advance of the date assigned
and thus present an unbroken series of papers,
and that only four days later than they would
have appeared in the previous issue.

foreign.
In France the heirs of the late M. Chevreul
have presented his valuable scientific library,
numbering 10,000 volumes, to the Paris Museum
of Natural History.

In Switzerland the profession is well organ-
ized. The Schweizerischer Aerztlicher Central
Verein, Societe Medicale de la Suisse Romande,
and Societa Medicale della Svizzera Italiana held
joint meetings at Berne on May 25.

In Germany an Odontological Society has
been organized in Berlin under the presidency of
Prof. Busch. Drs. E. von Bergmann and von
Esmarch have recently been honored with high
appointments in the Sanitary Corps of the armJ^
Dr. Curtius, of Erlagen, and Dr. Guttermann, of
Gottingen, two young German Professors of
Chemistry, have accepted a call from the faculty
of the new Clark University of Worcester, Mass.

In India rain has fallen in the Gamjam dis-
trict, and the number of deaths from cholera has
decreased from 1029 to S65. Dr. Waddell, Deputy
Sanitary Commissioner for Bengal, is investigat-
ing the question as to whether venemous snakes
are anti-toxic. Dr. Patric Hehir, in his report
on Cholera in the Chudder-Ghaut municipality,
and referring to the pollution of the drinking
water as the main cause of the epidemic, says :
"While investigating the cause of an outbreak in
the village of Kharatabad, I noticed a woman wash-
ing the clothes of her husband (who had died of
cholera), in a large well from which several
persons were actually drawing water for drinking
purposes." Leprosy is on the increase.

In England there has been a meeting of del-
egates to make preliminary arrangements for or-
ganizing an International Congress of Hygiene
and Statistics to meet in London in 1S91. There

6o

SOCIETY PROCEEDINGS.

[July 13,

are 402 medical practitioners and 119 medical
students on the roll of the British Medical Tem-
perance Association. Dr. C. B. Radcliff, an em-
inent phj^sician and an authoritj- on nervous dis-
eases, died recently in London. A feature of
the British Medical Journal is the occasional col-
umn contributed by -the Editor, entitled ' ' Topics
of the Daj'." The Charity Organization Society
is about to petition the House of Lords for an in-
quiry' in regard to the administration and organ-
ization of hospitals, dispensaries, and poor law
infirmaries. The British Medical Association will
hold its fiftj^-seventh annual meeting at Leeds i
from August 13 to 16. A new hospital for pa-
tients suffering from infectious diseases has been
opened at Muswell Hill. At Cambridge Univer- :
sit}'. Dr. W. H. Gaskell, Universits- lecturer in
advanced physiology, and Marshall Hall Prize-
man for his researches on the nervous system, has
been elected to a fellowship at Trinitj- Hall. The
Prince of Wales leads the movement that the peo-
ple of England shall give practical expression to '
their admiration of Father Damien by the erec-
tion of a monument to his memorj- at Molokai.

SOCIETY PROCEEDINGS.

American Medical Association. Fortietli
Annual Meeting, at Ne'wport, R. I.

Section on the Practice of Medicine, Materia Med-
ica and Physiology.

First Day, June 25, 1889.

The session was opened bj- an introductory
paper on A Review of Progress, by Dr. F. C.
Shattuck, of Boston, Chairman of the Section.
A complete resume of all later forms of treat-
ment was placed before the Section. (Seep. 19.)

Dr. Chas. G. Stockton, of Buffalo, read a pa-
per On the Passage 0/ Portal Blood into the General
Circulation, and its Probable Relations to Toxtrmia.
This elicited quite a spirited discussion, in which
some of the claims of the essayist were criticised,
but ably answered by Dr. Stockton.

Dr. G. R. Martine read a paper entitled A
New Plan for the Treatment of Pneumonia, which
was virtually the Veratrum Viride treatment.
Discussion entered into by Drs. Hall and Atkin-
son.

Dr. I. H. MussER presented a paper on Some
Clinical Aspects of I'omiting, dwelling on the va-
rious forms of vomiting and their differential di-
agnosis.

Dr. I. E. Atkinson read an extensive paper
on Sotnc of the Rarer and Grazer forms of Cincho-
nium. The discussion which followed was taken
part in by the two classes of practitioners who
advocated on the one side, and on the other dep-
recated the use of large doses of quinine.

Dr. Robert T. Edes read a paper on Hydro-
nephrosis; Especially as Caused by Functiotial Dis-
orders 0/ Micturition.

Second Day, June 26.

Dr. Fell, of Buffalo, presented to the Section
on ^Medicine an apparatus for keeping up respi-
ration in narcotic poisoning. With this means
he had saved four lives that would have been lost
without the use of the apparatus.

Dr. Francis Delafield read a paper on Chron-
ic Endocarditis. The paper was thoroughly dis-
cussed by Dr. Pepper.

Dr. Wm. Osler reported an interesting case of
JVo>d Blindness n'ith Hemianopsia, together with
a presentation of specimens and diagrams. Dr.
Osier also exhibited specimens of brains, prepared
according to the Italian method.

Dr. James Tyson, of Philadelphia, read a pa-
per on The Induction of Premature Labor in
BrighV s Disease Complicating Pregnancy.

Dr. Vaughan, in discussing the paper, agreed
with the essaj-ist in the main points except as to
its induction in primapara. Establishing it as a
rule to induce premature labor in such patients
that have had similar experience previously. He
treated b\' limiting the patient's diet and assisting
elimination.

Dr. Atkinson insisted on this plan of treat-
ment as soon as the mildest symptoms were man-
ifested. The most frequent and dangerous cases
are due to the contracted kidney.

Dr. Scott gave the Section a review of his
valuable and long experience.

Drs. Chamberl.^ix, Carpenter, Tru.\x and
Nelson added their arguments to the discussion,

Dr. Prentiss next called attention to the im-
portance of the work in forming the Pharmaco-
poeia of 1890.

Dr. Prentiss also moved that the Chairman of
this Section be requested to offer the following
resolution at the general meeting to-morrow
(Thursday) :

Resell ed. That the President of the American Medical
Association be authorized to appoint three delegates to
the Convention for the Revision of the U. S. Pharniaco-
pceia, which meets in Washington in May, 1890.

Carried.

Dr. Geo. M. Garland's paper on Raynaud's

Disease, with report of a case, was received with
great favor. The presentation was rendered more
interesting by the exhibition of illustrations.

Dr. C.\kpknter had seen the patient whose
histon,- was given in this paper, and treated him
during the latter part of his life.

1889.]

SOCIETY PROCEEDINGS.

61

Dr. Shoemaker treated ou the new remedj%
Dioscorca J 'illosa .

Third D.\y, June 27.

Dr. ^^aughan opened the meeting with a pa-
per on The Etiology and Pathology of Typhoid
Fever. In it he presented a detailed histon,- of
all investigations and discoveries hitherto brought
forward, and an enumeration of experiments
made by himself.

Drs. Welch and Tyson, in the discussion,
dwelt upon the conditions necessary to establish
the causal relation of germs and disease.

Dr. J.AMES C. Wilson read an elaborate paper
on the Propliylaxis of Tuberculosis.

Dr. Henick, in the discussion, still doubted
that positive proof of the contagiousness of tuber-
culosis had been presented.

Drs. Cutter and Whitney entered into the
discussion in the same spirit.

Dr. Cohen was very happy in his remarks,
occupjnng a middle position between those of
Dr. Wilson, who ably defended his position in
the concluding remarks.

Dr. M. R. Crain presented a paper entitled
Toxic Agents in the Blood as a Cause of Diseases
0/ the Nervous System.

Dr. W. L,. Schenck offered Sovie Thoughts on
the Etiology, Pathology and Therapeutics of Phthi-
sis Pulmonalis.

Dr. Solomon Solis-Cohen, of Philadelphia,
read an excellent paper entitled Food iii the Treat-
ynent of Consumption.

Drs. E. and J. A. Cutter followed with an
essay on Trophopathy in the Fatty and Fibroid
Degenerations : with Presentatio7i of Case of Cure.

Section on Obstetrics and Diseases of J I omen.
First Day, June 25, 1889.

Dr. Horatio R. Storer, of Newport, R. I.,
read a paper on The Medals of Benjamin Rush,
Obstetrician.

Dr. Storer' s paper calls forcible attention to the
fact, that to Dr. Rush was owing the first sugges-
tion, or rather prophecy, of obstetrical anaesthesia.
He quotes various passages from Rush's work,
which demonstrate that " he was, throughout, a
skilful obstetrician. In the verj' title of one of
his papers, he closely associates the pains of labor
with its dangers, he announces that they can
both be lessened, he recognizes that they are the
potent cause of subsequent disease, and he teaches
its prevention."

Dr. Storer particularly calls attention to the
following passage of Rush : "I have expressed
a hope in another place that a medicine would be
discovered that should suspend sensibility alto-
gether, and leave irritabilit}-, or the power of mo-
tion, unimpaired, and thereby destroy labor-
pains altogether." '

^ " Medical Inquiries and Obsen-atiolis," 3d edition, iv, p. 376.

The importance of this extraordinarj- interest-
ing passage seems to have been recognized only
by Channing, Gaillard Thomas, and Paget, of
New Orleans. It was lost sight of entirely
through the ether-chloroform controversy. Dr.
Storer after exhaustive research, in which he has
been aided by Dr. Toner, of Washington, fails to
find other reference to it, and in this impression
he is coincided with by Drs. Munde, Chadwick,
and Gaillard Thomas, to whom he had appealed
as probablj' most familiar with modern obstetric
literature.

Dr. Storer exhibited enlarged photographs of
the two extremely rare medals of Rush, which are
in his collection, and expres.sed the hope that
they would be found of use in giving the correct
features of the ' ' American Sydenham ' ' when his
monument, undertaken by the Association, shall
be raised, and that the paper itself might tend
towards a better appreciation of the true merits
of the man himself.

Dr. W. W. Potter, of Buffalo, N. Y., then
read a practical paper on Note on the Uses of
Boric Acid in Gyiiesic Practice.

(See page 46.)

The next paper, by Dr. Henry O. Marcy, of
Boston, on The Inversion of the Uterus; Reduction
by a Neiv Method, and the exhibition of instru-
ment, was one of great interest and brought out
a very complimentary discussion by Drs. Clark of
Cambridge, Lusk and Cleveland of New York.
This paper will be published in the next issue of
The JouRN.iL.

Dr. Joseph Price, of Philadelphia, read a pa-
per entitled. Series of Five Hundred Confinetnents
in a Maternity. Dr. Price described briefly the
Maternity Retreat of Philadelphia, in which such
brilliant results are made possible by the absolute
system of cleanliness prevailing at that institu-
tion. As this excellent paper as a whole was but
a brief summan,- of much labor, the reader must
be referred to the paper itself as it appears subse-
quentlj- in full in these columns.

This paper was discussed by Dr. Thomas Opie,
of Baltimore, Prof. Lusk, of New York, and oth-
ers, all agreeing in the main with the writer, and
emphasizing strict antiseptic methods as a require-
ment of success in obstetrics.

Dr. Henry D. Fry, of Washington, read the
next paper, his subject being : The Application of
Forceps to Transverse and Oblique Positions of the
Head; Description of a New Forceps.

The author advised strongly the application
alwaj^s of the obstetrical forceps to the biparietal
diameter of the head without regard to its position
in the pelvis, and presented forceps the construc-
tion of which makes it practicable to apply the
instrument to the transverse or oblique position
of the head.

Before the discussion was opened on the above
paper another paper was read by Dr. W. S. Stew-

62

SOCIETY PROCEEDINGS.

[July 13,

ART, of Philadelphia, on When shoUld the Obstet-
ric Forceps be Used and -what Form of Instrumeyit
is Required? A new forcep was presented by Dr.
Stewart in which was involved the principle by
which either blade may be applied first.

Dr. Joseph Taber Johnson, of Wa.shington,
opened the discussion, He said that Dr. Fry's
paper had interested him very much, and although
he had had. no experience in the use of his forceps,
he certainl)' should avail himself of the first op-
portunity presented to do so.

Dr. Parvin, of Philadelphia, said that the in-
.strument of Dr. Fry's for transverse and oblique
positions was the revival of an old instrument,
and he predicted that the result would be short-
lived in the present case. He objected to Dr.
Stewart's forceps because of the length and com-
plication of the handles.

Dr. Joseph Price objected to Dr. Fry's forceps
because he was sure that dangerous compression
of the neck of the child would result from its use.

Dr. Thomas Opie, of Baltimore, then read a
paper on The Obstetrician as a Counselor.
Second Day, June 26, 1889.

The following officers were elected for the en-
suing year : Dr. W. W. Potter, of Buffalo, Pres-
ident, and Dr. Hoffman, of Philadelphia, Secre-
tars'.

The Address of the Chairman, Dr. Wathen,
of Louisville, was on the Pathology of Ectopic
Pregnancy and Pelvic Hcrmatocele.

He referred to the fact that nearly everything
written on ectopic pregnancy prior to 1880 is of
no real value. He treated his subject in the fol-
lowing order :

1. The ovum is never impregnated in the uter-
ine cavity, and the conjugation of the male and
female elements must take place before or just
after the ovum enters the tube.

2. Ectopic pregnancy is always primarilj' tubal,
with the possible exception of ovarian pregnancy.
The tube usually ruptures before the fourteenth
week into the folds of the broad ligament, or into
the peritoneum.

3. Abdominal pregnancy cannot occur except
as a result of primary or secondar\' rupture, and
if the villous or placental attachments are de-
-stroyed the ovum immediately dies, because it
cannot form secondary attachments to other struc-
tures.

4. If, in ruptures into the peritoneum, the ovum
retains villous or placental attachments, it may be
possible, under certain conditions, for the pregnan-
cy to continue, though not probable. If the am-
nion is ruptured in the early months the embryo
will die.

5. So-called interstitial pregnancy does not al-
ways rupture into the peritoneum; it usually does.

6. If we define pelvic hscmatocele as an en-
cysted or confined tumor formed of blood, then
intraperitoneal haematocele is not possible.

He treated the subject in detail, and gave many
valuable facts in proof of the above propositions.
In a general sense, he accepted the conclusions of
Mr. Tait, but he differed with him in his belief
that in normal pregnancy the male and female
elements meet in the uterus, and that, in a healthy
condition of the tubes, the spermatozoids cannot
pass out to the ovaries. He claimed that the cili-
ated epithelium has no influence on the move-
ments of the spermatozoids, but that they move
by an inherent force, and may reach the ovaries
through a healthy or a diseased opening. In his
argument that primarj' abdominal pregnancy is
impossible he says: "The ovum cannot form
villous attachments until it is held immovably in
the maternal structures, and this is not possible
except in the tube or uterus. If the ovum fails
to enter the tube it will soon perish in the abdom-
inal cavity, for it cannot fix itself to the perito-
neum, as this and surrounding structures are in
nearly constant motion." He did not believe it
has been positively proven that any of the speci-
mens were ovarian pregnancy, for this could not
be done except by a thorough microscopical ex-
amination of all parts of the gestation sac and the
demonstration of a general distribution of ovarian
stroma. The address was in every way creditable
to its author, and the Section voted him a unan-
imous vote of thanks.

A paper was read by Dr. Theophilus Par-
vin, of Philadelphia, on Casuistry in Obstettics,
which will appear in full in The Journal.

Dr. a. Van Der Veer, of Albany, N, Y.,
read a paper on Concealed Pregnancy, its Relatioti
to Abdominal Surgery.

This paper was based upon the .stud}' of seventy
cases of abdominal section wherein pregnancy
existed as an undiagnosticated complication. A
diligent effort had been made to obtain full his-
tories of cases, and many prominent operators
from all portions of the world had made contri-
butions. Two complete tables were given, being
twenty-six cases were pregnane}- existed with
fibroid, ten cases simple pregnancy, five cases in
which the pregnancy existed in a rudimentary
form of a bi-cornated uterus, and twenty-nine
ca.ses in which simple ovarian cyst alone existed.
In the majority of the cases no symptoms of preg-
nane)' are noted. Rapid growth and changes in
the consistency of the tumor in fibroids was ob-
served in nearly all of the cases. The physical
signs of pregnancy, prior to the fourth month,
may be either obscured or concealed by the
presence of a fibromyxoma. Hydramnion as a
complication of pregnancy led to abdominal sec-
tion twice. It was clearly shown that the state-
ment of unmarried women with abdominal en-
largements must not be relied upon. The paper
is certainly a valuable one upon this subject, and
the conclusions to the point. Namely, That the
probable diagnosis should be based upon the

1889.]

SOCIETY PROCEEDINGS.

63

physical signs contained in the notes of the case
by the rational signs contained in the clinical
historJ^ and not by simple abdominal palpation,
and the dim light of a pelvic examination. That
whenever the slightest probability of pregnancy
exists it shonld be fully explained to the patient
and to her friends. That the necessity for opera-
tive relief, and the consequences of dela^-, or
neglect, should be carefully stated to the parties
interested before obtaining their formal consent
to the operation. That it is the dutj- of every
operator to report fully all such cases, that the
methods of diagnosis maj' be improved if possible.
That it is the duty of the profession at large to
maintain that pregnane}' may be absolutely con-
cealed, especially prior to the fourth or fifth
month, by other intra-abdominal conditions.

Dr. W. H. Parrish, of Philadelphia, read a
paper on Pelvic Abscess in the Female, which will
be published in full.

Dr. Jos. Taber Johnson, of Washington, D.
C, read a paper upon Tetanus folloiviiig Ovariot-
omy. The Dr. gave the historj' of the case which
formed the basis of his paper, she being a lady
over 60 years of age, from whom he removed a
sarcomatous tumor of the left ovan,- the size of a
child's head. Patient convalesced unusually well
for twelve days, when tetanus set in and she died
three days later of lock jaw. Of this very rare
complication of ovariotomy Dr. J. had collected
from publications about fifteen cases, including
ten cases collected by Dr. Parvin in 1877.

The infectious nature of the disease was dis-
cussed, and instances narrated where it had been
communicated from animals, especiallj- horses, to
man.

The tetanus bacillus was shown to be the same
in animals and in the human family, and the
workers in abdominal surgery- were warned against
the possible contamination of their cases by the
contagium emanating from tetanus, cases origi-
nating in either human or animal sources.

In the discussion Dr. Polk, of New York, com-
plimented Dr. Johnson upon the practical value
of his paper, and thought the warning against
this new and, to many, unknown danger, a verj'
timely and important one.

A paper was then read by Dr. A. Reeves
Jackson, of Chicago, on Injiuies to the Bladder
During Laparotomy. Dr. Jackson's report in-
cluded sixty-seven cases of injuries to the blad-
der gathered from the profession at large by means
of a circular letter. The paper contained many
valuable suggestions, which will appear in full
when the paper is published in The Journal.

After Dr. Jackson's paper was read the discus-
sion of all the papers of the afternoon took place,
in which Drs, Polk, of New York, Joseph Price,
of Philadelphia, Gordon, of Portland. Me., Baldy
and Hoffman, of Philadelphia, and Dudlej-, of
New York, took an active part.

The proceedings of the third day included a
paper by Dr. A. B. Carpenter, of Cleveland, O.,
on Alexander's Operation ; icith a lYezv Method of
Securing the Roinid Ligaments ; and one by Dr.
Augustus P. Clarke, of Cambridge, Mass., on
Chronic Cystitis in the Female.

Surgery and Anatomy.
First Day, June 25, 1889.

Dr. N. p. Dandridge, of Cincinnati, Chair-
man, of the Section, delivered an address on
Surgical Interference in Fractures of the Spine.

(See page 37.)

The discussion was opened bj' Dr. \Vm. H.
Pancoast, of Philadelphia, who cited several
cases similar to those given in the paper, and re-
ported post-mortems on hanged criminals whose
death was caused bj- shock and not by fracture or
dislocation of cer\-ical vertebrae. In one criminal
a vertebra was broken but not displaced.

In the absence of Dr. W. W. Keen, of Phila-
delphia, the paper on Surgery of the Lateral
l^entricles of the Brain was omitted.

Dr. H. H. Smith, of Philadelphia, read a
paper on Concussio7i of the Spine in its Medico-
Legal Aspect. He said a medical man should not
act both as medical expert and medical adviser
for an}' corporation, and gave forty-nine cases of
concussion of spine or "railway spine," of which
thirty-six were real or probable deceptions ;
mostly cases of similation and one case of substi-
tution.

1. Can any force be so supplied as to cause
real concussion of spinal cord ? Yes, but it is not
a common occurrence.

2. How are the normal functions of the cord
disturbed by such injuries?

a. Anaesthesia, hyperaesthesia, etc.; b. Motor
disturbances ; c. Vaso-motor disturbances ; d.
atrophic changes.

3. Pathological changes.

If the disturbance is functional it may be cured.
Neurasthenia can produce all the symptoms usu-
ally attributed to concussion. Molecular changes
may be produced by severe shaking of cord with-
out any injur}- to the canal. Injury to cord in
any accident is followed very quickly by the
symptoms, and we must look with suspicion upon
cases where spinal symptoms are not developed
for several -weeks or months.

Conclusions : i. Concussion of the spinal cord
is no longer a matter of doubt. 2. Pathological
changes noted in the molecular condition may be
due to other cau.ses. 3. There is a possibility of
preexisting spinal disease. Therefore, no physi-
cian should go into court and swear that a man
has spinal concussion due to a certain injur}' and
permanent.

Dr. Herbert Judd, of Galesburg, 111., read a

64

SOCIETY PROCEEDINGS.

[Jt'LY 13,

twenty-five minute paper in which he set forth
the same general conclusions as Dr. Smith.

Dr. Wm. Brodie, of Detroit, Mich., cited two
cases, in one of which his testimony was for the
plaintiff; in the other, against. The jury gave
the plaintiff heax^y damages in both cases. Con-
clusions : Immediate!}' after a man is hurt the
railroad surgeon should advise the company to
settle.

Dr. B. a. Watson, of Jersey City, N. J.:
Spinal concussions are not so frequent as would
seem from court decisions. I have observed as
the most frequent injuries following railroad ac-
cidents: I. Hsemorrhagic infarction in lungs.

2. Lacerations of liver, spleen, lungs or kidnej's.

3. Rupture of blood-vessels and bladder.

Dr. C. B. Pexrose, of Philadelphia, being ab-
sent, the Secretan.- read a paper in consonance
with the preceeding discussion.

Dr. J. H. MuRPHV, of St. Paul, Minn., said:
Erichson has. cost the railroads thousands of
dollars. He cited several cases of malingering.

Dr. \V:w. H. P.\nco.\st, of Philadelphia, said:
The question under discussion has two heads :

1. Is there such an injurj' as spinal concussion?

2, Are there malingerers who assume the symp-
toms ? He discussed clearh- these two questions,
ending with the conclusion that many railroad in-
juries can be adjudicated, and the real sufferers
properly compensated, by the judicious surgeon
acting as the mediator between the opposing
lawyers to the honorable satisfaction of both
parties.

Dr. M.\urice Rich.\rdson, of Boston, read a
paper on Surgery of the Peripheral Nerves, illus-
trated by black-board drawing. He said : Neu-
rectomj- is the proper treatment for wrj-neck, and
gave new landmarks for reaching the spinal ac-
cessory bj- making an incision on the anterior
border of mastoid parallel with course of muscle.
In cases of nerve suture he had used both catgut
and silk, but prefers silk if it is aseptic. In
most cases there is return of motion and sensa-
tion ; in no case has healing b}' first intention
been observed. Many interesting cases cited,
most of which were successful.

Dr. Wm. H. Panco.\ST, of Philadelphia,
made a spirited speech, claiming the honor of the
first neurotomy of the fifth pair of ner\''es for his
distinguished father.

Drs. Dever, of Philadelphia ; W. O. Roberts,
the Secretan,- of Section : S. C. Gordon, of Port-
land, Me.; and Burns, of Philadelphia, followed
in the discussion, all citing cases from their prac-
tice in consonance with the ideas of Dr. Rich-
ardson.

Drs. C. C. Hunt, Dixon, 111., and E, H. Brad-
ford, Boston were absent.

Dr. Carpenter's paper on Pathology and Treat-
ment of Chronic Sciatica, was deferred till the
second day.

Second Day, June 26.

Dr. C. B. Porter, of Boston, read a paper on
Ectrovcrsion of the Bladder.

He said : Whatever operation is chosen the
free exit of the urine is necessary' to success. A
case was exhibited. Girl, set. 8 ^-ears, had com-
plete ectroversion ; congenital gap at symphysis
pubis 3 inches ; mucous membrane of bladder and
vagina freely exposed to air and friction of cloth-
ing ; suffering and uncleanliness extreme. Oper-
ation Jan, II, 1889, consisted in making large
pear-shaped flap, hinged at mons veneris, and ex-
tending to umbilicus. This flap was turned down,
covering in the bladder, with the skin surface
making the anterior wall of bladder. The exter-
nal raw surface of the flap was covered by two
half-size flaps cut from the inguinal region and
turned around toward the median line. The sur-
face exposed on anterior aspect of abdomen was
drawn together by sutures ; the other two surfaces
healed by granulation. A hot dressing was ap-
plied. Three months after the operation the girl
joined her plaj-mates, relieved of all pain and
wearing a shield between the legs. There is
always incontinence of urine in these cases.

In the absence of the author. Dr. C. C. Hunt,
of Dixon, 111., the paper on Suspension and Ex-
tension in Treatment of Sciatica, was read by
title.

Dr. W. T. Briggs, of Nashville, Tennessee,
read a paper on The Choice of Operations fr the
Remoial of Urinary Calculus. He said : In chil-
dren under 16, the cutting operation should by
all means be chosen ; after puberty, litholapaxy.
In old age mortality is greater in both operations,
but crushing in the hands of a skilful operator is
better. The composition of the calculus is im-
portant. Large uric acid calculi, or oxalic cal-
culi are hard to crush, and better be cut for.
Stones return with less frequency after litholapaxy.
The size and toleration of the urethra are import-
ant factors. Lithotomy should be chosen in the
following cases: i. Children; 2. Large and
hard stone ; 3. Encysted stone; 4. Indurated and
crooked urethra ; 5. Prostatic enlargement ;
6. Prostatic overgrowth ; 7, Prostatic enlarge-
ment with putrid urine ; 8. Tumor of bladder ;
9. Chronic cystitis.

Litholapaxy should be chosen : i. For adults;
2. In cases of soft stones ; 3. Where urethra is of
good calibre and tolerant. The supra-pubic-
lithotomy may be performed in cases where stone
is too hard to be crushed, and too large for
perineum. The raphe is nature's field for in-
cision, and the niedio-lateral incision is almost de-
void of any danger to life. He reported 186
cases in his practice with three deaths.

Dr. a. T. Cabot, of Boston, read a paper on
The Choice of Operations for Stone in the Blad-
der. The best operation is the one which is
followed by the fewest deaths ; provided there is

1889.]

SOCIETY PROCEEDINGS.

65

no permanent disability. The statistics of recent
years make litholapaxj- and perineal lithotomy of
equal value for children. During adult life
litholapaxy is rather safer than perineal lith-
otomy and in old age it is much safer. In all
cases supra-pubic lithotomy should be resorted to
last, for its death-rate is from three to six times
as gpreat as either of the others. He reported
forty-seven cases : Litholapaxy forty-two, deaths
two; lithotomy four, deaths one; supra-pubic
lithotomy one, death one.

Dr. Dudley Allen, of Cleveland, Ohio, read
a paper on Litholapaxy in Childre?i. Dr. Allen
thinks litholapax}' is better because the public is
not afraid of it. They delay the cutting opera-
tion too long often. After litholapaxy the patient
is confined to his bed 5.7 days, after lithotomy
17.6 da\-s. The return of stone is no more fre-
quent in litholapaxy than in lithotomy. If stone
returns, the patient will, as a precaution wash
the bladder for several days after the operation.

Dr. J. W. S. GouLEV, of New York, read a
paper on The Choice of Treatment of Urinary
Concretions. He said : Lithotrity at several short
sittings without ansesthesia is devoid of the often
serious complication of ether- nephritis; it does
not incapacitate the patient from work during
treatment. It is never followed by traumatic
acute cystitis, and there is no greater tendency
for return of the stone. However, the proper
choice of treatment of urinarj' calculus can only
be made after a careful study of the case.

Sir James Gr.^nt, of Ontario, said that as far
as his experience went he much preferred lateral
lithotomy, and spoke in verj- complimentarj- terms
of the advances in surgery made by the surgeons
of the United States.

Dr. Trem.\ne said that suprapubic lithotomy
is an American operation. He has performed
perineal lithotomy on eighteen persons in boy-
hood. They grew up around him, all of them
got married, and but one of them had children.
This is significant. Sir Henry Thompson agrees
with him that after 5 years the suprapubic opera-
tion is free of most of the disadvantages of peri-
neal lithotomy.

Dr. W. H. P.\nco.\st, of Philadelphia, urged
the importance of recognizing the difference of
irritability of the bladder; the extreme irritability
of some bladders making lithotritj' and lithola-
paxy dangerous in those patients.

Dr. R. T. Morris, of New York, read a paper
on What Dressing Shall Lie Next to the Wound f
He recommends, in fresh wounds, the use of Lis-
ter's protective oiled-silk. On a large granulating
surface use peroxide of hydrogen freely to make
the wound and the adjacent parts a.septic, cover
with oiled-silk, apply dr>', absorbent dressing that |
may remain from one to four weeks. Whether
bichloride gauze is used or absorbent cotton is
immaterial.

Dr. H. O. Marcy, of Boston, said he agreed
with Dr. Morris in his treatment of granulating
wounds, but in fresh incised wounds he uses no
dressing, simply drj-ing the surface and painting
with iodoform collodion.

Dr. W. H. Pancoast, of Philadelphia, report-
ed the very successful use of iron- dyed silk both
as dressing and as sutures.

Drs. M. A. Crain, of Rutland, Vt., I. N. Quim-
by, of Jersey City, N. J., and Thos. H. Manley,
of New York, continued the discussion.

Dr. J. C. Warren, of Boston, read a paper on
the Manageinent and Treatment of Large Heniier.

He had used on a ver>' large scrotal hernia a
bag with inela.stic exterior afld elastic lining. In-
flating space between bag and its lining by means
of a fountain syringe, a steady pressure was pro-
duced upon all surfaces of the hernia except the
pedicle. The result was successful. In old men
who fear a cutting operation, an inelastic suspen-
sory bandage has been used successfully. He
concluded by advising the gradual reduction of a
hernia hy pressure of air, water or rubber. It is
not a new treatment, but its value is not generally
recognized.

Dr. H. O. Marcy, of Boston, read a paper ou
Radical Cure of a Hernia by use of the Aseptic
Animal Suture.

He reported fourteen cases, exhibiting the
hernia sacs removed, stuffed with cotton and pre-
served in alcohol. The requirements of the oper-
ation are : Dissect out sac, reduce gut and omen-
tum, draw down sac, ligate it, the ligated neck
retracts within the internal ring. L^se animal
sutures in such a way as to make the canal oblique.
The obliquit}- of the canal is of great importance ;
it is nature's safet}- valve — the greater the inter-
nal pressure, the tighter the valve. Close the
external wound with deep sutures (animal ) with-
out drainage and dress with iodoform collodion.
Catgut sutures and ligatures may be used, but the
tendon suture is his choice.

Dr. W.\rren, of Boston, does not believe in
animal sutures. Uses silk or linen, and places
them in such a way as to make a knuckle of
peritoneum over the internal ring.

Dr. J. B. Deaver, of Philadelphia, read a
paper on The Radical Cure of Hernia.

He reported several cases. One case compli-
cated with vesicle hernia, where the bladder was
mistaken for a second hernia sac containing a
loop of intestines. It was ligated and resected.
Within 24 hours the patient died in collapse, the
ligated bladder having escaped from the ligature
and the urine and blood passed into the abdomi-
nal cavity.

Dr. C. W, Dulles, of Philadelphia, read a
paper on Properitoncal Hernia.

The paper showed wide research, and the
author made a new classification of this rare form
of hernia.

66

SOCIETY PROCEEDINGS.

[July 13,

A general informal discussion then ensued on
the subject of Treatment of He7~nia. The follow-
ing members took part : Drs. T. H, Manley, of
New York City ; Dudley Allen, Cleveland, O, ;
E. W. Cushing, Boston ; A. P. Clark, Cambridge,
Mass.; H. J. Herrick, Cleveland, O.: W. H. Long,
United States Marine Hospital, Cleveland, O. : R.
T. Morris, New York City. ; L. W. Steinbach,
Philadelphia ; \V. H. Pancoast, Philadelphia ;
Murphy, St. Paul, Minn. ; H. D. Didama, Syra-
cuse, N. Y.

Third Day, June 27.

Dr. Thomas S. K. Morton, of Philadelphia,
read a paper entitled .S"tv«t» Further Considerations
and Statistics of Abdominal Sections for Traii-
7natism.

He said severe abdominal injuries may exist
without shock. Emphysema around a wound is
not conclusive evidence that the intestine is
wounded. A sufBcient indication for laparotomj-
is the presence of a wound perforating the ab-
dominal wall. Shock is a contra-indication unless
it be from haemorrhage. The earliest possible
moment after the injur j- should be chosen for the
operation. The incision should be median
always, unless the injury- be very far from median
line, and the failure to readily find or repair the
internal wound should drive the operator imme-
diately to the median line.

Wounds of the kidnej-s, liver and spleen should
"be drained — a small glass tube is best. The
stomach should be washed out to avoid vomiting.
Rectal alimentation when the alimentary' tract
has been wounded, unless that wound be in the
rectum itself Though he could not concede to
hydrogen gas all that has been claimed for it, he
could claim something new for it — its injection
into the bladder to discover wounds in the walls
of that viscus. When we find that thirty -six
deaths have occurred, in the number reported to
him from delay, we ought to take that as a perti-
nent suggestion.

Dr. J. W. Price, of Philadelphia, read a paper
on Pelvic Surgery by Abdominal Section ; its Past,
Present and Future.

He said : Aseptic surgery maj- be obtained
without the introduction of chemical antiseptics
into the wound. Cleanliness, water and neat
surger}' are the best antiseptics. In incipient
peritonitis use saline cathartics. Begin operative
procedure early. Procrastination is not only the
thief of time, he is the servant of death. Gonor-
rhoea may be the cause in a woman of one of the
most serious pelvic disea.ses — pyosalpinx. He
doubts that electricity in treatment of pelvic dis-
orders has the value that is claimed for it.

Dr. J. M. Baldy, of Philadelphia, read a paper
on Peritonitis.

He said : That peritonitis is idiopathic and a
distinct disease, is denied bv manv. He had

never seen a case where a cause could not be
found. This being the case narcotics are not in-
dicated in its treatment, except sufficient anodyne
to take the edge oflF the pain. The paramount
indications for treatment are : First, drainage, and
second, depletion, both of which mary, in man}-
cases, be effected through the alimentary canal
by saline cathartics. Magnesium sulphate .lij to
3j to get twelve or fifteen profuse waten,' stools.
Salines cannot be indiscriminately used. Study
the case. Some require surgical interference. In
treatment by purgation, the prognosis can be
made in 48 hours, and surgical procedure insti-
tuted in some cases. Chronic peritonitis can be
best treated by the surgeon even when the disease
is tubercular.

The paper by Dr. Ch.\s. B. Penrose, of Phil-
adelphia, on Drainage in Abdominal Surgery,
was read bj' title.

The paper by Dr. M. Price, of Philadelphia,
on A Plea for Early Abdominal JJ'ork, was read
by title.

Dr. N. B. Carson, of St. Louis, read a paper
on Chylous Cyst of Mesentery with Report of a Case.

He reported a case, an interesting one, which
was diagnosed by palpitation and aspiration.
Operation : Incision, drainage, dressing, iodoform
gauze ; result, perfect. Origin of chylous cysts :
I. Thoracic Duct. 2. Receptaculum ch54i. 3.
Mesenteric glands. Of seven cases reported, one
died. He advises operation as soon as the tumor
inconveniences the patient.

The following members took part in the inter-
esting discussion : Conser\-ative — Drs. E. Gris-
wold, Sharon, Penn.; Quimby, Jersey City; and
Lee, of Chicago. Radical — Drs. R. T. Morris,
Steven Smith, and T. H. Manley, of New York ;
and J. B. Deaver, of Philadelphia.

Dr. Addinell Hewson, of Philadelphia, read
a length}' and amusing paper on The Use 2^
Years Ago of Polarity for Locating the Where-
abouts of a Leaden Bullet Deeply Imbedded in the
Body.

Dr. Thos. H. Manley, of New York, reported
A Unique Case of Fractured Exostoses of the Pubis.

Diagnosis obscure, abscess found pointing in
Scarpa's triangle. No apparent cause, pus fetid.
Operation : Incision and drainage, with explora-
tion for offending object. Post mortem discovered
upon the brim of the pelvis an exostoses which
had become dislodged from its connection with
the pubis, thus becoming a foreign body and the
origin of the abscess, which was a multilocular
one, and extended from the popliteal space to the
origin of the psoas muscles. The form of the ex-
ostosis suggests that it is a reduplication of the
pubic bone. The pyogenic membrane was ver>'
dense and effectually protected the system from
sepsis. If we had not operated the case might
have spontaneously terminated favorably.

Dr. Rout. Newm.^x, of New York, read a

1889.]

SOCIETY PROCEEDINGS.

67

paper on Electrolysis in the Treatment of Stricture
of the Rectum.

He cited a number of cases which were cured
or improved. Conclusions : I. Electrolysis in
the treatment of stricture is not a panacea, and it
will probably fail if the stricture is due to carci-
noma. 2. Electrolysis will give improvement in
rectal strictures where other methods have failed.
3. Electrolysis cures a certain class of cases bet-
ter than other methods. 4. There is the best
chance of a cure in a fibroid stricture. 5. Use a
metal bulb with fle.Kible stalk.

Fourth Day, June 28.

Dr. Ch.\s. Denison, of Denver, presented A
New Rib Cutter and a Case of Resection of Ribs for
Drainage of a Pulmonarv Cavity.

He reported a case of pulmonarj- abscess, asso-
ciated with tubercular infection, opening in-
teriorly and discharging i'2 pints of pus daily.
Operation : Resection and incision. Treatment :
Drainage, injection of an antiseptic wash and
dressing, after filling the abscess cavitj' with
salol solution 10 per cent in liquid vaseline. Re-
sult : After a few months patient returned to
hotel clerkship at a high altitude in mountains,
feeling well and weight increasing. Abscess
cavity much decreased in size.

He exhibited a new and ingenious instrument,
of his own invention, which combines a perios-
teum lifter and a rib cutter, works easily and
quickly, cuts a smooth surface and is not costl3'.

Dr. J. O. Whitney, of Pawtucket, R. I., said :
Empyema and pulmonarj- abscess are to be
treated on the general principles which have
governed them for years : Drain, but, as a rule,
do not inject disinfectants.

Discussion was continued by Drs. S. H, Weeks,
of Portland, Me,, and J. L. McComas, of Oak-
land, Me.

Dr. J. B. Hopkins, of Philadelphia, read a
paper on The Absorption of Dead Bone.

He gave a history of several experiments in
which dowels of sterilized dead bone were driven
into holes drilled in dog femurs. The dogs were
subsequently killed at varying lengths of time
after the operation, and the gross and micro-
scopic appearances studied.

The following conclusions were reached : i.
When sterilized dead bone is placed in close con-
tact with the living bone, it will undergo absorp-
tion or organization. 2. The process goes on
most rapidly during the period between the third
and eighth weeks. 3. When sterilized dowels of
dead bone are used for mechanical service they
may be relied upon for four to six weeks.

Discussion followed by Drs. Quimbj', of Jersey
City; J. O. Whitney, of Pawtucket, R. I.; and
J. L. McComas, of Oakland, Me.

Dr. J. G. Carpenter, of Stanford, Ky., read
a paper on Pathology and Treatment of Chronic
Sciatica.

The author believes in trying medicinal agents
first and resorting at last, in case of their failure,
to surgical interference in the form of nerve
stretching. The after treatment consists in keep-
ing the limb stretched for a few days, followed by
extension by means of splints or plaster of Paris
boot for three to six weeks. The limb should be
bandaged to obviate swelling.

A paper on The After Treatment in Cases of
Abdominal Section by Dr. L. S. McMurtry, of
lyOuisville, Kj-., was read b}- title,

A paper on Cranial Surgery, by Dr. H. O.
Walker, of Detroit, Mich., was read by title.

An abstract of the paper on The Surgery of the
Spine, by Dr. J. W. White, of Phi'ladelphia,
was read by the secretary'. Spinal trouble which
may necessitate surgical interference : i. Trau-
matism. 2. Caries. 3. Neoplasms. It is cus-
tomar\' and proper in deciding upon any serious
surgical procedure, involving risk to life, to con-
sider well the prospects of the patient in the event
of non-interference, and to be largely influenced
bj' them. This principle is eminently applicable
in cases of spinal surgery.

Section on State J/edicine.
First Day, June 25.

The first paper read was on the subject of
International Comity in State Medicine, by Dr.
John B. Hamilton, Surgeon-General U. S. M. H.
S. Dr. Hamilton took as his text a portion of
the resolutions recently adopted at the last Quar-
antine Convention held in this countrj', viz : the
one in Montgomer>% Alabama. The portion re-
ferred to reads as follows : " Resolved that this
Conference is of opinion that it is a duty devolv-
ing on all nations, to take measures to eradicate
anj' plague centre from their territory, and that
the existence of plague centres is a menace to all
other nations, and that our State Department be
requested to take measures through proper
diplomatic channels, for the conveyance of this
opinion to the Governments deemed obnoxious to
the opinion as herein expressed."

Dr. Hamilton made a strong plea for the ex-
tension of such action, and at the close of his
paper, upon motion it was re.solved that the reso-
lution of the Montgomerj- Sanitary Association
be adopted and transmitted to the general body
of the Association.

Dr. W. C. Rives, of New York, read a paper
on The Importance and Essential Needs of Local
Boards of Health. This paper was an admirable
plea for the extension of efficient sanitation, by
means of local boards of health.

Dr. Hibbard, of Indiana, remarked that there
is always a temptation to lay out too extensive a
programme, and thus defeat the object arrived at.
Action in the direction suggested should be con-

68

FOREIGN CORRESPONDENCE.

[July 13,

formable to and commensurate with the environ-
ments and conditions present.

Dr. Smart, U. S. A., added but a word to the
discussion, saying that he believed in the utmost
energy.

Dr. Morris, of Baltimore, referred to the Sani-
tary Association of Newport, which comprises
such able sanitarians, and which yet permitted
the existence of unsanitary closets in public
places. For his part he is greatl}^ interested in
good plumbing everywhere.

Dr. Storer, of Newport, arose to explain that
while the Association was aware of the conditions
referred to, it found some of them nevertheless,
beyond their jurisdiction.

Dr. N. S. Davis, of Chicago, read a paper on
The Aniericaji Medical Association and its Re-
lations to Public Health.

The reader pointed out the work done by the
Association since its inception. It began with
the matter of the registration of vital statistics
shortly after the founding of the Association.
Next the adulteration of drugs received their at-
tention. In both directions they succeeded in
procuring valuable legislation. Later on, drain-
age, street cleaning, water supply, the use of dis-
infectants, and the effects of tea and coffee in
children, all received their attention. Next thej-
took up the stud}' of epidemics. In 1S50 a re-
port was made on sources of typhus fever, with
the necessarj' remedies. \'aluable reports were
also made on the subject of cholera. In 185 1 the
States were divided into eight groups, and in
1852 reports on epidemics were received from the
groups. The sanitation of ships also received
attention. Up to 1859, indeed the reports of the
Association on the various subjects of sanitation
and State Medicine, were most extensive, the
reader himself being amazed to find that they
formed nearly one-third of the bulk of the tran-
sactions during the j-ears included. In 1859, at
Dr. Lindsley's suggestion, five Sections were es-
tablished, from one of which arose the Section of
State Medicine of to-day. From i'847 to 1882,
we find in the Transactions of the Association the
verj- best record of epidemic diseases to be found.
The influence of the Association was reflected
upon the State and local societies, and it even
led to the formation of new organizations, especi-
ally State and local boards of health. To- day
we have in The Journal a most valuable agencj'
for the propagation of the work that has been so
■well done by the Association.

Dr. Morris, of Baltimore, took exception to
the claims of Dr. Davis for the Association as the
chief agent in .securing the reform alluded to.
He finds in the Association comparatively few
active sanitarians, whereas in the American Pub-
lic Health Association they have not onlj- medi-
cal sanitarians but also architects and engineers.

Dr. Smart, U. S. A,, rose to say that Dr.

Davis claims that this Association is the father of
the latter, and therefore entitled to credit for the
deeds of the son.

Dr. LindslEY, of Ohio, regretted that the As-
sociation had not of late 3'ears maintained the
reputation which it had established so many years
ago in the field of sanitation.

Geo. E. Waring, Esq., of Newport, read a
paper on Modern Sanitary Conditions.

Mr. Waring felt confident that, by improved
sanitan,' measures, the death-rate in cities could
easily be reduced from 18 to 12 per mil., or, in
other words, 365,000 lives could annually be
saved. To accomplish this it is necessary to re-
move the organic waste of life before putrefaction
occurs. This involves mereh- matters of drain-
age, garbage removal, improvement in water sup-
ply and increase of elevation.

Dr. Baker, of Lansing, Mich., said that there
were diseases that could not be stopped by im-
proved sewage and water supply. These diseases,
such as scarlet fever, diphtheria and small-pox,
are to be dealt with by legislation and disinfec-
tion. By these means it will be possible to reduce
the death-rate even below Mr. Waring's limit.

Dr. Hibbard, of Indiana, thought that both
methods should go hand in hand, for it is impos-
sible to secure disinfection without engineering.
(. To be concluded. \

FOREIGN CORRESPONDENCE.

LETTER FROM CAIRO, EGYPT.

The Sanitary Condition of India and its Teach-
ifigs.'

In our last article we gave an account by an
eye witness of the normal sanitar\- condition of a
native hamlet in the suburbs of Calcutta, while
no epidemic was raging. We now propose to lay
before our readers an account of a visit, in Decem-
ber, 1887, to an Indian cholera .stricken village
also in the suburbs of Calcutta, in order that we
may profit by the lessons taught us by the sad
narrative. The epidemic here described is only
part of that cholera epidemic, which has been
spreading over the length and breadth of India
since last year, and which is now raging in all its
intensity in the Punjab. As all our readers
know, India is the hot-bed of cholera, where it is
always present in its endemic form, and where
every three or four years it assumes an epidemic
character, when it threatens to spread not only
over India, but to ever\- part having communica-
tion with that countrj-. The destroying angel
passing over the land of the Pharaohs and smit-
ing the first-boni in everj- Eg3"ptian household,
cannot have produced a more heart-rending

• Written for the " Ar.^bic Mcdic.il Journal '" and coniutunicated
to us through Dr. Joseph Jones, of New Orleans. La.

1889.]

FOREIGN CORRESPONDENCE.

69

scene than the one uow presented, on a smaller
scale at Hathibagan, a suburban village, not
a

to their constituents, no amount of education or
lecturing will ever effect a change. The change

more than a quarter of a mile from the centre of I must come over those who are in municipal
Calcutta. There withm an area of small compass, \ power— that is from those who are in authority
more than twenty families, are each bewailing the j At the present time the sanitarN^ condition of the
death of some member or members of their j suburbs of Calcutta

family. The sound of the dirge and lament is
heard at nearly ever\- door, for within the last few
days cholera has visited house after house, carry-
ing with it sorrow and ruin, and panic. People
are hurrying their dead to the burial and bury-
ing grounds, while others are fleeing for safety
from the place. Among the refugees are not a
few who have fled too late, only to be struck
down on the roadside. Custom and apathy have
so ordered that no pitying eye takes note of these
things, no helping hand stretches forth succor to
the suffering people in their affliction. Hope-
lessly left to shift for them.selves they die in all
the horrors and pangs of a cholera death. But

is an outrage on humanity,
a satire on civilization, and a disgrace to all con-
cerned.^

The closing words of the above report are
even more trenchant than we dare use towards
our authorities, how ever much tempted to do so.
Now what can we Egj'ptians learn from this
picture of the sanitary condition of our neighbors?
What about the air we breathe ? What about the
soil on which our habitations stand ? What about
our drinking water supply ? True, we have not
cholera to deal with, unless when it is imported,
but we have other death producing diseases
always present, that are equally dependent for
their existence and propagation, on what feeds

tinguishes the authorities in their attitude towards
the sufferings of the inhabitants is only surpassed
in permitting the causes of the pestilence to re-
main unremoved. The sanitary condition of the
village has, out of India, no parallel in the civi-
lized world. There are tanks supplying the in-
habitants with drinking water and at the same
time receiving the contents of their latrines.

this is not an. The moral insensibility which dis- j cholera and other contagious diseases. It is not
" ' "'" "" -•----' -- - -' true that the air in and about the majoritj' of our

dwellings is pestilential ; and have we not evi-
dence enough that the soil is saturated with filth,
and is becoming more and more so ever}- day ?
As to our drinking water : if we have no means
of showing the high Nile water, for about three
months in the year we have to drink what may
be truthfully designated sewage water, while,
ditches full of the blackest and most putrid of I during the other months of the vear the river is
mire, the soil soaked with the foulest and most I only comparatively pure by reason of the abund-
noxious of filth, while the air is laden with im- 1 ance of water, which helps to multiply the bad
purities and redolent with stinks. Literally the effects of the organic matter thrown into the
place IS a vast cesspool ; air, water, soil are alike ] Nile by the natives, for there is no sacredness at-
poisoned. Here the external and most potent tachea to it, as gold, wherebv it was kept unde-
causes of disease are in full play and germ, and . filed. We have heard a great deal lately about
ghastly indeed are the effects. Cholera, the child the excessive death-rate throughout E<^ypt but
of filth, revels m its home, gaining m strength more especially in Cairo, and it may well attract
and vitality until conditions arise which shall our attention and draw out our concern What
give an opportunity of leaving its native soil, and ; are the best means to be adopted and are they be-
visiting other places and countries congenial to its i ing used ? In other departments of the Govern-
tastes. Doubtless the authorities will declare that ; ment service we hear of great projects proposed
the endemic or epidemic is due to seasonal influ- 1 and attempted at a great cost to the State but
euces, and that the deaths are not more than usual, [the Public Health of Egvpt is, in many respects
This apolog>- has ever and at all seasons been a Hke the Public Health of India, left almost out of
convenient cloak for inaction ; but how long is I count, although disease and death threaten the
the truth to be suppressed for the ease of the au- very existence of such a small nation as this is
thorities? Seasonal causes are myths of a by-, India, with its population of 300,000000 can
gone day, and must give way to the irresistibly afford to be well purged of its extra population
large accumulation of facts which evidence that | by keeping up its sanitary- condition, but this is
polluted soil, polluted air, and polluted water, are I not the case with Egypt, which is, at this moment
alone a means of nurturing tnis fell disease, and that, suffering from scarcity of tillers of the soil'
the removal of this pollution is alone the remedy. There is no lack of immigrants, but none of them
How long are the inhabitants to be deprived of a
pure water-suppl}-, of drainage, and of measures

can replace the fellaheen. The cultivation of
laborers ought then, one would think, to attract

of cleansing, which are among the ordinary the attention of our political economists a little

necessaries of healthy aggregate life? It is idle
to speak of the filthy habits of the people when
the ordinar}- means whereby they can be clean
are not placed within their reach. If municipal
commissioners will not supply these three wants

more, even than
.sugar cane. We
this is the case, but

the cultivation of cotton and

question very much whether

the shoe will pinch more

2 " Journal of the Health Society for Calcutta and its
Vol. iv, Part I, 1SS8.

7°

MISCELLANY.

[July 13,

tightly some of these days, if some serious, well
digested sanitary measures are not speedily
adopted and carried out. There is a remarkable
similarity between Egypt and India in the sani-
tarj' conditions, and in the apathy of the author-
ities, as to sanitary questions that involve the
health and stability of the native population.
One has only to walk through our cities and
villages to be sensibly assured of the pollution of
the air and soil, and in nine cases out of ten,
that pollution is far more intense inside the houses
of the natives than it is in the streets. Even the
European houses are not exempt from unsanitarj'
smells that might easily, by proper ventilation,
be carried off and disinfected in the open air be-
fore destroying the health of the inmates. We
read of the filthy water-supply in India, and of
its deleterious effects on those who drink it, and
we are not astonished to find that an impure
water supply in Egypt is, accompanied by a high
death-rate. Just look at those green stagnant
pools at low Nile, that surround the Egyptian
villages — that receive the filth and washings of
the villages, and at the same time serve as a
water-supply for man and beast. Can it be won-
dered at that the native population is dying out
by a slow process of blood poisoning? Here
there is no lack of polluted air, polluted soil,
polluted water supply, and these, combined with
the excessive heat of summer, ignorance and
crime, make our demographic statistics, simply
deplorable. The present sanitarj- condition of
India has been designated an outrage on hu-
manity. This may equally be said of the sani-
tary state of Egypt.

Surely things are not going to remain as they
are. It becomes more and more evident, every
day, that a Minister of Public Health is urgently
needed in the Council of Ministers. There is no
lack of intelligent and well-digested sanitary
measures to be carried through, but as they are
not immediatel}' remunerative they are pigeon-
holed and remain a dead letter ! We have raised
our feeble voice in the cause of sanitary reform,
and we have indicated some of the ways by
which the health of the people might be improved.
As far as the climate is concerned little requires
to be done, as it is so excellent. The heat of
summer is, no doubt, some years excessive, and
children suffer from the effect it has on their milk
food, and many die from summer diarrhoea. This
could be controlled .somewhat, if the people were
less ignorant and knew more about the proper
preparation of food for the delicate stomachs of
their children. The cold of winter does not last
long, -SO that chest disease is not common among
the natives, but we have .seen many cases that
would have better health if they had more cloth-
ing. We consider that a little more education
would enable the natives to intelligently combat
the evils arising from the climate. We think that

it is the duty of the Government to take the ad-
vice of its Sanitarj' Department as to the laying
out of towns and villages, and as to the construc-
tion of individual houses, so as to secure pure
air for its people to breathe. Many of the wild
beasts have better dens to live in than the Egyp-
tians have houses. The honey-comb principle,
on which the houses of the villages are built, is
entirel}- wrong. This could be rectified without
much trouble, as they are but crude brick huts at
best.

The Government is certainly responsible for a
pure water-supply for man and beast, all the year
round, and it would be wise, in fulfilling this duty,
to make arrangements beforehand for carrying off
the waste. When that is done, we shall have no
more of the green stinking ponds around the na-
tive villages. At this moment Cairo is supplied
with an abundance of water, but the sewers have
been destroyed, so that, unless something is sub-
stituted for them soon, we shall have our streets
flooded, if nothing worse befall us. We are de-
sirous to see the Public Instruction and Sanitary
Department in a more flourishing condition.

J, A. S. Grant (Bey).

MISCELLANY.

Married, June 26th, at the home of the bride at North
Brookfield, N. Y., by Rev. W. T. S. Lumbar, Howard F.
Hubbard, M.D., of Verona, Oneida Co., N. Y., and Miss
GeraldineL., daughter of Gilbert Birdsall, M.D. , of North
Brookfield, N. Y.

The Brooklyx Throat Hospital was formally
opened on the 19th ult.

Georgia State Medical Association. — At the an-
nual meeting of this Association held at Macon, recent-
ly, the following were elected officers for the ensuing
year: President, Dr. J. S. B. Holmes, of Rome; First
Vice-President, Dr. R. O. Engram, of Montezuma; Sec-
ond Vice-President, Dr. P. R. Cortelyou, Marietta; Cen-
sor, Dr. G. W. Mulligan, of Washington; Orator, Dr. W.
F. Westmoreland, of Atlanta.

Personal.— Dr. J. M. Fox, formerly of Troy, N. Y.,
but now a resident of London and an M.P., win return to
this country again and locate either in Albanv or New-
York. Dr. Joseph P. Ross, a well-known physician of
Chicago, is seriously indisposed. Cairo, 111., has erected
a handsome monument to the memory of Dr. Roswell
Waldo, at Mound City, in recognition of his services in
the yellow fever epidemic in 1S78.

The Sanitation of the Lavndrv. — In speaking of
this subject The Lancet, in the interest of the general
public, says: \ possible source of danger to health, and
one which \\\Ay. upon occasion, become the centre of in-
calculable mischief, is the laundry. The absence of any
regulating authority, and the lowly condition of many
of the proprietors of the.se establishments, render theiii
particularly liable to faults of management; while the
necessity which the dwellers in town are under of giving
out their laundry work creates a limitless demand. It
becomes, therefore, a matter of importance that from

1889.]

MISCELLANY.

71

time to time the warning voice should be raised, and the
public put upon their guard respecting the lurking harm.
A certain, even a considerable, risk must at the very best
attend the institution of a common laundry. No readier
method of disseminating the germs of infectious disease
could well be devised than by the intermingling of wear-
ing apparel, and where this intermingling takes place
the use of antiseptics can afford no more than an un-
trustworthy and insecure protection from the risks of
•contamination.

Hence, the verj- safest plan is to arrange, where possi-
ble, for the laundry work to be done at home, and bj'
resident domestic servants. But this is a ''counsel of
perfection " and can seldom be put into actual practice.
The common laundry' is a necessit}' of modern conditions
■of life, and that being so, the only thing remaining to be
■done is to turn the force of public opinion in the direc-
tion of insisting upon such precautions and safeguards
as will minimize its inevitable risks. It is, we fear, an
obvious deduction from this principle that the cottager
laundress ought hardly to be encouraged. She may be
a very worthy person, whose industry and independence
■we should all respect and strongly desire to support.
But, in towns at least, where space is narrow and one's
next-door neighbor is tmknown, there are serious draw-
"backsto her position. She is too dependent on the good-
will of her customers to be able to enforce a quarantine
■of infected linen if it be offered to her, and probably too
little acquainted with their domestic affairs to know
"«'hether there is or is not ground for suspicion. Hence,
housekeepers who take a wise view of their responsibil-
ities will prefer to avail themselves of the facilities and
guarantees offered by laundries on a larger scale, where
the capital employed suffices to provide adequate accom-
modation and the scale of the operation enables the man-
agers to exercise a judicious supervision over the work
which they undertake, and makes it not only possible,
but also commercially necessary, for them to decline
such as would involve the risk of introducing contagium
to their general stock of clothes. Such laundries are at
work, and it is, we hope, a question of time onlv, and
that not a long time, for better and more scientific meth-
ods to supersede entirely the dangerous laxity of the
■washerwoman industry.

The Medical News says : " The election of Dr. E. M.
Moore, of Rochester, for the presidency of the American
Medical Association will be regarded throughout the
country with universal satisfaction, both for his personal ;
■worth and in recognition of his valuable contributions to i
practical surgery. It is the crowning honor of a long
■career devoted to the furtherance of the best interests off
the profession and to the material advancement of surgi- \
•cal knowledge. Nashville as the place of meeting has
the merit of being central and accessible from all direc-
tions."

Medical Society Notes.— At the one hundred and
twenty-third annual meeting of the Medical Society of
New Jersey the following officers were elected: Presi-
dent, Dr. B. A. Watson, Jersey City; First Vice-President,
Dr. James S. Green, Elizabeth: Second Vice-President,
Dr. E. J. Marsh. Patterson: Third Vice-President, Dr.
■George T. Welch, Keyport; Corresponding Secretary,
Dr. William Elmer. Trenton; Recording .Secretary, Dr.
William Pierson. Orange; Treasurer, Dr. W. W. L. Phil-
ips, Trenton; Standing Committee, Dr. T. J. Smith.
Bridgeton; Dr. D. C. English, New Brunswick; and Dr.
J. G. Ryerson, Boonton. Essayist for the next meeting.
Dr. E. L. B. Godfrey, Camden. The Society will hold
its next meeting at Schooley's Mountain.

The Gratiot County, Mich., Medical Society, will hold
its annual meeting at Dr. Scott's office, Ithaca, on the
24th inst.

The officers elected by the Toronto (Ont.) Medical Soci-
ety for the coming year are: President, Dr. A. B. Atherton;

First Vice-President, Dr. B. Spencer; Second Vice-Pres-
ident, Dr. N. A. Powell; Recording Secretary, Dr. G.
Acheson; Corresponding Secretarj-, Dr. W. B. Thistle;
Treasurer, Dr. W. J. Greig; Councillors, Drs. J. E. Gra-
ham, G. A. Peters, and W. H. B. Aikins.

The Ontario Medical Association have elected the fol-
lowing officers: President, Dr. J. Algernon Temple.
Vice-Presidents, First, Dr. Lund}', Preston; Second, Dr.
G. Shaw, Hamilton; Third, Dr. K. N. Fenwick, Kings-
ton; Fourth, Dr. Hanlep, Waubashene. General Secre-
tary, Dr. D. J. Gibb Wishart, Toronto. Treasurer, Dr.
E. J. Barrick, Toronto. .•Assistant Secretary, Dr. W. P.
Caven, Toronto.

Anent The Journ.-^l. — The British Medical Journal
of the 22d ult., in referring to the Newport meeting says:
" Owing in great part to the quiet advocacy of the excel-
lent weekly journal w'hich it owns, the American Medi-
cal .Association has recently been steadily gro^sviug in
numbers and in influence."

The Therapeutic .Inalyst says: "The Journal of
THE -American Medical .Association issued on May 25
an extra edition of 75,000 copies, devoted principally to
the interests of the profession in connection with the
meeting of the -Association at Newport, R. I. This enor-
mous edition was sent out gratuitously to the profession.
The Journal, although always awake to the welfare of
the Association, was never more ably edited and judi-
ciously managed than at present."

The' Occidental Medical Times says: ' ' The Trustees of
The Journ.\l have issued an extra edition of 75,000,
which, by good business management, has paid for itself
It contains, amongst other valuable papers, a special ar-
ticle by Dr. Wm. G. E.ggleston, on "Our Medical Col-
leges," that will be read with interest, and should be
kept for reference. The full programme of the .Associa-
tion meeting is published, with a description of Newport,
handsomely illustrated. The Journ.al is steadily gain-
ing in favor with the profession, as the published report
of the Trustees will indicate. When it is remembered
that any physician belonging to a medical society, in
good standing, can, on the payment of 55. become at
once a member of the .Association, and receive The
Journal gratis, it is strange that the membership has
not increased more rapidly. We hope that this extra
edition, which will reach every physician in the United
States, will be followed by a large accession."

The Universily Medical .Vag-a: in e says; " The Jour-
nal OF THE .American Medical .Associ.\.tion for May
25, 1SS9, of which an edition of 75, (x» copies was issued,
was in all respects a most acceptable and praiseworthy
enterprise. In addition to the strictly scientific matter,
and the satisfactory programme of the Fortieth .Annual
Meeting of the .American Medical .Association, the most
important contribution is the special article from the pen
of Dr. Wm. G. E.ggleston, of Chicago, on "Our Medical
Colleges." Dr. Eggleston is to be congratulated upon
the interesting and carefully gathered statistical infor-
mation which is found in his report, and especially upon
the preparation of the table of -American Medical Col-
leges, together with their matriculation and graduation
requirements, obligatory practical and laboratory cours-
es, and other information in regard to the methods of in-
struction and curriculum."

The Te.x'as Health Journal says : "An extra edition of
75.000 copies of The Journal of the .American Med-
ical Association was published on May 25. This was a
.great enterprise and should be appreciated by the profes-
sion of the United States in a substantial manner. The
list of Medical Colleges therein contained is of great sta-
tistical value.

The Journ.\l is getting better each year and the med-
ical profession ought to keep the edition standing at
75,000 weekl}- ; this could be done and then there would
be about 10,000 physicians without The Journ.al."

The Canadian Practitioner says : The organ of the

72

MISCELLANY.

[July 13, 1889.

American Medical Association has shown marvellous
journalistic enterprise in sending out a special edition of
75,000 copies."

PAMPHLETS RECEIVED.

The Control and Care of Pauper Inebriates of Towns
and Cities. By Lewis D. Mason, M.D., Brooklyn, N. Y.
(^Reprint.)

On the \'alue of Frequently Repeated Doses of Arsenic
in the Treatment of Bullous Diseases of the Skin, espe-
cially in Children. By L. Duncan Bulkley, A.M., M.D.,
New York. I Reprint. )

On Unusual Methods of Acquiring Syphilis, with Re-
ports of Cases. Same author.

The .\uimal Suture in Intra-Vaginal Plastic Surgery.
By Thomas A. Ashby, :\I.D., Baltimore, Md. (Reprint.)

Is more Conser\'atism desirable in the Treatment of
the Joint Diseases of Children. By A. B. Judson, M.D.,
Xew York.

Fourteenth Annual .Announcement of Meharry Medi-
cal Department Central Tennessee College, Nashville,
Tenn.

.Announcement of the National Medical College, Med-
ical Department of the Columbian University, Washing-
ton, D. C. .

Announcement of the Dental Department of Columbian
University, Washington, D. C.

Announcement of the Hospital College of Medicine,
Louisville, Ky.

.Announcement of the Texas Medifal College and Hos-
pital, Galveston, Tex.

.Announcement of the Woman's Medical College of the
New York Infirmary.

Fourth .Annual Report of the New York Cancer Hos-
pital.

Stomach Washing in Infants. By .A. Seibert, M.D.,
New York.

.A Contribution to the Study of Muscular Tremor. By
Frederick Peterson, M.D., New York. (Reprint.)

A. Carrington, New Haven, Conn.; Dr. C. S. Boynton,
Burlington, Vt.; Dr. H. C. Dalton, St. Louis, Mo.; Pap-
penheim's Zeitung-Verlag, Yienna, .Austria ; Women's
Medical College, New York City ; F. -A. Davis, Philadel-
phia, Pa.; Dr. David Barrow, Lexington, Ky. ; .American
& Continental Sanitas Co., New York City ; J. J. Rendle-
man, Cairo, 111. ; Dr. Wm. Pepper, Philadelphia; Dr.
John E. Owen, Evansville, Ind.; Dr. J. T. Davis, Zanes-
ville, 0.; L. von Olst, Orange Citv, la.; Dr. W. S. Watson,.
Matteawau, N. Y.; Dr. L. Woodruff, .Alton, O.; L. A.
Yocum, Wooster, O.; National Druggist, St. Louis ; Dr.
D. K. White, Richmond, O.; Dr. Samuel .A. Fisk, Den-
ver, Col.; Dr. J. H. Murphy, St. Paul, Minn.; Dr. J. Ber-
rien Lindsley, Nashville, Tenn.; Dr. John H. Hollister,,
Newport, R. I.

LETTERS RECEIVED.
S. S. White Dental Mfg. Co., Philadelphia ; Dr. M. E.
Stephens, .Albany, N.Y.; Dr. .Addison H. Foster.Chicago;
Dr. W. H. Begg, Columbus Grove, O. ; Dr. James Egau,
Racine, Wis.;" Dr. Ramsay, St. Cloud, Minn.; Dr. R. T.
Bates, New Lebanon, N. Y. ; Oneida Spring Co., Utica,
N. Y.; Fairchild, Bros. & Foster, New York ; Dr. H. M.
Lane, Las Paulo, Brazil ; Dr. J. W. S. Gouley, New York ;
Dr. J. W. Powers, Hudson, la.; Dr. W. F. Waugh, Phila-
delphia ; Dr. F. S. Dodds, .Anna, 111. ; Dr. N. S. Lane,
Evota, Minn.; Dr. J. W. Thompson, St. Paul, Minn.; Dr.
C.'F. McGahan, Chattanooga, Tenn.; Dr. C.L.Ford,
Ann Arbor, Mich.; E. T. Boag, New York ; Dr. S. P.
DufReld, Detroit, Mich.; Dr. C. A. Har\-ey, New York ;
Dr. I. N. Brainerd,.Alnia, Mich.; Dr. P. O. Hooper.Cincin-
nati, O. ; Dr. F. G. Groner, Big Rapids, Mich.; Dr. Joseph
Price, Philadelphia ; Dr. J. H. Black, Philadelphia ;
Mcintosh Batterv and Optical Co., Chicago ; Dr. Thos.
L- Stednian, New York ; Dr. J. B. Murdoch, Pittsburgh ;
Thos. F. Goode, Buffalo Lithia Springs, Ya.; Dr. D. W.
Prentiss, Washington, D. C; Dr. .A. R. Stuart, Toledo, O.;
Cupples & Hurd, Boston ; Dr. J. H. Bryan, Washington,
D.C.; Dr. Maris Gibson, Wilke-sbarre, Pa.; Dr. John Gem-
mill, Tvronc, Pa.; Dr. R.J. Dunglison, Philadelphia;
The Clinical Reporter, St. Louis, Mo.; Dr.Thomas Elliott,
Worth, Pa.; Mrs. .A. S. JL Morgan, Pittsburgh, Pa.; J.
.Astier, Paris, France ; Dr. I). Bernardino, Muscoda.Wis. ;
Dr. Wm. WoodrutT, London, Ontario ; Dr. J. M. Long,
Minden Mines, Mo.; Dr. John B. Rosson, Ava, 111.; Dr.
R. M. Wycoff, Brooklyn, N. Y.; Dr. W. G. Brownlow,
New Canaan, Conn.; Dr. C. B. Miller, Lawrenceburgh,
Ind.; Dr. M. O. Lower, North Manchester, Ind.; I. Hal-
denstein. New York Citv ; Dr. Edwin Meigs Ground,
Bartlett, N. H.; I.ehn .S:' I'ink, New York City ; Dr. H.

Official List of Changes in the Stations and Duties of
Officers Serving in the Medical Department, U. S.
Army\fro)n June 22, iSSg, to July ^, iSSg.

Major William H. Forwood, Surgeon, extension of Ipave
of absence on surgeon's certificate of disability granted
in S. O. 1 18, May 23, 1SS9, from this office, is further
extended tour months on surgeon's certificate of disa-
bilitv, by direction of the Secretary of War. Par. 14,
S. O. 142, -A. G. O., Washington, June 20, 1SS9.

Major J. K. Corson, Surgeon U. S. Army, granted leave
of absence for one month, with permission to apply
for an extension of one month. Par. 2, S. O. 65,
Hdqrs. Dept. of the Columbia.

Bj- direction of the Secretary of War, Major Ezra Wood-
ruff, Surgeon, is relieved from temporary duty at Ft.
Monroe, Ya., and will report in person to the com-
manding officer at Ft. Hamilton, N. Y., for duty at
that station. Par. 5, S. O. 146, .A. G. O., June 25, I'S-Sg.

Capt. Walter W. R. Fisher, .Asst. Surgeon, extension of
leave of absence granted in S. O. 41, Div. of the Pacific,
June 12, 1S89, is still further extended fifteen days, by
direction of the Secretary of War. Par. S, S. 6. 146,^
A. G. O., Washington, June 25, 18S9.

Capt. John Yan R. Hoff, Asst. Surgeon U. S. Army, is-
relieved from dutv at Ft. Reno, Ind. Ter., and ordered
to Ft. Riley, Kan. Par. 6, S. O. 145, A. G. O., Wash-
ington, D. C, June 24, 1S89.

Major Dallas Bache, Surgeon U. S. Army, is relieved
from dutv at Ft. Riley, Kan., and ordered to report to
the commanding General, Dept. of the Platte, for duty
as Medical Director of that Department. Par. 6, S. O.
145, A. G. O., Washington, D. C, June 24, 1889.'

Major J. K. Corson, Surgeon, leave of absence for one
month granted by par. 2, S. O. 65, c. s., Dept. of the
Columbia, is extended one month. Par. i, S. O. 45,
Hdqrs. Div. of the Pacific, June 24, 1889.

Capt. A. R. Chapin, .Asst. Surgeon U. S. Army, granted
leave of absence for twenty-five days, to commence"on
or about July 2, 18S9. Par. 6, S. O. 145, Div. of the
Atlantic, June 27, 1S89.

Capt. R. J. Gibson, .Asst. Surgeon U. S. .Army, reports-
arrival July 2, 18S9, at Camp Lewis, Fisher's Island, N.
Y., in compliance with par. 5, S. O. 155, Div. of the
.Atlantic, which designated him as medical officer for
the encampment (rifle practice! at Fisher's Island,
N. Y.

Capt. George T. Beale, Medical Storekeeper, is granted
leave of absence for two months, bv direction of the
Secretary of War. Par. 8, S. O. 148, A. G. O., June
27, 1889.'

Official List of Changes in the Medical Corps 0/ the U. S.

Nazy/or the Week Ending June 2q. iSSg.
Surgeon C. -A. Siegfried, detached from the U. S. S.

" Quinnebaug" and wait orders.
P. A. Surgeon L. W. Curtis, detached from the U. S. S.

"Quinnebaug" and wait orders.
Asst. Surgeon Geo. T. Smith, ordered to the .Army ami

Navy Hospital, Hot Springs, .Ark.

THE

Journal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.

PUBLISHED WEEKLY.

Vol,. XIII.

CHICAGO, JUI.Y 20, 1889.

No. 3.

ADDRESSES.

CONSIDERATIONS CONCERNING SOME!
EXTERNAL SOURCES OF INFECTION
IN THEIR BEARING ON PRE-
VENTIVE MEDICINE.

Being the Addtfss on State Medicine delivered befote the American
Medical Association, in Xewport, on June sS, l88g,

BY WM. H. \VELCH. M.D.,

PROFESSOR OF PATHOLOGY, JOHNS HOPKINS UNIVERSITY,
BALTIMORE.

No department of medicine has been cultivated
in recent years with such zeal and with such fruit-
ful results, as that relating to the causes of in-
fectious diseases. The most important of these
results for preventive medicine, and for the wel-
fare of mankind is the knowledge that a large
proportion of the causes of sickness and death are
removable.

It is evident that efforts to preser\'e health will
be most intelligently and effectually applied when
they are based upon an accurate and full knowl-
edge of the agencies which cause disease. Pub-
lic and private hygiene, however, can not, and
fortunate!}' has not, waited for the full light of
that day whose dawn has only begun to appear,
when we shall have a clear insight into the causa-
tion of preventable disea.ses. Cleanliness and
comfort demand that niean_f shall be taken to
render pure the ground on which we live, the air
which we breathe, and the water and food with
which we are supplied, and we must meet these
needs without waiting to learn just what relation
infectious agents bear to the earth, air, water and
food.

It is a fortunate circumstance that modern sani-
tation has been controlled so largely by the be-
lief in the dependence of endemic and epidemic
diseases upon organic impurities in the soil and
in the water. Incomplete and even erroneous in
many respects, as are the views which have pre-
vailed concerning the origin and .spread of epi-
demic diseases by the decomposition of organic
substances, the sanitary measures which have
been directed toward the removal of filth have
achieved great conquests in limiting the develop-
ment and extension of many infectious diseases.

The benefits which one Commonwealth of this
country has derived from the intelligent employ-
ment of public sanitary measures were clearly
and forcibly presented before this Association last
year by Dr. Walcott in his admirable Address on
State Medicine.

While nothing should be said, or need be said,
to lessen the importance of cleanliness for public
health, it is important to bear in mind, that hy-
gienic cleanliness and aesthetic cleanliness are not
identical. In water which meets the most severe
chemical tests of purity typhoid bacilli have been
found. On the other hand, the air in the Berlin
sewers, which certainly does not meet the most
modest demands of aesthetic cleanliness, has been
found to be nearh- or quite free from bacteria.

It needs only to be stated to be generally ad-
mitted that the scientific basis of preventive medi-
cine must be the accurate knowledge of the causa-
tive agents of preventable diseases, a knowledge
which can be derived only from a careful study of

i all of the properties of these agents, the modes of

I their reception and of their elimination by the
body, the circumstances which favor, and those
which retard or prevent their development and
spread, their behavior in the various substances
which surround us, or which we take into our

' bodies and the sources of infection, not only
those which laboratory experiments show to be
possible, but those which are actually operative.
So long as we were unacquainted with the living
organisms causing infection, the means at our dis-
posal for studying the etiology of infectious dis-
eases were limited to the observation of all of the
circumstances which we could determine regard-
ing the origin and spread of the.se diseases. We
could only infer what might be the properties of
the infectious agents from the study of phenomena
often obscure and difficult of interpretation.
Chiefly by this method of investigation the sci-
ence of epidemiology has been built up. It has

I established facts and laws no less of practical than
of scientific importance. But it has left unsolved
many problems, and has filled gaps with specula-
tions. Admitted epidemiological facts' are often
open to various interpretations.

We are evidently at a great advantage when we
can stud}' the epidemiological facts with a knowl-

I edge of the substances which actually cause in-

74

ADDRESS ON STATE MEDICINE.

QULY 20,

fection, and this we are now enabled to do for a
limited number of the infectious diseases. This
new method of research, which thus far has been
mainly bacteriological, has aided us not so much
by simplifying the problems of etiology, which
still remain complicated enough, as by affording
greater accuracy to the results.

It is my aim in this address to consider some
results of the modern studies of pathogenic micro-
organisms in their bearing upon preventive medi-
cine, more particularly upon the sources of infec-
tion. It is, of course, impossible within the
limits of the address, to attempt a complete sur-
vey of this important field. Time will permit
the presentation of only some of the salient
points.

Infectious diseases are those which are caused
by the multiplication within the body of patho-
genic microorganisms.

It has always been recognized that some in-
fectious diseases, such as the exanthematous
fevers, are conveyed directly from the sick to the
healthy. It is not disputed that in these, evi-
dently contagious diseases, the infectious germ is
discharged from the body in a state capable at 1
once of giving rise to infection.

In a second group of infectious diseases, of I
which malaria is the type, the infected individual
neither transmits the disease to another person,
nor, so far as we know, is capable of infecting a j
locality. Here there is a reason to believe that
the infectious germ is not thrown oflf in a living
state from the body, but is destroyed within the
body. In this group the origin of infection under
natural conditions is always outside of the body.
In a third group there is still dispute whether
the disease can be transmitted directly from per-
son to person, but all are agreed that the infected
individual can infect a locality. It is especially
fortunate that the bacteria which cause cholera
and typhoid fever, the two most important repre-
sentatives of this group of so-called miasmatic-
contagious diseases, have been discovered and
isolated in pure culture. These are the diseases
about whose origin and epidemic extension there
has been the greatest controversy. They, above
all other diseases, have given the impulse to pub-
lic sanitation during the last half century. The
degree of success with which their extension in a
community is prevented is an important gauge of
the excellence of the local sanitary arrangements.
A clear comprehension of the origin and spread
of these diseases signifies the solution of many of
the most vexed and important problems of epi-
demiology and of State hygiene.

It is difficult to understand how tho.se who ac-
cept the discovery that the bacteria causing
typhoid fever and cholera, have been found and
cultivated from the .stools of patients affected with
these disea.ses, can doubt that these patients are
possible sources of contagion, or can entertain the

view once so widely prevalent that the infectious
germs of these diseases are discharged from the
bod}' in a condition incapable of producing im-
mediate infection. In an address delivered on
another occasion, I have endeavored to present
the consideration which reconcile the comparative
infrequency of direct contagion for these diseases,
with the belief in the elimination of the causative
germs in an active state from the body, and have
there pointed out several well known factors
which determine the frequency of conveyance of
an infectious disease bj' contagion. There are
reasons, some of them verj' obvious, wh}' diseases
in which the infectious substances are operative
only when received into the digestive tract, and
are discharged usually only with the feces, are
less likelj' . to be transmitted by immediate con-
tagion than tho.se diseases in which the virus is
thrown off from the skin on epidermal scales.

But the field of operation of direct contagion
for these so-called miasmatic-contagious diseases
is at most a restricted one, and the chief sources
of infection are outside of the body from which
primaril)' the infectious germs may have been de-
rived. It is to these external sources of infection,
which are of such importance in public hygiene,
that I wish especially to direct attention.

A full comprehension of the sources of infec-
tion is, of course, to be obtained only by a de-
tailed study of the etiology of the individual in-
fectious diseases, but this is, of course, impossi-
ble within the limits of an address. It may,
however, be useful to present some of the facts
which have a general bearing upon the subject.
Let us consider, then, from the point of view of
modern bacteriological studies, what role in har-
boring or transporting infectious agents, may be
played by those substances or media with which
, we necessarily come into intimate contact, such
as the air, the ground, the water and our food.

It is universall}' admitted that many infectious
agents may be transported by the air, but the ex-
tent of danger from this source has often been ex-
aggerated. It is a pbpular error to suppose that
most of the minute particles of dust in the air
either are or contain living organisms. The
• methods for determining the number, and kind of
bacteria and fungi in the air, are now fairly satis-
factory, although by no means perfect. These
have shown that while the number of living bac-
teria and fungi in the atmosphere, in and around
human habitations cannot be considered small,
still it is greatly inferior to that in the ground or
in most waters. Unlike fungus spores, bacteria
do not seem to occur to any extent in the air as
single detached particles, which would then neces-
sarily be extremely miiuite, but rather in clumps
or attached to particles of dust of relatively large
size. As a result in a perfectly quiet atmosphere,
the.se comparatively heavy particles which con-
tain bacteria, rapidly .settle to the ground or upon

1889.]

ADDRESS ON STATE MEDICINE.

75

underlying objects, and are easily filtered out bj-
passing the air through porous substances, such
as cotton-wool or sand. Rain washes down a
large number of bacteria from the air. That the
air bacteria are derived from the ground or ob-
jects upon it is shown by their total absence, as a
rule, from sea air at a distance from land, this dis-
tance naturally varying with the direction and
strength of the wind.

A fact of capital importance in understanding
the relations of bacteria to the air, and one of
great significance for preventive medicine, is the
impossibility of currents of air detaching bac-
teria from moist surfaces. Substances containing
pathogenic bacteria, as, for instance, sputum con-
taining tubercle bacilli or excreta holding typhoid
bacilli, can not, therefore, infect the air unless
these substances first become dry and converted
into a fine powder. We are able to understand
why the expired breath is free from bacteria and
cannot convej^ infection, except as little particles
may be mechanically detached by acts of cough-
ing, sneezing or hawking. Those bacteria, the
vitality of which is rapidly destroyed by com-
plete desiccation, such as those of Asiatic cholera,
evidently are not likely to be transported as in-
fectious agents by the air, if we except such oc-
casional occurrences as their coiu'eyance for a
short distance in spraj-.

The only pathogenic bacteria which hitherto
have been found in the air, are the pus organisms,
including the streptococcus, found by Prudden in
a series of cases of diphtheria, and tubercle bacilli,
but no far-reaching conclusions can be drawn
from the failure to find other infectious organisms
when we consider the imperfection of our methods,
and the small number of observations directed to
this point. The evidence in other ways is con-
clusive that many infectious agent.s — and here the
malarial germ should be prominentlj^ mentioned
— can be, and often are, conveyed by the air.
While we are inclined to restrict within narrower
limits than has been customary the danger of in-
fection through the air, we must recognize that
this still remains an important source of infection
for many diseases. All those, however, who
have worked practically with the cultivation of
microorganisms, have come to regard contact with
infected substances as more dangerous than ex-
posure to the air, and the same lesson maj^ be
learned from the methods which modern surgeons
have found best adapted to prevent the infection
of wounds with the cosmopolitan bacteria, which
cause suppuration.

We are not, of course, to suppose that infecti-
ous germs floating in the form of dust in the at-
mosphere are dangerous, only from the possibility
of our drawing them in with the breath. Such
germs may be deposited on substances with which
we readily come into contact, or they may fall on 1
articles of food where thej^ may find conditions |

suitable for their reproduction, which cannot oc-
cur when they are suspended in the air in conse-
quence of the lack of moisture.

From the facts which have been mentioned con-
cerning the relations of bacteria to the air, what
points of view present themselves to guide us in
preventing infection through this channel ? Surely
something more than that this purpose is ac-
complished simpl}' by abolishing foul odors.

Certain indications are so plain as to need onlj^
to be mentioned in this connection, such as the
disinfection and removal, as far as possible, of all
infected substances, an indication which applies
equally to all channels of infection, and which it
is much easier to mention than it is to describe
how it shall be realized. But there are two indi-
cations which appl}' especially to the prevention
of the transportation of disease germs by the air.
One is the nece.ssity of guarding, so far as practica-
ble, against the desiccation, when exposed to the
air, of substances which contain infectious germs
not destroyed by drying, and another is free
ventilation.

For no disease is the importance of the first of
these indications so evident and so well es-
tablished as for tuberculosis, the most devastating
of all infectious diseases. Against this disease,
formidable as it may seem to cope with it, the
courageous crusade of preventive medicine has
begun, and is destined to continue.

It is now generally recognized that the princi-
pal, although not the sole, sources of tuberculous
infection are the sputum of individuals affected
with pulmonary tuberculosis and the milk of
tuberculous cows. Cornet, who has made a
laborious and most instructive experimental study
of the modes and dangers of infection from
tuberculous sputum, has also elaborated the
practical measures which should be adopted to
diminish or annihilate these dangers. These
measures have been so recently and so widely
published in medical journals, and so clearly pre-
sented before a Section of this Association, that I
mention them only to call the attention of practi-
tioners of medicine to their importance, and to
emphasize the fact that they are based chiefly
upon the principle that infectious substances of
such nature as tuberculous sputum should not be
allowed to become dry and converted into dust
when exposed to the air.

By means of free ventilation, disease-producing
microorganisms which may be present in the air
of rooms, are carried away and distributed so far
apart that the chance of infection from this source
is removed or reduced to a minimum. It is a
well-established clinical observation that the
distance through which the specific microbes of
such diseases as small-pox or .scarlatina are likely
to be carried from the patient by the air, in such,
concentration as to cause infection, is small, usu-
ally not more than a few feet, but increases by

76

ADDRESS ON STATE MEDICINE.

[July 20,

crowding of patients and absence of free ventila-
tion. The well-known experiences in the proph5'-
laxis and treatment of typhus fever are a forcible
illustration of the value of free ventilation.

It is, of course, not to be understood that by
ventilation we accomplish the disinfection of a
house or apartment. Ventilation is only an ad-
junct of such disinfection which, as already men-
tioned, is of first importance. Time will not
permit, nor is it in the plan of this address, to
discuss the details of such questions as house dis-
infection, but I may be permitted to say that the
methods for disinfecting apartments have been
worked out on a satisfactorj' experimental basis,
and should be known, at least, by all public
health officers. Whether it be pertinent to this
occasion or not, I cannot forbear to add my pro-
test to that of others against placing reliance upon
any method hitherto employed of disinfecting
houses or apartments by fumigation. And I
would, furthermore, call attention to the lack in
most cities of this country of public disinfecting
establishments, such as are in use with excellent
results in many cities of Europe, and which are
indispensable for the thorough and convenient I
disinfection of clothing, bedding, carpets, cur-
tains, etc.

After this short digression let us pass from the
consideration of the air as a carrier of infection to
another important external source of infection,
namely, the ground. That the prevalence of
many infectious diseases depends upon conditions
pertaining to the soil cannot be qestioned, but the
nature and the extent of this influence have been
and are the subjects of lively discussion. The
epidemiological school led by Pettenkofer, assigns
as is well-known, to the ground the chief, and even
a specific and indispensable influence in the
spread of many epidemic diseases, particularly
cholera and typhoid fever. The statistics, studies
and speculations of epidemiologists which have
related to this subject, probably surpass in number
and extent those concerning any other epidemio-
logical factor. The exclusive ground hypothesis
has become an ingenious and carefully elaborated
doctrine with those who believe that such diseases
as cholera and typhoid fever can never be trans-
mitted by contagion. These authorities cling to
this doctrine with a tenacity which indicates that
on it depends the survival of the exclusively
localistic dogma for these diseases.

To all who have not held aloof from modern
bacteriological investigations, it must be clear
that views which have widely prevailed concern-
ing the relations of many infectious germs to the
soil require revision. The question is still a diSi-
cult and perplexing one, but on some hitherto
obscure or misunderstood points these investiga-
tions have shed light, and from the same source
we may expect further important contributions to
a comprehension of the relations of the ground to
the development of infectious diseases.

The ground, unlike the air, is the resting or the
breeding place of a vast number of species of
microorganisms, including some which are patho-
genic. Instead of a few bacteria or fungi in a
liter as with the air, we find in most specimens of
earth thousands, and often hundreds of thousands
of microorganisms in a cubic centimeter. Fraenkel
found the virgin soil almost as rich in bacteria
and fungi as that around human habitations.

This vast richness in microorganisms belongs,
however, only to the superficial layers of the
earth. Where the ground has not been greatly
disturbed by human hands, there is, as a rule,
about three to five feet below the surface an ab-
rupt diminution in the number of living organ-
isms, and at the depth where the sub-soil water
usually lies, bacteria and fungi have nearly or en-
tirely disappeared. Fraenkel, who first observed
this sudden diminution in the number of micro-
organisms at a certain level beneath the surface,
explains this singular fact by the formation at
this level of that stickj- accumulation of fine
particles consisting largely of bacteria which
forms the efficient layer in large sand filters for
water. Of course the number of bacteria, and
the depth to which they penetrate, will vary
somewhat with the character, especially the por-
ositj- of the soil and . its treatment, but the im-
portant fact that all, or nearly all of the bacteria
and fungi are retained in the ground above the
level of the sub-soil water, will doubtless hold
true for most situations.

The conditions are not favorable for the multi-
plication of bacteria, in the depth of the ground,
as is shown by the fact that in specimens of earth
brought to the surface from a depth of a few feet,
the bacteria which are at first present, rapidly
multiply. What all of the conditions are which
prevent the reproduction of bacteria in the deep
soil has not been ascertained, but the fact necessi-
tates similar precautions in the bacteriological ex-
amination of the soil as in that of water.

We have but meagre information as to the kinds
of bacteria present in the ground in comparison
with their vast number. Many of those which
have been isolated and studied in pure culture
possess but little interest for us so far as we know.
To some of the microorganisms in the soil appears
to be assigned the role of reducing or of oxidizing
} highly organized substances to the simple forms
i required for the nutrition of plants. We are in
the habit of considering so much the injurious
bacteria that it is pleasant to contemplate this
beneficent function, so essential to the presen-ation
of life on this globe.

Among the pathogenic bacteria which have
their natural home in the soil the most widely
distributed are the bacilli of malignant redema
and those of tetanus. I have found some garden
earth iu Baltimore extremely rich in tetanus ba-
cilli, so that the inoculation of animals in the

1889.]

ADDRESS ON STATE MEDICINE.

77

laboratory with small bits of this earth rarely
fails to produce tetanus. In infected localities
the anthrax bacillus and in two instances the tj--
phoid bacillus, so far as it was possible to iden-
tify it, have been discovered in the earth. There
is reason to believe that other germs infectious to
human beings may have their abiding place in
the ground ; certainly no one doubts that the ma-
larial germ lives there. As the malarial germ has
been shown to be an organism entirely different
from the bacteria and the fungi, we cannot apply
directly to its behavior in the soil and its trans-
portation by the air, facts which have been ascer-
tained onh' for the latter species of microorgan-
isms, and the same precautions must be observed
for other disea.ses with whose agents of infection
wearenotacquainted.as, for instance, j-ellow fever.

In view of the facility with which infectious
germs derived from human beings or animals may
gain access to the soil, it becomes a matter of
great importance to determine how far such germs
find in the soil conditions favorable for their pres-
ervation or their growth. We have, as is well
known, a number of epidemiological observations
bearing upon this subject, but with few exceptions
these can be variously interpreted, and it is not my
purpose to discuss them. The more exact bacte-
riological methods can, of course, be applied only
to the comparatively small number of infectious
diseases the causative germs of which have been
isolated and cultivated, and these methods hitherto
have been applied to this question onlj' imperfectly.
We cannot regard the soil as a definite and unva-
rying substance in its chemical, physical and bio-
logical properties. What has been found true of
one kind of soil may not be so of another. More-
over, we cannot in our experiments bring together
all of the conditions in nature which may have a
bearing on the behavior of specific microorganisms
in the soil. We must, therefore, be cautious in
coming to positive conclusions on this point on
the basis of experiments, especially those with
negative result. With these cautious kept con-
stantly in mind the question, however, is one em-
inently open to experimental study.

The experiments which have thus far been made
to determine the behavior of infectious microor-
ganisms in the ground have related especially to
the bacilli of anthrax, of typhoid fever and of
cholera, and, fortunately, these are the diseases
about whose relations to the ground there has
been the most discussion, and concerning which
■we are most eager to acquire definite information.

As regards anthrax bacilli, it has been deter-
mined that in ordinary garden or field earth they
•do not multiply, but in earth contaminated by
blood, urine or fasces their reproduction can occur.
They can grow on various vegetable sub.strata.
There is no reason to doubt, therefore, that the
anthrax bacilli can find in or on the ground suit-
able conditions for their multiplication, although

such conditions are not everj-where present. For
durable infection of the soil with anthrax bacilli
it is, however, more important that these bacilli
should find there suitable conditions for the for-
mation of spores, than that thej' should be able
simply to multiply. The vegetable forms of an-
thrax bacilli would not, as a rule, be able to sur-
vive for any great length of time the hostile in-
fluences which thej' are likely to encounter in the
ground, such as insufficient or exhausted nutri-
ment, ab.sence of sufficient moisture and the
attacks of saprophytic organisms. On the other
hand, against the.se injurious influences the an-
thrax spores have great resistance. In the super-
i ficial layers of the ground the anthrax bacilli
may often find those conditions of moisture, of
temperature, of oxygen supply and of insufficient
food which we know are most favorable for the
development of their spores ; indeed, Soj-ka has
shown that the ground presents often these con-
ditions better than our culture media. A circum-
stance discovered by Feltz, which, however, needs
confirmation, is, if true, of not little significance.
He finds that anthrax bacilli may undergo a pro-
gressive diminution in virulence in the soil. If
this should be true likewise of other infectious
microorganisms, we should be able to account in
some instances for.the variable degree of virulence
which clinical observation indicates that certain
agents of infection acquire. So far as anthrax
bacilli are concerned, we ma}- conclude, therefore,
that the ground occasional!}- offers suitable condi-
tions for their reproduction, but what is of greater
importance, it offers especially favorable condi-
tions for their long-continued presen'ation in the
form of .spores. I must forego here the further
consideration of the special circumstances inherent
in the soil which control the origin and spread of
epidemics of anthrax in cattle, although many
interesting investigations have been directed to
this subject.

Of greater interest to physicians is the behavior
of typhoid and of cholera bacteria in the ground.
As has already been intimated, the ground is re-
garded by Pettenkofer and his school as the prin-
cipal breeding-place of these microorganisms out-
side of the body. This view, however, is not
supported by bacteriological investigations. In-
asmuch as the cholera and typhoid bacilli may
multiply on various vegetable substrata and sub-
stances derived from animals at temperatures often
present in the ground, it is evident that here and
there conditions may be present for their growth
in the ground, but this growth is likely to be soon
interrupted by the invasion of ordinary saprophy-
tic organisms and other harmful influences. The
typhoid bacilli are more hardy in resisting these
invaders than are the cholera bacteria, which
easily succumb, but even for the former, so far as
our present knowledge extends, the ground can
rarely serve as a favorable breeding-place.

78

ADDRESS ON STATE MEDICINE.

[July 20,

It is not, however, necessary that these organ-
isms should multiply in order to infect for a con- |
siderable time the ground ; it is sufEcient if their |
vitality is preserved. As to this latter point, the ■
reports of different investigators are not altogether
concordant. Such excellent obser\-ers as Koch,
Kitasato and Uffelmann found that the cholera
bacteria, when added to faeces or a mixture of
faeces and urine, rapidly diminished in number
and, at the end of three or four days at the most,
had wholly disappeared. In a mixture of the 1
intestinal contents from a cholera corpse with {
earth and water Koch found numerous cholera j
bacteria at the end of three days, but none at the
end of five daj-s. On the other hand, Gruber reports
the detection of cholera bacteria in cholera dejecta
fifteen days old. The weight of bacteriological
evidence, therefore, is opposed to the supposition
that the bacteria of Asiatic cholera preserve their
vitality for anj- considerable time in the ground or
in the excreta.

With respect to the bacilli which cause tj^phoid
fever, it has been shown by Uffelmann that these
may live in faeces, mixture of fasces and urine,
and mixture of garden earth, fseces and urine for
at least four and five months, and doubtless longer,
although they may die at the end of a shorter
period. He also finds that, under these apparentlj'
unfavorable conditions, some multiplication of the
bacilli may occur, although not to any consider-
able extent. Grancher and Deschamps found that
tj'phoid bacilli may live in the soil for at least five
months and a half Unlike the cholera bacteria,
therefore, the typhoid bacilli may exist for months
at least in the ground and in faecal matter, holding
their own against the growth of multitudes of
saprophytes. This difference in the behavior of
cholera and of typhoid germs is in harmony with
clinical experience.

As regards other infectious bacteria than those
which have been considered I shall only mention
that tubercle bacilli, although incapable of multi-
plication under the ordinary' conditions of nature
outside of the body, may preser\'e their vitality
for a long period in the ground, on account of
their resistant character ; and furthermore, that
the pyogenic cocci, on account of their considerably
resistant nature and their modest demands in the
way of nutriment, can be preserved and sometimes,
probably, grow in the ground. Indeed, the staph)--
lococcus pyogenes aureus has been found in the
earth by Liibbert.

The conclusion which we may draw from the
observations mentioned is that, in general, the
soil is not a good breeding-place for most of the
infectious bacteria with which we are acquainted,
but that it can retain for a long time with unim-
paired vitality those which produce spores or
which offer considerable resistance to injurious
agencies, such as anthrax bacilli, typhoid bacilli,
tubercle bacilli and the pyogenic cocci.

In order to become infected with bacteria in
or on the ground these bacteria must in some
way be introduced into the body ; and we must,
therefore, now attempt to determine how bacteria
may be transported to us from the ground. So
various and intricate are the possibilities for this
transportation that it is hopeless to attempt to
specify- them all.

There occurs to us first the possibility of the
conveyance of infectious microorganisms from the
soil b}' means of currents of air, a mode of carrj--
ing infection which has already been considered,
Here I shall only repeat that the wind can remove
bacteria from the ground only when the surface is
dr>' and presents particles of dust, and that the
sole, and perhaps the chief, danger is not that we
may inhale the infected dust.

Manifold are the ways in which we may be
brought into contact with infectious bacteria in
the ground, either directlj' or bj' means of vege-
tables to which particles of earth are attached, by
the intervention of domestic animals, by the me-
dium of flies or other insects, and in a variety of
other ways, more or less apparent.

An important, doubtless for some diseases the
most important, medium of transportation of bac-
teria from an infected soil is the water which we
drink or use for domestic purposes. From what
has been said it is evidently not the subsoil water
which is dangerous, for infectious like other bac-
teria cannot generally reach this in a living state,
but the danger is from the surface water and from
that which trickles through the upper layers of
the ground, as well, as from that which escapes
from defective drains, gutters, cesspools, privy
vaults and wronglj- constructed sewers or im-
proper disposal of sewage. I shall have some-
thing to say presentlj- of water as a source of
infection and shall not further elaborate here the
dangers of infection of drinking-water through
contaminated soil, dangers which, especially' as
regards typhoid fever, are widely appreciated in
this country, even if often imperfectly counter-
acted.

A point which has been much discussed, and
one of interest, is whether bacteria which are in
the depths of the ground can come to the surface.
Two agencies especially have been considered by
some as capable of transporting bacteria from the
depth to the surface. One is ascending currents
of air in the ground and the other is the capillarity
of fluids in the minute pores of the ground. The
first of these suspected agencies must be unques-
tionably rejected in view of the fact that even a
few inches of sand is sufficient to filter all of the
bacteria out of the air, even when it is in much
more rapid motion than can occur within the
ground. Moreover, that degree of dryness which
is essential for the detachment of bacteria by air-
currents is not likelj- to be present much below
the surface of the ground. The experiments

1889.]

ADDRESS ON STATE MEDICINE.

79

which have been made to determine to what ex-
tent bacteria may be carried upward b}- the capil-
larity of fluids in the ground have not yielded
harmonious results, but the weight of evidence is
opposed to the belief that this is a factor of anj'
considerable importance for this purpose.

From what has been said concerning the growth
of pathogenic bacteria in the soil we shall not be
inclined to attribute to the multiplication and the
motility of these organisms much influence in
changing their place in the ground.

The somewhat sensational role assigned by
Pasteur to earth worms of bringing bacteria to
the surface cannot be wholly ignored and has re-
ceived support from observations of Bollinger re-
garding anthrax, but it is questionable whether
much importance is to be attached to this
agency.

Regarding the depth to which typhoid bacilli
maj' penetrate in the soil, the experiments of
Grancher and Deschamps show that at the end of
five weeks the}- may reach a depth of 16 to 20
inches below the surface. As Hoffmann has de-
monstrated the extraordinary slowness with which
fluids and fine particles penetrate the soil, it is
probable that in the course of time a greater
depth than this may be reached. Indeed, Mace
claims to have found in the neighborhood of a
wall, suspected of infection, typhoid bacilli, to-
gether with ordinarj- intestinal bacteria, at a depth
of at least 6^2 feet below the surface. There are
a number of instances recorded in which there is
good reason to believe that turning up the soil
and cleaning out privies or dung-heaps in which
tj'phoid stools have been thrown, have given rise
to tj-phoid fever, even after the infectious excreta
have remained there a year and more.

It cannot be said that bacteriological investiga-
tions have as j-et shed much light upon a factor
which plays a great role in epidemiology, namely,
predisposition to infection from the ground, ac-
cording to locality and time, and this deficiency
receives constant and vehement emphasis from
the localistic school of epidemiologists. We can,
however, readily understand that varying condi-
tions, such as temperature, moisture, porosity,
quality of soil may exert a controlling influence
in determining the behavior of infectious germs
in the soil and the facility of their transportation
to human beings or animals. As regards that
much-discussed question, the significance of vari-
ations in the height of the subsoil water, in rela-
tion to the prevalence of certain epidemic dis-
eases, particularly cholera and typhoid fever, we
now know that this cannot depend upon the pres-
ence of bacteria in the subsoil water itself or in
the capillary layers immediately above it. It has
been plausibly suggested that with the sinking of
the subsoil water fluids from infected cesspools,
privy vaults, and other localities may more readily
be drawn into wells or other sources of water-

supply, and that bj^ the same cause the surface of
the ground becomes dn,', so that dust particles
may be lifted by the wind. Other more or less
plausible explanations have also been ofiered, but
it must be confessed that our positive information
on this point is meagre. There can, however, be
little doubt that this significance of the variations
in subsoil water is apparent only for certain local-
ities and has been considerably exaggerated and
often misunderstood. It is not, however, perti-
nent to my theme to discuss this or other purely
epidemiological obser\'ations concerning the rela-
tions of the ground to the spread of epidemic
diseases, interesting and important as are many of
these observations.

Before leaving the subject of the ground as a
source of infection, permit me to indicate briefly
some conclusions which may be drawn from what
has been said as to the principles which should
guide us in preventing infection directly or indi-
rectly' from the ground.

First in importance is to keep infectious sub-
stances, so far as possible, from the ground. This
implies the earlj' disinfection or destruction of
such substances as typhoid and cholera excreta
and tuberculous sputum.

Second. The ground should be rendered, so
far as practicable, unsuitable for the continued
existence of infectious germs. This, at least for
some diseases, is accomplished by a proper sj^s-
tem of drainage, which, moreover, for other
reasons possesses hygienic importance.

Third, Means should be provided to prevent
waste products from getting into the ground
around human habitations or from gaining access
to water used for drinking or domestic purposes.
In cities this can be accomplished only bj^ a prop-
erly constructed system of sewers. The system of
storing waste products in cesspools, whence thej'
are to be occasionallj- removed cannot be approved
on hygienic grounds. There are conditions in
which the disposal of waste products in deep wells
onl}^ used for this purpose and whence these pro-
ducts can filter into the deep laj-ers of the ground
may be permissible, butthis can never be considered
an ideal method of getting rid of excrementitious
substances and is wholly wrong in regions where
wells are used for drinking water. But I am tres-
passing with these remarks upon a province which
does not belong to me, but rather to practical
sanitarians and engineers. I shall onl}- add that
the advantage gained by preventing organic waste
from soaking into the ground is not so much that
the ground is thereby rendered better adapted for
the existence of infectious microorganisms, but is
due rather to the fact that this waste is likely to
contain infectious germs.

Finally, in cities good pavements, absence of
unnecessary- disturbance of the soil, cleanliness of
the streets and laying of the dust by sprinkling
are not only conducive to comfort but are some-

8o

ADDRESS ON STATE MEDICINE.

[July 20,

times hygienically important in preventing infec-
tion from the ground and dust.

In passing from the consideration of the ground
to that of water one feels that he now has to do '
with a possible source of infection again.st which '
in this countrj^ and in England he is at liberty to
make any accusation he chooses without fear of
contradiction. There is reason to believe that
such accusation has been repeatedly made without
any proof of misdemeanor on the part of the
water. It is not, therefore, with any desire to
awaken further the medical or public conscience
that I wish to say a few words concerning the
behavior of bacteria in water and the dangers of
infection from this source. That such dangers
are very real must be apparent when we consider
the universal employment of water and its ex-
posure to contamination from all kinds of sources.

Ordinary water, as is well known, contains
bacteria in large number. Not a few species of
bacteria can multipl}' rapidly and to a large
amount even in distilled water. These are so-
called water-bacteria, and like most of the micro-
organisms found in ordinarj' drinking water are
perfectly harmless saprophytes. What we wish to
know is, how pathogenic microorganisms conduct
themselves in water. Can they grow or be pre-
served for anj^ length of time in a living condition ■
in water ? As regards the multiplication of patho-
genic bacteria in water the results of diiferent ,
experimenters do not altogether agree. Whereas
Bolton failed to find any growth, but rather a
progressive diminution in number of pathogenic
bacteria planted in sterilized water, Wolffhiigel
and Riedel observed a limited reproduction of
such bacteria, including those of typhoid fever
and of cholera. This difference is due probably |
to the methods of experimentation employed.
According to Kraus, these latter bacteria diminish
rapidly in number in unsterilized spring or well
water kept at a low temperature. These experi-
ments indicate that water, even when contami-
nated with more organic impurities than are likely
ever to be present in drinking water, is not a
favorable breeding place for pathogenic bacteria.
Still it is to be remembered that these laboratory
experiments do not reproduce exactly all of the |
conditions in nature, and it may happen that in
some nook or cranny or vegetable deposit at the
side of a well or stream some pathogenic bacteria
may find suitable conditions for their multipli-
cation.

But, as has been repeatedly emphasized in this
address, it is not nece.ssary that pathogenic bac-
teria should actually multiply in a medium in
order to render it infectious. It is sufficient if
their life and virulence are not destroyed in a very
short time. As to this important point, Bolton
found that in sterilized water typhoid bacilli may
preserve their vitality for over three months and
cholera bacteria for eight to fourteen days, while

Wolffhiigel and Riedel preserved the latter in
water for about eighty days. Under natural con-
ditions, however, these organisms are exposed to
the overgrowth of the water bacteria, so that
Kraus found in unsterilized water kept at a tem-
perature of 10.5° C. the typhoid bacilli no longer
demonstrable after seven days, and the cholera
bacteria after two days. The conditions in Kraus's
experiments were as unfavorable as possible for
the continued existence of these pathogenic bac-
teria, more unfavorable than those often present
at the season of prevalence of cholera and typhoid
fever, neverthless I do not see that they justify
the conclusions of Kraus as to the slight proba-
bility of drinking water ever conveying infection
with the germs of typhoid fever and of cholera.
To render such a conclusion probable it would be
necessary to demonstrate a much shorter preser-
vation than even Kraus himself found. In judg-
ing this question it should not be overlooked that
infection of drinking water with the typhoid or
the cholera germs is not so often the result of
throwing typhoid or cholera stools directly into
the source of water-suppl}- as it is the consequence
of leaky drains, cesspools, privy^-vaults or infected
soil, so that there may be continued or repeated
accessions of infected material to the water.

In view of the facts presented, there is no suffi-
cient reason, therefore, from a bacteriological point
of view, of rejecting the transmissibility of typhoid
fever and cholera by the medium of drinking
water. This conclusion seems irresistible when
we call to mind that Koch once found the cholera
bacteria in large number in the water of a tank
in India, and that the typhoid bacilli have been
repeatedly found in drinking water of localities
where typhoid fever existed. Nor do I see how
it is possible to interpret certain epidemiological
facts in any other way than by assuming that
these diseases can be contracted from infected
drinking water, although I know that there are still
high authorities who obstinately- refuse to accept
this interpretation of the facts.

In this connection it may be mentioned that
pathogenic bacteria may preserve their vitality'
longer in ice than in unsterilized drinking water.
Thus Prudden found typhoid bacilli still alive
which had been contained in ice 103 days.

When we come to consider the ways in which
water may become infected with pathogenic mi-
croorganisms we recognize at once a distinction
in this respect between surface water and subsoil
water. Whereas the sub.soil water may be re-
garded under ordinary circumstances and in most
places as germ-free, the surface water, such as
that in rivers and streams, is exposed to all man-
ner of infection from the ground, the air, and the
direct admission of waste substances. Unfortun-
ately in the ordinary way of obtaining subsoil
water for drinking purposes by means of dug
wells this distinction is obliterated, for the water

1889.]

ADDRESS ON STATE MEDICINE.

81

which enters these wells free from bacteria is con-
verted into a surface water often exposed, bj^ the
situation of the well, to more dangerous contam-
ination than other surface waters used for drinking
purposes.

Now let us turn our attention, as we have done
with other sources of infection, to a brief outline
of certain general principles which may help us
in avoiding infection from the water.

We shall in the first place avoid so far as possi-
ble the use of water suspected of infection, espe-
cially with the germs of such diseases as typhoid
fever and cholera. When it is necessarj- to use
this suspected water it should be boiled.

As regards the vital question of water-supplj^
it maj' be stated as a general principle that no
h3^gienic guarantee can be given for the purity of
surface water which has not been subjected to a
proper system of filtration, or for the purity of
spring or well water fed from the subsoil, unless
such water is protected from the possibilitj^ of
infection through the upper layers of the soil or
from the air. This is not saying that water which
meets certain chemical and biological tests and
which is so situated that the opportunities for its
contamination appear to be absent or reduced to
a minimum is not admissible for the supply of
drinking water, but the possibility of infection
can be removed only by the fulfillment of the
conditions just named, and upon these conditions
the hygienic purist will always insist,

Unfortunatelj' we have at present no domestic
filters which are satisfactory, and most of those
in common use are worse than none, as they soon
furnish a filtrate richer in bacteria than the orig-
inal water. The only effective method of water-
filtration for the general supplj- is by means of
large sand filters, such as are in use with excel-
lent results in Berlin and some other cities. These
require skilled attention. I cannot on this occa-
sion discuss the construction or working of these
filters, but would refer those who are interested
to the full and careful investigation of the Berlin
filters by Wolffhiigel and by Plagge and Pros-
kauer.

What is accomplished by these artificial sand fil- !
ters is accomplished under natural conditions, also
by the ground, which furnishes a subsoil water
free from microorganisms, and to obtain pure
water we have onh^ to devise means bv which
this subsoil water may be secured without the
chance of contamination. Just as the water which
has passed through the sand filters is collected in
suitable reser\-oirs and is distributed in pipes,
which do no not admit contamination from with-
out, so by means of properly constructed artesian I
or driven wells we may secure the naturally fil-
tered subsoil water with the same freedom from
the chances of infection.

It is well to bear in mind that no biological or
chemical tests of water can replace those measures

which have been mentioned as necessary to secure
purity of water-supplj-. These tests are of value
only when applied with proper precautions and
with due consideration of the special circum-
stances of each case for which they are employed.
There has been much profitless discussion as to
whether greater significance is to be attached to
the chemical or to the bacteriological examination
of water. Each has its own special field of appli-
cation and in this the one cannot replace the other
method. The bacteriological examination has
for hygienic purposes the advantage that it may
enable us to detect the specific agents of infection
in the form of microorganisms, as has alreadj^
been done for cholera bacteria and typhoid bacilli,
but this is a comparatively rare result and does
not at present afford a wide field of application
for this method. The significance of the bacteri-
ological test is to be based more frequently upon
the fact that it concerns itself with the same class
of microorganisms to which some of the recog-
nized and doubtless many of the undiscovered
infectious agents belong and from the behavior of
which in some respects conclusions can be drawn
as to the behavior of the pathogenic organisms.
Thus the bacteriological test is the ouly one
which enables us to judge correctly of the efficacy
of those methods of filtration of surface water
and of construction of wells which insure purity
of water-supply. The points of view from which
we can estimate correctly according to our pres-
ent knowledge the relative merits and fields of
application of the chemical and of the bacterio-
logical methods of water examination have been
clearly indicated by Plagge and Proskauer, and
by Wolfi"hiigel. The theme is one beyond the
limits or the scope of this discourse and I have
referred to it chiefl}- to emphasize the fact that we
cannot reh- upon chemical or bacteriological tests
of water to the exclusion of those protective
measures which have been mentioned, although
I do not intend to imply that each of these tests
when properly employed does not afford impor-
tant information and is not of great value in many
cases.

I have already taxed so largely your time and
patience that I must pass over with brief mention
the food as a source of infection. Unlike those
external sources of infection which we have hith-
erto considered, manj' articles of food afford an
excellent nutritive medium for the growth of a
number of species of pathogenic microorganisms,
and in many instances this growth may be abun-
dant without appreciable change in the appear-
ance or taste of the food.

When we consider in how large degree the cer-
tainty and the severity of infection with many
kinds of pathogenic microorgaisms depend upon
the number of such organisms received into the
body, we can appreciate that the danger of infec-
tion from food which contains a mass of growing

82

ADDRESS ON STATE MEDICINE.

[July 20,

pathogenic bacteria ma}' be much greater than
that resulting from the reception of infected water
or aid, media in which infectious organisms are
rarely present in other than a verj' dilute condi-
tion. The entrance into the body of a single in-
fections bacterium with the inspired air is, at least
in the case of many diseases, not likely to cause
infection, but let this bacterium fall upon some
article of food, as for instance upon milk, where
it can multiph' in a short time at a favorable tem-
perature mam' thousand- fold and evidently the
chances of infection become vastly increased.

Among the various agencies bj- which infectious
organisms may gain access to the food ma}' be
mentioned the deposition of dust conveyed by the
air, earth adhering to vegetables, water used in
mixing with or in the preparation of food, in cleans-
ing dishes, clothes, etc., and contact in manifold
other waj-s with infected substances. 1

Fortunatelj- a very large part of our food is
sterilized in the process of cooking shortly before
it is partaken, so that the dangers of infection
from this source is greatly diminished and comes
into consideration only for uncooked or partly
cooked food and for food which, altnough it maj-
have been thorough!}' sterilized by heat, is allowed
to stand a considerable time before it is used. Milk,
in consequence of its extensive employment in an
unsterilized state and of the excellent nutritive
conditions which it presents to man}- pathogenic
bacteria, should be emphasized as especialh- liable
to convey certain kinds of infection; a fact sup-
ported not less b}- bacteriological than b}- clinical
observations. Hesse found that also a large num-
ber of ordinary articles of food prepared in the
kitchen in the usual way for the table and then
sterilized afford a good medium for the growth
and preservation of typhoid and cholera bacteria,
frequentlj' without appreciable change in the ap-
pearance of food.

Upon solid articles of food bacteria ma}' multi-
pi}' in separate colonies, so that it may readily
happen that only one or two of those who partake
of the food eat the infected part, whereas with
infected liquids, such as milk, the infection is
more likely to be transmitted to a larger number
of those who are exposed.

In another important particular the food differs
from the other sources of infection which we
have considered. Not only the growth of infec-
tious bacteria, but also that of bacteria incapable
of multiplication within the body niay give rise
in milk and other kinds of food to various
ptomaines, products of fermentation and other
injurious substances which when injested are
likely to cause more or le.ss severe intoxication or
to render the alimentary tract more su.sceptible to
the invasion and multiplication of genuinely in-
fectious organisms.

It is plain that the liability to infection from
food will var}' according to locality and season.

In some places and among some races the propor-
tions of uncooked food used is much greater than
in other places and among other races. In general
in summer and in autumn the quantity of fruit
and food ingested in the raw state is greater than
at other seasons, and during the summer and
autumn there is also greater danger from the
transportation of disease germs from the ground
in the form of dust, and the amount of liquids
imbibed is greater. The elements of predisposi-
tion according to place and time upon which
epidemiologists are so fond of laying stress are
not therefore absent from the source of infection
now under consideration.

I have thus far spoken only of the secondary
infection of food by pathogenic microorganisms,
but as is well known the substances used for food
may be primarily infected. Chief in importance
in the latter category are the various entozoa and
other parasites which infect animals slaughtered
for food. The dangers to mankind resulting from
the diseases of animals form a separate theme,
which would require more time and space than
this address affords for their proper consideration.
I shall content myself on this occasion with only
a brief reference to infections from the milk and
flesh of tuberculous cattle.

It has been abundantly demonstrated by nu-
merous experiments that the milk from tubercu-
lous cows is capable when ingested of causing
tuberculosis. How serious is this danger may be
seen from the statistics of Bollinger, who found
with cows affected with extensive tuberculosis
the milk infections in So per cent, of the cases,
in cows with moderate tuberculosis the milk in-
fections in 66 per cent, of the cases, and in cows
with only slight tuberculosis the milk infections
in 33 per cent of the cases. Dilution of the in-
fected milk with other milk or with water dimin-
ished or in suSicient degree it removed the danger
of infection. Bollinger estimates that at least 5
per cent, of the cows are tuberculous. From sta-
tistics furnished me by Mr. A.W. Clement, V, S.,
it appears that the number of tuberculous cows
in Baltimore which are slaughtered is not less
than 3 to 4 per cent. Among some breeds of
cattle tuberculosis is known to be much more
prevalent than this.

There is no evidence that the meat of tuber-
culous cattle contains tubercle bacilli in sufficient
numbers to convey infection, unless it be ver}-
exceptionally. Nevertheless one will not willingly
consume meat from an animal known to be tuber-
culous. This instinctive repugnance, as well as the
possibility of post-mortem inspection of the meat in
dressing the animal seem good grounds for discard-
ing such meat. The.question, however, as to the re-
jection of meat of tuberculous animals has impor-
tant economic bearings and has not been entirely
-settled. As to the rejection of the milk from such
animals, however, there can be no difference of

1889.]

ADDRESS ON STATE MEDICINE.

83

opinion, although this is a point not easily con-
trolled.

The practical measures to adopt in order to
avoid infection from the food are for the most part
sufficienth' obvious. Still it is not to be expected
that ever}' possibility of infection from this source
will be avoided. It is diificult to discuss the mat-
ters considered in this address without seeming to
pose as an alarmist. But it is the superficial and
half knowledge of these subjects which is most
likeh' to exaggerate the dangers. While one will
not under ordinary circumstances refrain from
eating raw fruit or food which has not been thor-
oughly sterilized, or from using unboiled or
natural waters in the fear that he may swallow
typhoid or cholera bacteria, still in a locality in-
fected with cholera or typhoid fever he will, if
wise, not allow himself the same freedom in these
respects. Cow's milk, unless its source can be
carefull)' controlled, should, when used as a
habitual article of diet, as with infants, be boiled,
or the mixed milk of a number of cows should
be selected, but this latter precaution offers less
protection than the former.

In most places in this country we are sadly
lacking in good sanitary inspection of the food,
especiall}' of the animal food, offered for sale.
One cannot visit the slaughter-house in Berlin or
Munich, and doubtless similar ones are to be found
elsewhere, and watch the intelligent and skilled
inspection of slaughtered animals without being
impressed with our deficiency in this respect. In
large cities an es,sential condition for the efficient
sanitary inspection of animal food is that there
should be onlj- a few places, and preferably onlj'
one place, where animals are permitted to be
slaughtered. Skilled veterinarians should be se-
lected for much of the work of inspection.

It may reasonably be asked that the National
Government, which has already spent so much
money for the study and extermination of such dis-
eases as pleuro-pneuraonia, of cattle, and hog
cholera, which are not known to endanger the life
of human beings, should turn its energies also to
means for eradicating tuberculosis from cattle,
which is a scourge not only to the economic inter-
ests of farmers and dairymen, but also to the
health of human beings.

Without any pretension to having done more
in this address than to sketch here and there a
few principles derived from bacteriological re-
searches concerning onlj- some of the most widely
distributed external sources of infection, I trust
that enough has been said to show the folly of
any exclusive dogma as to modes of infection.
The ways of infection, even in one and the same
•disease, are manifold and various, and can never
be resolved into exclusive hypotheses, such as
the drinking-water hypothesis, the ground hy-
pothesis, etc.

It follows, therefore, that it is not by sanitary
improvements in one direction only that we can
control the spread of preventable epidemic dis-
eases. In one situation the improvements in the
supply of drinking water check the prevalence of
t}-phoid fever, in another place similar measures
show no such influence ; or again, in one city the
introduction of a good system of sewerage dimin-
ishes epidemic diseases, and in another no similar
result follows. We should, therefore, aim to secure
so far as possible good sanitary arrangements in
all directions and in all respects.

It has also been rendered evident in what has
been said that infectious agents differ markedly
from each other in their behavior, so that while
public sanitation aims at those measures which
are found to be most widely beneficial, it should

: not forget that each infectious disease is as much

I a separate problem in its prophylaxis as in its
symptomatology, etiolog}' and treatment. It will
not aim to combat cholera with the means found

I best adapted to scarlet fever, but it will adopt
preventive mea.sures as directlj- to the .specific end
in view as possible.

In presenting to j-ou the results of researches
chiefly bacteriological concerning the scientific
basis of preventive medicine, I hope to escape the
accusation of onesidedness and narrowness by the
statement that I do not for a moment intend to
implj' that the bacteriological method is our only
source of accurate knowledge on the subjects
which have been considered. My aim is accom-
plished if I have succeeded in making clear that
this method has established facts which aid in a
clearer conception of the causes of some impor-

j tant infectious diseases, in a better understanding
of the sources and danger of infection, and in a
more efficient selection and application of sani-
tary measures.

If this science of only a few years' growth has
furnished already acquisitions to knowledge so
important, so far reaching, may we not look for-

] ward with assurance to the solution of manj'
dark problems in the domain of infectious dis-
eases, problems the solution of which may yield
to preventive medicine a future of usefulness and
success which we cannot now foresee.

Dr. Philip F. Brakely, who for forty years
was the Secretary' of the Medical Society of War-
ren County, N. J., died in Belvidere, at the age
of 75, on July 3. He was a representative man
in northern New Jersey, just as Dr. Wm. Elmer,
who died six days before him, was an able stan-
dard bearer in the southern section of the State.
Dr. Brakely was early identified with the Amer-
ican Medical Association, and a permanent mem-
ber of the State Society. His death has been
ascribed to the infirmities of advancing age, cul-
minating in cardiac syncope.

84

PROGRESS OF MEDICAL SCIENCE.

[July 20,

ADDRESS ON THE PROGRESS OF MEDI-
CAL SCIENCE DURING THE
PAST HALF CENTURY.

BY SIR JAMES GRANT, M.D., K.C.M.G.,

PHYSICIAN TO THE GOVERNOR-GENERAL OF CANADA.

Delivered at the Fortieth Annual Meeting of the American Medical
Association, Neivport, R. I., June 27, iSSg.

Sir James Grant, M.D., of Ottawa, Canada,
upon being called upon, rose and spoke as fol-
lows : I beg to return to you my sincere thanks
for the invitation extended by a committee of this
Association to be present at this meeting of the
medical profession of the United States, and it is
an additional source of gratification that I am
asked to a seat on this platform. I am reminded
of the fact that when the Marquis of Lome was
governor of Canada, the Royal Society was in-
vited to lunch at the government house. When
the health of the president of the United States
was proposed, a sentiment which we Canadians
fullj' appreciate, and which we are delighted to
honor next to that of our glorious Queen \'ictoria,
Mark Twain was asked to respond. He thanked
his excellency for the compliment and was proud
to be the recipient of the distinction, but regretted
that being unprepared he was unable to respond.
I feel very much iti the same position on being
called upon to speak to this large bodj' before
me. For fully twenty-five years I have been in
the habit of attending the meetings of your Asso-
ciation at various points, and it is to me a source
of pride and gratitude to be able to note the
progress of that profession to which I have the
honor to belong. This is an exceedingly im-
portant epoch in the historj- of our profession.
You have just celebrated your one hundredth
anniversary, which marks the progress of this
great countrj'. In entering the hall to-day, the
obser\'ation dropped from a bystander that the
insane doctors were meeting here. It struck me
as somewhat peculiar, inasmuch as I was not
aware of the fact that this meeting could appro-
priate that idea. It was soon cleared up as I
learned that that branch of the profession met
here. Let me, for a short time, draw your atten-
tion to the remarkable advance in the several de-
partments of the profession, which has been made
within the past centurj-.

It was in 1835 that Gardner Hill, of the Lin-
coln Lunatic Asylum, announced the treatment
of insanity by non-restraint. Prior to that time
the poor lunatic was subject to be confined in the
corner of a cell with chains round his neck, his
arms manacled, and pendulous clubs attached to
his feet in order to prevent locomotion. His food
was served to him as it would be to an ordinary
quadruped, and in fact the whole treatment of the
insane in tho.se days was most irrational in its
character. Much credit is due to Pinel in Paris,
Tuke of York, and Charlesworth in the city of

Lincoln asylum, in which the grand final exper-
imenting of entire freedom of the insane was car-
ried out.

We find here that in the great institutions of
this country for the treatment of the insane every
indication of progressive development as to the
principles of treatment in cases of mental aberra-
tion have been carried into operation most suc-
cessfully. You have undoubtedly great workers
in the subject of psycological investigations.
When in Edinburgh some years ago. Dr. Tuke,
the author of that admirable work on " In-
sanity," remarked to me that by far the best
journal on psycological medicine was that pub-
lished by the late Dr. Jewell, of Chicago. The
investigations of the late Dr. Gray, of Utica, are
well known, doubtless, to everj' member of the
Association. The subject of cerebral pathology-
attracted his closest attention, and his demonstra-
tions by the large microscopic sections of the
brain, which he was enabled to make, did much
to convey an accurate idea of cerebral structure
under ^•erJ' diverse circumstances. Strange to
say that some of the most violent forms of in-
sanity ever under the microscope have not been
traced to anything like change of structure. Such,
also, was the impression conveyed to me by Tuke,
of Edinburgh. These, of course, may be looked
upon as irregular cases, as usually insanity
rarel}' takes place without some definable reason
in the great ner\'ous center. Under these circum-
stances is not the trite and laconic obser%-ation of
Punch brought home to us with more than ordi-
nary force: "What is matter, never mind, and
what is mind, that's the matter." Pursuing this
subject still further the investigations of our
physiologists within the past quarter of a century
have certainly accomplished much as regards our
knowledge of the ner\'ous system. Disturbed
cerebral centers, frequently telegraph their ab-
normal condition to the peripheral surface, pro-
ducing an abnormal condition of facial expres-
sion. By a process of careful analytical induc-
tion such men as Ferrier, of London, Hamilton
and Seguin, of New York, and Hammond, of
Washington, have been enabled to take stock of
the changes and define the region of the dis-
turbed centers. This embraces the great recent
advances in the subject of cerebral localization,
and is the ven,' cue to the advances in cranial
surgerj' undertaken bj' such men as Horseley, of
London, McKeon, of Glasgow, and Seguin and
Warren, of New York,

In looking around me on this platfonn, I am
extremely grateful to find present one of the ex-
presidents of this Association, Dr. Bowditch, of
Boston, whose name is so closely associated in
the subject of pleuritic effusion, and who worked
so vigorously to convey his accurate impressions
as regards the treatment of this important tho-
racic disease. Not alone have his observations

1889.]

PROGRESS OF MEDICAL SCIENCE.

85

been confined to the chest, but in the domain of
preventive medicine he has also been one of the
pioneers. It has been well said that "an ounce
of prevention is better that a pound of cure," and
notwithstanding the fact that the members of the
medical profession in the advocacy of sanitary

the progress of surgerj^ during the latter half of
this century. There is another department con-
cerning which I desire to allude briefly, namely,
that of therapeutics. We have with us to-day
Shoemaker, of Philadelphia, and Prof Stuart, of
McGill University in Montreal, both of whom are

science, are curtailing ver>' effectively the means actively engaged in therapeutic inquiry. Medi-
of their ordinary livelihood, and still their phi- 1 cines are now no longer, we hope, administered
lanthropic efforts are never stayed where they can j empirically ; the why and wherefore are being in-
be of advantage to the public at large. The ' quired into most carefully. How the remedial
great public institutions of this country give evi- 1 agents act directly or indirectly on the blood and
dence of the principles of sanitary science. The J tissues is the subject of much physiological re-
jails are made comfortable even for the most de- j search. Here comes in a question of the slowing
jected criminal. The hospitals give evidences of : of the heart's action by digitalis and the reduc-
thorough ventilation and ample supply of light i tion febrile states of the system by antipyretics.
and all the modern improvements for sewage and | Much credit is due to the pharmaceutical associa-
water supply, very important factors in the treat- : tions of this country for the elegance of the prep-
ment of the sick. The articles of diet are being j arations placed before the profession, so much so
carefully investigated. Milk is now known to be ; that the old British pharmacopoeia must undergo
a prolific source both of scarlet fever and diphthe- 1 considerable modification. There is also a marked
ria, and in early life being a common source of 1 advance in dietetics embracing peptonoids and
diet, how necessary are the investigations of the j very digestive materials introduced to tone and
sanitarian. Less than half a centur>' ago, Farr, ! assist digestive function, Cod liver oil and its

of London, gave a great impulse to the progress
of sanitary science by the introduction of tabu-
lated statistics as to the life and death rate. In
the various medical institutions in this country,
as well as in Canada, the subject of sanitary
science is receiving the most careful considera-
tion, and very justly so, inasmuch as it pertains
most closely to the welfare of society at large.
Let me draw your attention for a few moments to

emulsion also occupy an important place as ther-
apeutic adjuncts. And in addition the triturates
so recently introduced are doubtless valuable as
means of medicinal administration.

On my way from Boston, yesterday, I was
gratified to read the instructive address of the
Hon. Chauncy Depew to the legal profession, in
which he referred to the representation of this
country. Of the thirty-two presidents, eighteen

a great gymnasium of the human system, of j were members of the legal profession, and during

which we have evidence in the surgerj' of the ab-
dominal cavity. This country has reason to feel
proud of what has been accomplished in this de-
partment. The name of Ephraim McDowell, of
Kentucky, with you, as with ourselves, is a house-
hold word. He possessed the skill, the fore-

the past one hundred years, in eighty-two of that
period the presidential chair has been occupied
by legal lights of this country. The bearing of
this subject is extremely important, inasmuch as
the medical profession is concerned. In the Com-
mons of Canada there are at least fifteen or twenty

thought, and the knowledge which enabled him medical men, and in the Senate also quite a num-
to undertake the first ovariotomy. Following j ber of members of the medical profession. In the

rapidly in his path came Dunlop, of Ohio, and
Kimball, of Lowell, Mass., the latter of whom
maintains the vigor of youth, although consider-
ably over his seventieth year. These men con-
stitute an intellectual tripod, if I may so term it,
in the domain of abdominal surgery. Before me

local provincial parliaments our profession i.s
ably represented. Thus we have been enabled
to guide and direct public opinion towards the
important question of medical education. I lis-
tened with pleasure to the report of your com-
mittee on this subject, recommending the intro-

I see a gentleman whose name I cannot refrain ; duction of a higher standard in this country, both
from giving expression to. Dr. Senn, of Chicago, as to preliminarj- education and subsequent aca-
who has accomplished so much with reference to j demic study. Having been upwards of twenty-
the lesions of the intestinal canal. His name will : two years consecutively in the Medical Council of
undoubtedly become a household word amongst ! Ontario, I have had opportunities of observing
the members of our profession. While adverting j the importance of this question. The local Par-
thus personally to what your men have achieved, | liament of Ontario passed a bill for the formation
I feel confident you will join with me in recogniz- 1 of a Council, giving it the power to appoint ex-
ing the admirable achievements in the same line j aminers in medicine, irrespective of the teaching
of thought brought about by such men as Sir j bodies, and thus guard the portals of entrance
Spencer Wells, Drs. Thornton, Bantock, Lawson into the medical profession. Prior to this time

Tait, and Keith, of Edinburgh. Almost every
organ in this cavity has been operated on success-
fully, and the achievements mark beyond a doubt

the entrance of homoeopathists and eclectics into
the profession was very considerable, but now that
matters have been placed on a uniform basis of

86

CHRONIC INVERSION OF THE UTERUS.

[July 20,

examination, except in special subjects such as
homoeopath}- and eclectic materia medica, we find
that this elevated standard has improved verj' ■
materially the entire status of our profession ; in
fact, to-day there are very few graduating homce-
opathists or eclectics compared to the regular pro-
fession, greatly brought about by the introduction
of the elevated standard of medical education.

In the great medical centres of this countrj- we
cannot fail to miss manj' of the old landmarks,
men like Dunglison, Gross and Pancoast, of Phil- ;
adelphia ; Parker, Buck. Marion Sims, Flint, j
Hamilton and \'an Buren, of New York ; White, '
of Buffalo ; Brainard and Jewell, of Chicago.
These men gave a force, a character and an im- 1
pulse to the profession recognized throughout the |
civilized world. Younger men are following rap- ;
idly into the path of distinction, and have achieved 1
more than an ordinary- celebrity, such as Thomas ,
and Emmett, of New York ; Storer, of Boston ;
and Goodell, of Philadelphia ; particularly in the
diseases of women. I am pleased to obser\-e here
so man}- jounger members of the profession. To
attend these meetings is a dutj' thej- owe not oul}'
to themselves but to the communities in which
the}- are laboring. Here we receive, as it were, a
bird's eye view of the progress of our profession in
every department, and the ver}- intellectual fric-
tion produces a tonic influence which sends ever}-
member of this Association home with renewed
vigor in that profession we delight to honor. A
young Western physician, recently visiting Paris,
remarked to his professor if he knew so and so in
the medical profession ; the reply was that he did
not. " What has he written? " was the question
asked. The young physician answered, " He
has not written anything so far as I know, but he
has a very- large practice. ' ' To the younger mem-
bers of the medical profession I would say, in or-
der to achieve a lasting reputation, record your
facts, note carefully bedside obser^-ations and do
not be in a hurry in drawing sudden conclusions.
Thus you will be enabled to contribute your mite
to the journalism of this country, and support a
most commendable department of literature which
guards over the best interests of our profession.

To the profession in Canada permit me to say
that I consider ourselves one people. Placed as
we are on either side of an imaginary Chinese
wall we speak the same language, we enjoy the
same literature, we take our inspirations from the
same fountains of science in all that pertains to
the best interests of our profession, and I will say,
in as far as the unity of that profession is con-
cerned, that the beautiful sentiment expressed by
Her Majesty the Queen on the completion of the
Atlantic cable applies equally well to our profes-
sion : "What God hath joined together let no
man put asunder." In conclusion let me again
return you my warmest thanks for the kind recep-
tion I have received and the delight I have expe-

rienced in the presence of your great historian,
Bancroft, and many other old friends I see around
me still in the vigor of life. Let us then work
on to do honor to our profession, to alleviate the
sufferings of humanity, and in that profession to
perform the important responsibilities assigned to
our respective charges. And I feel I cannot do
better than express the lines so beautifully writ-
ten by your gifted poet who now slumbers amidst
the illustrious dead of this great Republic :

" Let us theu be up and doing.
With a heart for any fate;
Still achieving, still pursuing.
Learn to labor and to wait."

The distinguished speaker was frequently inter-
rupted by loud applause.

ORIGINAL ARTICLES.

CHRONIC INVERSION OF THE UTERUS.
REDUCTION BY A NEW METHOD.

Read in the Section of Obstetrics and Gynecologv, at the Fortieth An-
nual Meeting of the A merican Medical Association,
Jtme 2j, rSSg.

BY HENRY O. MARCY, M.D.,

OF BOSTON.

It is my purpose in this paper to consider only
chronic cases of inversion of the uterus, as they
are usually presented to the attention of the gyne-
cologist. Cases of partial inversion occurring at
labor are believed to be far more common than
the teachings of the text-books would lead us to
accept. More than- once it has occurred under
my own observation, and in a recent discussion
upon the subject by the members of the Boston
Gynecological Society, a considerable number of
cases were reported.

It was undoubtedly more frequent during the
earlier practice of the midwives, when traction
upon the umbilical cord was commonly practiced,
in order to bring away the placenta. There is
much disagreement of opinion as to the cause of
inversion even in these cases, although it is con-
ceded that the uterus is generally very flaccid and
muscular contraction of the organ is either irreg-
ular or wanting. When the inversion is complete,
under such circumstances, the haemorrhage and
shock are often so great as to endanger life.

When promptly recognized the reposition of
the organ is generally not attended with .serious
difliculty. If the placenta has not been detached
for the obvious reason of lessening hemorrhage,
it is better to replace, if possible, before separation.
This, however, is exceptional, since a more or less
partial separation takes place, accompanied by
j great haemorrhage. If the cervix is firmly con-
tracted reposition is no longer easy, but nothing
, is gained by delay and reduction must be accom-
; plished regardless of difficulty. When reposition
I has taken place, the uterus must be supported

1889.

CHRONIC INVERSION OF THE UTERUS.

S7

until it is firmly contracted. It has generall}^
been considered wise to tampon the vagina and to
retain the patient in the horizontal position, upon
the back, for a considerable period, in order to
prevent contraction of the abdominal muscles,
but it is extremely probable that such precaution
is unnecessarj- and ill-advised.

Intra-uterine growths, usually submucous myo-
ma, very rarely produce inversion of the uterus.
When it thus occurs the uterine contraction upon
the growth causes a deflection of the fundus or
place of attachment, which goes on slowly by
traction from above downwards to bring about
this result. The late Professor E. Martin, of
Berlin, reported a case, in 1869, where a myoma
the size of a fist was removed from the fundus of
a completely inverted uterus in a multipara, aged
46, which had produced profuse haemorrhage.
Spontaneous reduction of the organ took place a
few days later.

Langenbeck and McClintock each report a sim-
ilar case. Dr. Emmett, in 1869, removed a myo-
ma from the fundus with the ecraseur and reduced
the inversion by taxis. It is variouslj' estimated
that from 5 to 8 per cent, of the cases of inversion
are due to this cause.

Several writers of prominence have maintained
that irregular uterine action is occasionally the
cause of inversion, and that it usually commences
about one horn of the uterus. This was especiall)'
maintained by Kiwisch. Based upon this view,
Dr. E. Noeggerath, of New York, has devised
his method of reduction, which consists in com-
pressing the uterine bod}' opposite to each horn,
-SO as to indent one of these and thus offer to the
cervical canal a wedge which passes up and is
followed rapidly bj^ the other and the whole body
of the uterus. Dr. Thomas endorses this method
as of great value, and states that he has twice
reduced an inverted uterus successful!}' in this
way. Dr. Thomas reports a case operated upon
by Dr. Budd, of New York, for the removal of a
supposed fibrous polyp, the size of a hen's egg,
attached to the uterine cavity near the entrance
of the right Fallopian tube. Careful examination,
however, showed that it consisted of one horn of
the uterus, with a part of the corresponding Fal-
lopian tube and round ligament, thus demonstra-
ting the ca.se to have been one of partial inversion.
Reports of cases of inversion of the uterus, asso-
ciated with a variety of growths, usually a.scribed
as cause, are to be found scattered through the
literature of medicine. Pathological preparations
showing this interesting condition are also pre-
served in a considerable number of collections.

Improbable as it may seem, it still must be ac-
cepted as demonstrated that cases of so-called
spontaneous inversion have occurred. Several
such cases are recorded by Dr. Thomas and others.
These, however, as well as cases of spontaneous
reduction, must be considered as accidental curi-

osities. It is very probable that the more careful
study of cases of this character would make clear
a series of causes altogether overlooked. In the
Second Volume of the " American System of
Gynecology," recently published, is found an
excellent article upon chronic inversion of the
uterus, by our distinguished countryman, Dr. S.
C. Busey, of Washington. He concludes that
about 87.5 per centum of all the cases belong to
the puerperal variety. " Of 224 cases collected
by Crampton, 196 are noted as having occurred
simultaneously with the termination of labor.
Of the remaining 25 cases, in 12 the accident oc-
curred during the first hour after labor ; in 7 dur-
ing the first day ; in 2 during the first week ; in
2 during the first month ; in i during the fifth
month ; and in i during the thirteenth month.
The direct causal relation of parturition and the
puerperal period to the displacement is thus very
clearly demonstrated."

Inversion of the uterus is fortunately a very
rare accident. "Madden estimates it to occur
only once in 190,000 labors. Reeve at one in
140,000 cases, Aveling at one in 100,000. In the
Vienna Eying-in Hospital, from 1845 to 1882, in
a total of 280,000 labors, but one case occurred."
Crosse's' monograph upon inversion of the uterus
is still to be considered as one of the most valu-
able contributions upon the subject. He collected
the histor}' of about 400 cases. He states that
about one-third of all the cases, under whatever
circumstances, or in whatever degree they occur,
prove fatal either very soon or within one month.
He analyzed 109 fatal cases. Sevent}'-two proved
fatal within a few hours, most of them within half
an hour ; 8 cases proved fatal in from one to seven
days ; and 6 in from one to four weeks. If the
patient survive a month the case is chronic and
the immediate danger is small. But the danger
recommences at eight or nine months, when the
menstrual function is resumed. Many of these
will die within two years. Cases as usually pre-
sented to the gynecologist, by a careful examina-
tion, should be easily diagnosticated. Yet in the
earlier history of uterine surger}' the organ was
occasionally removed, under the belief that the
operator was dealing with a uterine polyp.

The treatment of chronic inversion of the uterus
furnishes a chapter of exceptional interest to the
surgeon. Until within the present generation the
reposition of the organ was supposed scarcely
possible, and if life was .seriously threatened am-
putation was advised. It was not until about
1858 that the attention of the profession was seri-
ously called to the systematic attempt at reduction
of the uterus in chronic inversion. The few cases
that had been successfully treated prior to this
date had been reduced by manipulative dexterity
and regarded as accidental rather than systematic.

I An essay upon
don, 1S45,

' Invertio Uteri,'' by John Green Crosse, I.on-

88

CHRONIC INVERSION OF THE UTERUS.

[July 20,

In 1858 the late Professor James P. White, of
Buffalo, published his method of reduction by
continued elastic pressure. His first case occurred
in 1856. His second in 1858, Dr. Tyler Smith,
of lyondon, published his method also in 1858,
which is a combination of elastic pressure and
taxis. Dr. White's procedures are so well known
that detailed description is unnecessarj'. A soft-
rubber, cup-shaped end of the instrument receives
the fundus. A wire spring capable of sustaining
ten pounds pressure is adjusted to the other end,
and so arranged that it may be brought to bear
against the breast of the operator. Bimanual
manipulation is an important part of Dr. White's
method. One hand grasps firmlj' the uterus thus
supported, while the counter pressure is main-
tained upon the cervix through the abdominal wall
by the other. In Dr. White's first case the inver-
sion was of eight days' standing ; in his second,
of nearly six months' duration. In this last the
organ was reduced after about one hour's contin-
uous effort. In Dr. White's article upon "Chronic
Inversion of the Uterus," published in the
' ' Transactions of the International Medical Con-
gress," Philadelphia, 1876, he concludes, based
upon the experience of ten cases, ' ' the result has
been, in all the cases encountered, restoration by
manipulation on the first trial, and, as is believed,
without serious injury to the tissues, thus con-
firming the conviction that all cases are curable,
irrespective of their duration."

Dr. Clifton E. Wing, of Boston, reported a case,
in 1879, where he reduced an inverted uterus of
aljout three months' duration by continuous elas-
tic pressure. Elastic tubing was attached to the
distal end or stem of a cup-shaped instrument
adjusted to the fundus. These ends were drawn
tight and attached in front and behind to a waist
belt. The amount and direction of the force was
found to be easily within control. ' ' The evening
of the second day there was evidentl}- some gain.
The evening of the third day the patient felt a

little restless She slept well

under a dose of morphine, but was waked in the
middle of the night by feeling something 'jump
inside.' On examination in the morning I found
the uterus replaced and the end of the instrument
extending up into its cavity." Rapid convales-
cence followed.

Aveling has modified the methods of Drs. White,
Tyler Smith, and Wing, by giving the stem sup-
porting the cup a sigmoid curve, so as to carry
the direction of the pressure in the line of the
upper axis of the pelvis. A belt is applied around
the waist and fastened to braces over the shoulders.
By this method elastic tension is secured. The
patient must be confined to the bed, morphia
given to control pain, and the bladder evacuated
by the catheter. In eleven successful cases Ave-
ling reports the average time for reduction at about
forty hours, the longest being fifty-four and a half
hours, the shortest nine hours.

Dr. Robert Barnes, of London, in his work upon
" Diseases of Women," figures an instrument
which he calls his elastic pessary. This he de-
scribed and first published in the Obstetrical Joiir-
nal, in 1873. He states "that he attempted to
reinvert the uterus in 1868, by continuous elastic
pressure, maintained for five daj's, but was unsuc-
cessful."

The elastic pressure applied by the late Dr.
Tyler Smith consisted of an air pessary, retained
in the vagina by a T bandage. Barnes, Wing, and
Aveling, only modified the method of Dr. White
by making the pressure in a graduated elastic
force minimized in amount, but which was neces-
sarily in the same ratio greatly extended in time.
No new principle was involved and the modifica-
tions of application, may, at the best, be considered
of doubtful value. Manual manipulative measures,
modified but systematized taxis, have also their
modern exponents.

Dr. Emmett's method consists of " encircling
with the fingers and thumb that portion of the
bod}^ close to the seat of the inversion, which is
firmlj- grasped, pushed upward, and the fingers
then immediatel)' separated to their utmost, at
the same time the other hand is employed over
the abdomen, in the attempt to roll out the parts
forming the ring, by sliding the abdominal parietes
over the edge. ' ' Thus the effort is systematically
made to return first the tissues last displaced,
rather than to bring to bear the force upon the
fundus proper. This is, physiologically, emi-
nently correct and scientific.

Courty" carried the index and middle fingers of
the left hand up the rectum and with them fixed
the cervix, and then continued the taxis, as ad-
vised by Emmett.

Tate' carried this method further, by the intro-
duction of one forefinger into the bladder, the
better to hold the cer\'ix for the purpose of coun-
ter pressure. The uterus held in fixation from
above downwards by fingers in the rectum and
bladder, the pressure is applied b}' the thumbs
upon the fundus.

Surgical inteiTcntion has not been wanting as
an aid for the reposition of the inversion of the
uterus. Such measures would uaturallj' be applied
to the constriction at the neck, the seeming objec-
tive factor to be overcome.

Dr. Barnes' writes, "For twenty j'ears I have
taught in my lectures that the unyielding cervix
may be divided by incisions carried into its sub-
stance from above downwards at different points
of its circumference. Pressure then applied will
cause it to yield more easih-. Huguier, Professor
Simpson, and Dr. Marion Sims have suggested
this plan." It was, however, not until 1868 that
Dr. Barnes had the opportunity to carry his teach-

- Maladies (ie rut<5rus. 1866.

1 Cincinnati Lancet and Observer, March, 1S7S.

4 Op. cit, page 635,

1889.]

CHRONIC INVERSION OF THE UTERUS.

89

ings into effect. After continuing elastic pressure
by the method of Tj'ler and Smith for five days
without success, Dr. Barnes secured the fundus by
a noose of tape and drew the organ as far exter-
nally as seemed safe, and then incised the neck
one-third of an inch deep, lateralh' and posteri-
orly. The cervix yielded and the restoration was
complete, although lacerations extended quite a
little from the incisions. A good recovery fol-
lowed. Dr. Barnes recommended only lateral in-
cisions of moderate depth, as an aid to sustained
elastic pressure. He has since used this method
with equal success. Dr. Thomas, of New York,
attempted it, but the bleeding proved so very seri-
ous, from the division of the circular artery, that
life was endangered. Haemorrhage was controlled
with much difficulty. About one week later he re-
duced the inversion by a method which he had had
under consideration for a considerable period by
opening the thin abdominal wall over the cervix
and dilating it by a glove-stretcher instrument.
This, however, was accomplished with much diffi-
cult}', owing to the elastic contraction of the cer-
vix. It has been resorted to several times by Dr.
Thomas and others, and is commended by this
author as affording another means of dealing with
this most distressing accident, which may be ac-
cepted in preference to amputation. In case of
failure amputation may at once be advantageously
performed.

The early statistics of amputation give as a re-
sult a mortality rate of 25 to 30 per cent. Although
the operation for amputation is doubtless ever to
be regarded as a major one, involving serious risks
to life, there can be no doubt that the death-rate
as shown by collated statistics is very much
greater than would occur under modern surgical
procedure. The comparative absence of danger
now attending aseptic laparotomy would cause
the profession to look upon Dr. Thomas' operation
far more favorably than when first published,
seeming, as it then did, a bold, ingenious, but
dangerous innovation. It is, however, to be con-
sidered if access to the uterus from above gives,
after all, the advantages which a priori had been
expected. The elastic contraction of the cervical
fibres is overcome only with the greatest difficulty.
In illustration of this I quote from a paper hy
Dr. Paul F. Munde, entitled "Laparotomy for
Reduction of an Inverted Uterus," read before the
Obstetrical Society of New York last October,
and published in the Americaji foumal 0/ Obstet-
rics for December, 1888.

" Rapidly making a 2-inch incision through
the abdominal wall, I pushed the uterus from the
vagina upwards, so as to almost bring the ring
into the wound, and, first with my fingers, then
with a Palmer's steel dilator tried to stretch it
apart. Failing in this, I sent for a glove stretcher,
which was disinfected and inserted through the
cervical ring to the verj' bottom of the inverted

uterus and separated to the utmost. The ring
was thus completely dilated and I expected im-
mediate reduction, but as the glove stretchers were
slowly withdrawn to allow the pari passu reposi-
tion, from the vagina, at the instant the stretcher
slipped out of the ring, the latter closed like a
vise ; and although the attempt was repeated
again and again, no rapidity or concurrence of
action in pressing the fundus upward, succeeded
in anticipating the contraction of the ring. It
seemed almost incredible that it should have been
impossible to so dilate and keep open the ring,
when it was not only easilj- accessible, but even
visible at the abdominal incision, so as to enable
me to slip the fundus back through it. But such
was nevertheless the case, and m}' spectators will,
I think, give me credit for having tried faithfully
to save this woman's uterus. As a last resort I
followed a suggestion of Dr. LilHenthal, my house-
surgeon, who assisted me, and passed a Peaslee's
needle from the vagina through the firmest por-
tion of the fundus uteri and out of the ring and
the abdominal wound, attached a long loop of the
thickest silk to it, drew the loop out of the vagina
and tied a piece of large, double-rubber drainage-
tube to it, as a fulcrum upon which to exert trac-
tion. I chose a flexible tube in preference to a
flat button of horn or metal, which were at hand,
because I feared the latter might prove an obstacle
at the contracted ring. Then dilating the ring
with the glove stretcher, I tried to draw the fundus
up through it by making steadj' traction on the
loop of silk. But the pulpy uterine tissue gave
away and the drainage-tube suddenly appeared in
the abdominal wound. ' ' Dr. Munde recognizing
that no further effort for saving the uterus was
justifiable drew the organ as far as possible from
the vagina and ligated high up with an elastic
cord. From the abdominal cavity he removed
the ovaries and tubes and closed the wound. On
the thirteenth day the elastic ligature was found
loose in the vagina, and after this the patient made
an uninterrupted recovery.

Were it possible to find easy and safe access to
the cervical canal through an opening in the ab-
dominal wall. Dr. Munde' s case emphasizes the
difficulties of overcoming the elastic contraction
of the cer\'ical fibres experienced by Dr. Thomas
in his first case, and which has been met also by
other operators, Again, we have to consider the
importance of the danger, and which, so far as I
know, has not been referred to by any operator, of
pressure upon the inverted Fallopian tubes, car-
ried as they are of necessit}- quite within the in-
verted uterus. The method of Dr. LilHenthal is
certainly ingenious, is philosophic, and was de-
serving of a better result. There can be little
doubt that the tissues of the fundus were materi-
ally impaired in their integrity by the previous
prolonged manipulative procedures.

In 1877 I devised a method for the reduction of

90

CHRONIC INVERSION OF THE UTERUS.

[July 20,

the inverted uterus by elastic pressure, the same
force to be applied simultaneouslj- upon both the
fundus and cervix. This was to be effected by
first tjang into the cervical tissue four metallic
rings. A strip of pure rubber about i '4 inches in
width and iS inches long was slit at either end and
nearlj' to the middle. The ends were to be thread-
ed through the rings and continuous traction ap-
plied. I was met with the objection that the
theorj' was perfect, but that the rings could not
be made to hold in the tissue. In order to demon-
strate the fact, as well as to serve another purpose,
which seemed to me might possess material ad-
vantage, I applied rings as above suggested to a
cervix uteri which I desired to dilate and thus car-
ried bj' elastic force a conical plug into the cervical
canal. When the sutures were deeply applied
the cervical tissue was found to bear any reason-
able amount of tension protracted through several
hours. After a long series of experimentation for
the purpose of dilation of the cervix these com-
paratively crude and clumsy efforts led up to the
construction of the repositor, which in its present
form seems to answer every requirement. After
waiting twelve years the following case gave the
opportunity of testing its value.

Mrs. B., aet. 33. Healthy girl. Menstruated
at 14. Married at 30. Well and regular in menses
until marriage, three years since. Eighteen
months ago aborted at the third month. June
19, 1888, was delivered at term with instruments,
under ether, by Dr. James McDonald, of Boston,
after twenty-four hours of severe labor. Made an
imperfect recovery, flowing more or less constantly
until operation for the reduction of the inverted
uterus, September Sth. Was in bed three weeks
and had been confined to room since birth of
child. Condition first determined by Dr. McDon-
ald in August. He feels quite sure the inversion
did not take place at time of labor. I first saw
Mrs. B. the day of the operation. Patient mark-
edly anemic. Dr. M., assisted by Dr. Lynch,
had made a prolonged attempt, under ether, that
morning at reduction b}- taxis, without avail.
Endometrius everywhere a bleeding surface. The
cervix constricted to render the organ distinctly
polypoid in shape. Could feel the edge of the cer-
vical ring. I introduced, with a large, full-curved
Hagerdon needle, long ligatures of No. 8 braided
silk deeply through the cervical tissues on each
of the four sides, equidistant, and brought them
into fixation with the repositor, A stead}-, uni-
form pressure was kept, at about 8 pounds by the
scale. After ten minutes the cer\'ix had yielded
perceptibly and in fifteen the organ was half in-
verted, tlie cup being covered by the retracted
cervix. The operation was completely finished
and instrument removed in twenty-six minutes
from commencement of pressure. No shock fol-
lowed and recovery was rapid. After five weeks
the patient flowed to soil two or three napkins.

The fourth regular menses occurred Dec. 20th.
Dec. 28th visited oiSce ; not seen before since
operation. Was in perfect health. Uterus not
tender, not enlarged, movable and normal to feel.
The pressure is applied by means of a spring con-
cealed in the handle. The scale is graduated up
to 15 pounds in order to determine the amount of
force used.

In reviewing the various methods devised for
the reduction of the inverted uterus it will be ob-
served that the place of counter pressure is of
necessity found in the vaginal attachment of the
organ. In order to bring the force to bear upon
the cenax the method of bimanual manipulation,
as devised by White, Sims, and others, was ap-
preciated as of great importance. First, by the
hand extended over the abdomen, then bj- two
fingers introduced into the rectum, this being
further supplemented by the finger introduced
into the bladder.

In the method for the application of continued
elastic force, first advocated bj' Drs. Tjder Smith
and Barnes, and perfected by Dr. Aveling, the
fixation of the cervix is necessarily abandoned
and the counter pressure is brought to bear di-
recth" upon the vagina and surrounding organs.
The force thus applied, at the best, acts only in-
directly on the cervical ring, which is the chief
criticism of the method. Theoretically a force
should be applied to draw down upon and invert
the constricted cervical fibres at the same time
that pressure is made upon the organ from below
upwards. This should be elastic and continuous,
but not too great. This force Dr. Emmett wisel}^
recognized in its application bj' his method of
taxis. As illustrated in the case of Dr. Munde,
the dilatation of the cervix, at the most, is only
one factor of the problem. Eet that force be con-
verted into one acting at the same time from be-
low upwards upon the fundus and the elastic
constriction becomes transformed into a power to
serve for the reduction of the organ. When ap-
plied in this manner the cervical fibres, little bj"-
little as they dilate, receive within their g^rasp and
retain the returning portion of the organ. My
method is simple and effective. The criticism of
a number of the profession is, "I wonder that it
has not been thought of before." I exhibited m}-
repositor to Dr. Priestlj-, of London, when my
guest in Boston, a little before the discussion of
Dr. Munde's paper, and he was kind enough to
speak favorably of my method at the discussion
above referred to. At the same meeting Dr. B.
McE. Emmett exhibited an instrument which he
had recentlj' devised. It consists of a ring on
three stems which is to encircle the cer\'ix. The
reinversion is to be accomplished by passing
stitches through the border of the cervix and
making traction outward over the rings, at the
same time pressure is made from below upwards.
Dr. Emmett recognizes, as I claim, that counter

iSSg.]

MEDICAL PROGRESS.

91

pressure to be of value must act upon the cervix
itself.

By whatsoever manner applied, it is certainly
rational to expect that the reduction of the in-
verted uterus would be best accomplished by
forces acting at the same time in opposite direc-
tions. As another means of securing this, Dr.
John Byrne, of Brooklyn, has invented a repositor
which consists of a cup for the reception of the
uterus, at the bottom of which is placed a mova-
ble disc attached to a stem which can be projected
upwards bj- means of a screw. In conjunction
with it he uses a bell-shaped instrument placed
over the abdomen, in order to fix the cer\'ix,
through the center of which a plug is projected
by a screw attachment, for the purpose of dilating
the cervix. In one or two instances this instru-
ment has been used with a satisfactory result.
Even so ingenious an instrument, although be-
lieved by Skeene to be the best devised is radically
faulty. The abdominal wall and bladder, possi-
bly other organs, must be involved between the
opposing forces, and iixatiou of the cervix can
never be absolute while there is no means of de-
termining the amount of force applied. If, how-
ever, a uniform elastic pressure can be brought to
bear at the same time, in the opposite direction,
upon both fundus and cervix, it is a manifest
gain. If this power is so applied that it is at
once, one and the same force, it is possessed of
still greater advantage. To place it entirely
within the control of the operator without possi-
bility of affecting any other organ, and reducing
the power to one of actual observation, as given
in pounds, is a still further manifest advantage.
All these are rendered as constant and well-known
factors in the application of the repositor which I
offer the profession for trial and, if found worthy,
adoption.

MEDICAL PROGRESS.

Concerning Glycogen in the Muscles. —
E. KiLZ found that the quantity of glycogen con-
tained in the muscles of the frog is increased under
the influence of daily subcutaneous injections of
grape sugar, even after extirpation of the liver.
It seems, therefore, that the muscles are capable
of making glycogen without any assistance on I
the part of the liver. This conclusion has re- ;
cently been attacked by Laves. He extirpates
the liver of geese and chickens after giving them
a meal of barley and oats ; ascertaining the
amount of glycogen in a fragment of the pectoral
muscle immediately before the operation, he re-
peats the determination some hours (one to thir-
teen hours) after the extirpation of the liver, and
continually finds less gl)-cogen at the second test.
He concludes therefrom that the pectoral muscle

is incapable of producing glycogen, in the absence
of the liver, at the expense of the feculents in the
nourishment.

Schmelz {^ZeUschrift fiir Biologic, xxv, p. 180,
1888) repeated Laves' experiments on chickens
whose livers had not been extirpated, in this waj^
that he ascertained the amount of gljxogen in the
muscles before and after a meal rich in hydrocar-
bonates (barley cane sugar), and he discovered
that even twenty-four to thirt}^-six hours after
the meal the muscles did not show 3^et an increase
in glj'cogen, although the liver was intact. It is,
therefore, hardly surprising that Laves discovered
no increase of glycogen after the liver had been
extirpated, and the experiments of Laves can
only serve to settle the question raised by E. Kiilz,
Schmelz completes his work by drawing a parallel
between the results of determinations of glycogen
by weight and hy circumpolarization. He recom-
mends the determination bj' polarimeter (origi-
nated by E. Kiilz), as expeditious and sufGciently
exact.

Luchsinger stated that glycogen disappeared
much more rapidly from the muscles than from
the livers of animals which had been given no
food for a long time, and that this substance did
not exist any more in the muscles after a few
days' fasting. He drew the conclusion from it
that glycogen should not be considered as an in-
dispensable constituent of muscle-fibre and as the
source of muscular energy.

Aldehoff lyZcitschrift fiir Biologic, xxv, p. 137,
1888) has taken up this question under the direc-
tion of R. Kiilz, using for the determination the
method of R. Kiilz and A. Cramer. He finds
that under the influence of fasting, in the chick-
en, the pigeon, the rabbit, the horse and the cat,
the glycogen diminishes less rapidly in the mus-
cles than in the liver, and that even after a pro-
tracted fast the mu.scles are still relatively rich in
glycogen. The muscles of two horses which had
received no food for nine days furnished the high-
est figures of glycogen (2.43, 1.34, 1.28 and o.gS
per cent.) which have ever been found in muscu-
lar tissue The hearts of these two animals con-
tained 0.82 and 0.58 per cent, of glycogen.

The results of determinations of glycogen made
by Manche {Zeitschrift fur Biologic, xxv, p. 163,
1888), by means of Kiilz' method, confirm in
general the statements of Weiss and Chandelon :
diminution of glycogen in the muscles through
tetanization of the muscles or through ligature of
the nutrient arteries; increase of glycogen through
cutting of the motor nerves. — Rcvuc des Sciences
Medicates, No. 66, 1889.

On the Treatment of Tabes by Suspen-
sion.— Dujardin-Beaumetz tried this treatment
on twenty patients, with the following results : In
most cases at first an improvement is noted. The
patient feels stronger and finds incoordination di-

92

MEDICAIv PROGRESS.

[July 20,

minishing ; the lumbar pains are also less intense.
But this improvement does not continue and
ceases after two or three weeks. In some cases
failure is total, and not the slightest improvement
is obtained. The author is as yet unable to say
why in some cases this method is effective and in
others it is a failure.

So far no experimental evidence of the improve-
ment obtained had been given; it has been furnished
by us by using Marey's method. It consists in the
reproduction by photography of the attitude of a
patient in walking. For this a photographic ap-
paratus is necessary, provided with an interrupter
which makes it possible to take pictures in a small
fraction of a second. A healthy individual is
dressed in black and made to walk before a dark
background, electric lamps are fastened to the
head, the shoulder, the hip, the knee, and the
ankle. A series of illuminated points is thus ob-
tained which connected constitute a schema of
the normal walk. The same procedure gone
through with an ataxic patient furnishes the pic-
ture of the walk peculiar to individuals afflicted
with tabes. The pictures taken after the suspen-
sion has been performed several times, show that
the walk of the patient approaches very near to
the normal. This is an absolute scientific proof
of the beneficial influence of suspension. As to
the mode of procedure the following should be
remembered : It is important that the chin and
nape of the neck are properly supported, and also
that the patient is supported at the armpits. At
first the patient should be left suspended for a
very short time onl}-, about fifteen to thirty sec-
onds ; gradually' this is increased until we arrive
at the maximum of three minutes. It has been
claimed that there is no danger in prolonging con-
siderably the time of suspension, but Dujardin-
Beaumetz thinks this is wrong and might result
in grave accidents.

Regarding the question, how suspension acts in
an ataxic patient, and how it is that this method
not only brings about a diminution of the inco-
ordination, but also relieves the lightning-pains
of patients with tabies, he says : " Against these
lightning-pains the elongation of the nerves has
been practiced, first by Langenbach, in 1879,
afterwards by Debove and Gillette, in France dur-
ing 1880. Elongation of nerves or nephrostheu}-
was first used in therapeutics by Nussbaum, in
1872, later on b}- Billroth. In 1876 \'erneuil ap-
plied it to the treatment of tetanus. According
to him elongation acts like an incomplete section
of the nerves. \'ogt maintains that elongation
produces its favorable results b}- acting upon the
neurolema, the pulling causing a rupture of the
vessels of the neurolema and the displacement of
the ner\^e-fibrils in the same. I believe that sus-
pension acts in the same way. It is probable that
the .sensitive cells of the marrow arc changed in
their molecular state."

However this may be, it is possible in certain
cases to obtain some benefits from suspension in
patients with tabes, and it would be wrong not to
try this method for the cure of an affection as
painful as locomotor ataxy. — Journal de Medicine
dc Paris, May 5, 1889.

On Reduction of Nitrates through Chol-
era Bacteria. — Dr. Petri has made a series of
experiments which yielded the following results :

1. Cholera bacteria reduce in their growth ni-
trates to nitrites.

2. The usual culture media, especiallj' gelatine,
and often also common cooking salt contain not
inconsiderable traces of nitrate.

3. The red cholera reaction is accomplished
through the medium of these impurities, i. e.,
through the reduction of the nitrates.

4. An oxidation of decomposed ammonia
through the vital action of the cholera bacteria
is not 3'et proven and is improbable, in view of
the fact first mentioned. — Centralblatt fiir Pakteri-
ologie iind Parasitenkunde, No. 18, 1889.

Experiments regarding the Production
OF THE Vesicular Murmur. — Dehio (of Dor-
pat) says : Contrary to the theory according to
which the vesicular murmur results soleh' from
the propagation of the tracheo-glottic murmur to
the parenchyma of the lung, the vesicular mur-
mur can be plainly distinguished on auscultation,
despite the intensitj' of the wheezing, in cases of
stenosis of the larynx. Besides, on auscultating
the lungs after Dehio had substituted a simple
rubber tube for the trachea and larynx, he could
distinctly hear a vesicular murmur which could
onlj- be attributed to a transmission of the concus-
sion in the interior of the alveoli of the residual
air by the column of inhaled air. — La Semai7ie
Medicate, No. 17, 1889.

Therapy of Diphtheria. — Dr. Burghardt
has been making for seven years experiments in
the cure of diphtheria by blowing a mixture
of sulphur and quinine in equal proportions into
the larj'ux, on the tonsils, into the nasal cavitj-
and into the pharynx. These applications were
made twice every day, and nothing must be taken
for two hours afterwards ; spitting must also be
avoided. The powder is odorless and does not
produce anj- disagreeable symptoms. Immedi-
ately after the application the patient is quieter,
fresher, the fever ceases, the feeling of weakness
leaves him. The applications are continued after
all symptoms have disappeared. Burghardt has
not met with a single failure. Of 33 cases, some
of which were verj' dangerous, not one terminated
fatally. Time of cure two weeks. — Wiener Med-
icinische Woch en sell rift, No. 17, 1S89.

1889.]

EDITORIAL.

93

Journal of the American Medical Association

PUBLISHED WEEKLY.

SnBSCRiPTiON Price. Including Postage.

Per Annum, in Advance $5-oo

Single Copies 10 cents.

Subscription may begin at any time. The safest mode of remit-
tance is by bank check or postal money order, drawn to the order
of The Journal. When neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
letters.

Address

JouRNAi, OF THE American Medical Association,

No. 6S Wabash Ave.,

Chicago, Illinois.
All members of the Association should send their Annual Dues
to the Treasurer, Richard J. Dunglison, M.D., Lock Box 1274, Phila
delphia, Pa.

London Office, 57 and 59 Ludgate Hill.
SATLTRDAY, JULY 20, 1889.

PREVENTIVE INOCULATION.

A lecture that should receive a great deal of
attention from the world of medicine is the
Croonian lecture on "Preventive Inoculation,"
recently delivered by M. Roux, in behalf of M.
Pasteur. It is almost eight years since the great
scientist laid before the members of the Inter-
national Medical Congress assembled in London
an account of the researches, carried on in his
laboratory, on preventive inoculations for chicken
cholera and splenic fever. Has the work then
begun fulfilled its promise ? What place have
the principles that it involved in the science of
to-day ?

In speaking of preventive inoculation we need
not stop to consider the great discovery of Jenner.
He showed that it is possible to protect ourselves
from a dreaded disease by inoculation with a
trivial one ; but be gave no general method lead-
ing to the prevention of other infections diseases.
The discovery of the power of artificially attenu-
ating— or weakening — a virus does furnish us
with a veritable method of preventive inoculation ;
and it has, says M, Roux, given us an uninter-
rupted series of good results. In revealing the
the nature of ferments Pasteur taught us the na-
ture of the poison of infectious diseases. We
know— or think we know — that viruses are living
beings, microbes, and that the development of
microbes in the living body produces the phe-
nomena of infectious disease. The processes by
which we are enabled to obtain the culture of
microbic ferments in a state of purity is the same

that has enabled us to obtain pure cultures of
microbic virus outside of the body. The indis-
pensable condition of success in these cultivations
is absolute purity. Having obtained them in a
state of purity can we not modify them by culti-
vation in the same way that other plants are
modified ? We know that many plants that are
poisonous ill a wild state are harmless or edible
in the cultivated state. To modify the viruses
by special modes of cultivation was the task
to which Pasteur set himself

Pasteur's first attenuated virus was obtained
while studying chicken cholera. His experi-
ments showed that the viruses of infectious dis-
eases are no more the unchangeable entities they
were supposed to be, but that, like all other living
beings, the microbic virus is susceptible of modi-
fications that heredity perpetuates ; that above
all, it is the virulent character that is modified,
and that this modification can be produced arti-
ficially, and regulated according to the wishes of
the experimenter. He established the attenu-
ating influence of the air, and explained how the
activity of a virus, under natural conditions as
seen in an epidemic, is preser^'ed or exhausted,
and how the same infectious maladj^ may be
sometimes malignant and again light. All that
was claimed by Pasteur in regard to chicken
cholera was confirmed by him in his inoculations
for anthrax — as is now admitted by Koch and
others that contested Pasteur's claims. And
taking into consideration the fact that we can
increase as well as decrease the virulence of a
virus, is it rash to believe that in the course of
ages new forms of virulence have been evolved,
and that the experiments on the variation of
virulence have thrown a flood, and will throw a
greater flood of light on that obscure question,
the origin of new virulent diseases ? We see
how one and the same kind of microbe can pro-
duce diverse morbid effects ; how, when it is
active or virulent, it causes a general disease,
rapidly ending in death, and in its passive or
attenuated condition it produces only a special
local lesion.

Almost all physicians are now familiar with
Pasteur's investigations in regard to roiiget or
swine fever. The extraordinary fact was brought
out by Pasteur andThuillier in these inoculations
that as the strength of the virus increases for the
rabbit it is diminished for the pig ; so much so

94

INTERNATIONAL COURTESIES.

[July 20,

that, after a sufficient number of passages of the
virus have been made through the rabbit, it has
become vaccine for swine, and able to exempt
them from the fatal forms of the malady. The
question now arises, what would happen with cer-
tain human diseases if they were made to pass
through a number of different kinds of animals?
This process we can see to a certain extent in na-
ture, and gives fresh support to the idea that the
vaccine of small-pox is modified by its passage
through the horse and cow. We are all familiar
with the great controversy in regard to Pasteur's
preventive inoculation for rabies — and we know
the verdict of the English Commission, which
should silence all objectors when taken in connec-
tion with the facts. The remarkable point in the
discovery of the preventive inoculation against
rabies is that the virus itself has not been discov-
ered. As j-et it is known to be a microbe by
analogy only, since no one has been able to iso-
late it. Thus, since it cannot be cultivated in
flasks and tubes, Pasteur has been obliged to cul-
tivate it in rabbits, and he has been able to do
this so easily and with such regularity that the
cultivations are ready for use at a specified time.
This is one of the strongest examples of the
power of the experimental method as applied in
medicine — the prevention of a malady the abso-
lute virus of which is still unknown.

The greatest source of danger from microbes is
in the poisonous products they form — their pto-
maines, a striking example of which is seen in
the case of diphtheria. The diphtheritic bacillus
does not grow in the interior of tissues, but only
on the surface of mucous membranes. The or-
ganism is poisoned by the ptomaines formed by
the bacillus. These products are found with
great difficulty in the body of an animal dead of
an infectious disease, since the complex surround-
ings of the ti.ssues is unsuitable for such research,
and the microbes of decomposition themselves
form ptomaines. But in cultivations in flasks
and tubes we can find these products of the pa-
thogenic activity of the microbes. The first ex-
periments of this kind were made by Pasteur with
the microbes of chicken cholera. The chemical
products obtained by cultivation of these microbes
are capable of causing the symptoms of the dis-
ease. In infectious diseases, therefore, the cause
of death is poisoning, and the microbes are not
only the means of spreading the disease, but also
the makers of the poison.

These facts have a distinct bearing upon the
question of preventive inoculation. When these
chemical products of pathogenic microbes are in-
troduced little by little into the bodies of animals,
in such manner as to avoid causing speedy poison-
ing, but so as to accustom the animal gradually
to their presence, the animal becomes refracton,^
to toxic doses, and to the microbe itself. Thus,
while formerl}' immunity could be secured only
by the introduction of the microbe itself into the
organism, it can now be secured by introducing
the chemical substance into the tissues ; these
vaccine substances being the same that are known
to be the cause of death in infectious diseases.
And while we can reason only from what we know,
we can say that, since these experiments on vac-
cination by means of soluble substances without
microbes have been successful in various maladies,
it is but natural to infer that their field of useful-
ness will be largely widened in the near future.
It may be possible, indeed, as Roux points out,
to protect ourselves from one malady by means of
another ; it is necessarj' only that the microbes of
the two diseases should produce similar chemical
substances.

What explanation can we give of the immunit}'
conferred by preventive inoculation ? At present
we can best explain it by sa^ang that when small
quantities of the attenuated virus are introduced
into the tissues the leucocj'tes — -or phagoc3^tes —
accustom themselves to its presence, and when
the active virus or microbes are afterwards inject-
ed the phagocytes attack and destroy them. But
the phagocytes of the non-refractor\' animals can-
not swallow and digest the active microbes, and
cannot prevent their development. Immunity is
the result of the habituation of the cells to the
poisonous products of the microbes.

INTERNATIONAL COURTESIES.

The medical profession of Canada was ably
represented at the annual meeting of the Associa-
tion at Newport.

The eloquent address of Sir James Grant was
greeted with rounds of applause, and its noble
sentiments met with generous response. In this
issue of The Journal a brief abstract of the ad-
dress will be found.

Another worthy representative of the profession
was Professor James Stewart, Registrar of Mc-

1889.]

EDITORIAL NOTES.

95

Gill University, one of the editors of the Montreal
Medical Joiinial. The able articles which have
eminated from his pen have been widely quoted.
A heart}- welcome was accorded to the entire dele-
gation. It is to be hoped that at the next an-
nual meeting, when it shall convene at Nashville,
the American Medical Association will be hon-
ored with a like representation, from Canada.

THE RUSH MONUMENT FUND.
Had Professor William Pepper, in his eloquent
address been able to speak to the entire member-
ship of the Association, and had they listened to
the stirring appeal of the Secretarj^ Dr. A. L.
Gihon, doubtless the entire amount of money
needed for the erection of the Rush Monument
would have been contributed upon the spot.
From the generous responses there made, it is
confidently believed that a later concerted move-
ment will accomplish this result. As a reason for
their not appearing in their regular order, in the
published proceedings of the Association, it
should be stated that it was deemed advisable to
hold the address of Dr. Pepper and the report of
Dr. Gihon for use in that connection.

THE ENTERTAINMENTS.

The provisions made by the Committee of Ar-
rangements, by the citizens of Newport, and by
the medical profession of the State of Rhode
Island, were in every respect all that could be de-
sired, and nothing but an enthusiastic interest in
the real work of the Association could have pre-
vented its members from giving themselves over
to a continued round of most attractive entertain-
ments at the City of Newport. Let not the
loyalt}' of the Association to its work in hand
lead the good people of that city and State to in-
fer that their generous hospitalities were not, to
the fullest extent appreciated.

A daj^ never to be forgotten was that when —
after the Association-work was over — the Rhode
Island Medical Society treated their guests to an
old-fashioned "clam-bake" on the shores of
Narraganset Bay.

THE JEWELL LIBRARY.
The ' ' Jewell Library ' ' has lately been secured
as the nucleus of a great medical libran,- for Chi-
cago. It contains about three thousand volumes

which embrace the most valuable medical litera-
ture published up to the time of Dr. Jewell's
death. The necessary subscriptions were secured
from a few medical men in an incredibly short
time. Thus a valuable collection of medical
works has been saved from being scattered under
the auctioneer's hammer and the library of one
of the most devoted doctors Chicago has ever
known is again made available to every reader.
It is expected that the Chicago Public Library
will take care of these books and the additions
which will be made to bring them down to the
present time, until a suitable building is provided
for their reception. Such building, to render the
library accessible, must be centrally located. This
will add greatly to the primary outlay. It is to
be hoped that some Dr. Pearsou will liberally en-
dow this librarv of medicine.

EDITORIAL NOTES.

HOME.

Dr. John S. Billings, of the Surgeon-Gen-
eral's office, Washington, D. C, has had conferred
upon him by the University of Oxford, the hon-
orary degjee of D.C.L.

Dr. Daniel H. Williams, of Chicago, has
recently been appointed by the Governor, a mem-
ber of the State Board of Health of Illinois.

DiPHTHERi.\ has been prevalent at Astoria and
Stineway, both places being within the jurisdic-
tion of Long Island City ; and that city, owing
to a deadlock among its officials, is in a bad sani-
tary condition.

New Medical Societies in Missouri. — We
are pleased to learn from the Kansas City Medical
Record, that the growth of county, district and
Section Societies in Missouri is verj- satisfactory,
new ones being reported nearlj' every week.
This is, as it should be, and we hope we may be
enabled to chronicle in the near future the same
activity among the profession in other States.

The Psychic Life of Microorganisms. —
The Open Court for Juh' 11, publislies the reply
of George John Romanes, LL.D., F.R.S., to the
criticisms of M. Alfred Binet on his psychological
work in its relation to microorganisms.

The Chicago Policlinic. — The following

96

KDITORIAL NOTES.

[July 20,

well-known physicians have been added to the
Facultj' : Dr. J. H. Etheridge as Professor of
Gynecology, and Dr. F. D, Porter as Professor of
Medicine.

A New Hospital. — The Michigan State Leg-
islature recently appropriated $50,000 for the erec-
tion of a new hospital at Ann Arbor. The citi-
zens have just supplemented that amount by
voting to issue bonds for $25,000.

A Medical Episode at Yale. — At the recent
Yale Commencement two of the favored guests
took snap shots at the profession of medicine.
Mr. Depew manufactured the following: " I once
knew a doctor who secured board with an under-
taker because he thought that it would improve
his business. He said he always knew when the
tmdertaker's business was good, for then there
was ice on the butter and flowers on the table. ' '

It is interesting to note the conspicuous abilitj^
of Mr, Depew, the great after-dinner undertaker,
to grapple with the financial problems involved
in such gravc-ioiderfakings.

Mr. Clemens (Mark Twain) aimed his alleged
wit "against the doctors," who, he says, have
reduced their labors and increased their charges :
"The doctor of to-day does not cart his medicines
'round in a wagon, but carries them in a portmon-
naie ; he puts three drops of nothing in a glass of
water and asks you to furnish the water; a month
later you will find the water charged in the bill
and you will have to pay for it, too. ' '

As men are willing to pay liberally for novelties,
we think Mark should pay for the water.

On the same occasion Mark Twain accused
President Oilman, of Johns Hopkins University,
of having neglected the rudiments of his educa-
tion, especially spelling, since he did not know
how " to spell 'John' correctl3\"

Mark is the last man that should criticise, since
he has always contended that orthography was
one of the "liberal aits."

FOREIGN.

In India the Legislative Council has drafted
a bill on the leprosy question — including segrega-
tion and medical care.

In Austr.\li.\ the Medical Society of Victoria
and the \'ictorian Branch of the British Medical
Association recently met to discuss the Bill to
amend the Medical Practitioners' Act of 1865,
when it was resolved to support the Bill. The

number of insane persons in South Australia oa
Dec. 31, 1888, was 758 — 430 males and 328 fe-
males.

In Chili the Government has created a "Su-
perior Council of Public Hygiene, ' ' consisting of
.seven members, whose duty it shall be to advise
the Government in ever\-thing that relates to the
public health throughout the Republic. The
Council has a laboratory' for chemical analysis
under its control.

In Russia, at a recent meeting of the St. Pe-
tersburg Deutscher Aertztlicher Verein, Dr. Ma-
gawly cited three cases of double central ambly-
opia, in two men and a boy, caused b}' looking at
an eclipse of the sun with unprotected eyes. After
a prolonged stay in a dark room and subsequent
wearing of dark protecting spectacles all the pa-
tients permanently recovered their sight.

In GRE.'i.T Britain we glean from our ex-
changes several items of interest. Lord Randolph
Churchill will introduce a draft Bill in the House
of Commons for the amendment of the constitu-
tion of fhe College of Surgeons. Sir James Paget has
been addressing the citizens of Oxford in support
of the extension of the Ej'e Hospital of that citj'.
The common iliac artery was ligatured for a large
and rapidly increasing aneurism of the external
iliac, by Mr. Clement Lucas, in Guy's Hospital,
recently ; the patient is doing well, the circula-
tion being well maintained in the foot. The
Council of the Royal College of Surgeons in Ire-
land has passed a resolution congratulating Sir
George Porter on the honor conferred on him by
the Queen, and through him to the College of
Surgeons. Sir George was recently created a
Baronet,

Celluloid Manufacture Dangerous. — The
French Government has ordered an official investi-
gation into the dangers to life and other interests,
attending the making of celluloid. During two
years three accidents, in each case having oc-
casioned serious injur}' and loss of life, have oc-
currea at factories making this inflammable ma-
terial. It is manifest that some form of restric-
tion, as to locality, must be ordained for this kind
of work. The process of making this substance
involves the use of a considerable proportion of
gun-cotton, which is too explosive and inflamma-
ble to be permitted to be used in thickly settled
neighborhoods.

1889.]

SOCIETY PROCEEDINGS.

97

SOCIETY PROCEEDINGS.

AMERICAN ]MEDICAL ASSOCIATION.

Official Repoi't of the Fortieth Annual
MeetinsT.

The American Medical Association convened
at Music Hall, Newport, Rhode Island, on June
25, 1889, at II A.M.

The Chairman of the Committee of Arrange-
ments, Dr. H. R. Stoker, called the meeting to
order and introduced the Rev. Thatcher Thaj'er,
D.D., who invoked the blessing of the Almighty
upon the Assembly. Dr. Storer then announced
the programme of the entire session and the loca-
tion of the halls for Sections,

The President, Dr. W. W. Dawson, Ohio ;
Vice-Presidents, Drs. W. L. Schenck. Kansas :
Frank Woodburj-, Penna. ; Henry O. Walker,
Mich.: the Permanent Secretary, Dr. William B.
Atkinson, Penna.; the Assistant Secretary, Dr.
V. M. Francis, Rhode Island ; the Treasurer, Dr.
Richard J. Dunglison, Penna., were present.

On motion, reading of the list of members reg-
istered was omitted.

Letters of regret from several members of the
United States Cabinet and others were read bj- the
"Chairman of the Committee of Arrangements.

Invitations were read and accepted for the mem-
bers to visit the various public buildings. Fort
Adams,Fort Wolcott,the U. S. Naval Torpedo Sta-
tion, the U. S. Naval Training School, the U, S.
Life-Saving Station, the Historical Society's build-
ing, the Redwood Librar}-, the Newport Hospital,
etc.

His Excellency, Herbert W. Ladd, Governor
of Rhode Island, welcomed the Association in a
brief speech, and was followed by Dr. James H.
Eldredge, an Ex-President of the State Medical
Society of Rhode Island.

(See page 14.)

The deaths of Dr. F. H. Rehwinkle, Chairman
of the Section of Dental and Oral Surgerj-, and of
Dr. J. B. Hunter, of New York, were announced.

On motion, all the phj-sicians of Newport not
otherwise entitled to be present were made mem-
bers by invitation.

Reference having been made to the failure to
obtain reduced rates on the railroads, on motion
of Dr. J. C. Culbertson, the subject was referred
to a special Committee consisting of Drs. Cul-
bertson, W. L. Schenck and J. H. Musser.

The Address of the President, Dr. W. W.
Dawson (see page i), was read bj- Dr. J. A. Lar-
rabee, of Ky., as Dr. Dawson was suffering from
an affection of his eye.

Vice-President Dr.W. L. Schenck occupied the
Chair.

On motion of Dr. W. Brodie, of Mich., a vote
of thanks was tendered to the President for his
ver3' able and interesting Address, and it was re-
ferred for publication.

On motion of Dr. A. L. Gihon, U. S. Navy,
the President was requested to telegraph to the
venerable Dr. D. Humphrej-s Storer, of Boston,
an Ex-President of the Association, a filial
greeting and regret that he was absent from the
meeting.

On motion, the Association adjourned until 10
A.M. on Wednesday.

Second Bay, June 26.

The President called the meeting to order at

ID A.M.

Prayer was offered by Right Rev. Thomas M.
Clark, the Episcopal Bishop of Rhode Island.

After some announcements bj- the Committee
of Arrangements, the President announced that
the Committee on Railroads would meet for a con-
sultation and report on Thursday.

The Permanent Secretary' read the names of
the Nominating Committee, as follows :

Ark., P. O." Hooper; Col., J. W. Graham;
Conn., J. A. Stokes; D. C, Dewitt C. Patterson;
Ga., J. B. S. Holmes ; III, J. S. Marshall ; Ind.,
S. J. Cook ; la., W. F. Peck ; Kan., J. E. Minney ;
Ky., J. M. Mathews ; La., J. L. Bland ; Me., F.
Hitchcock; Md., John Morris; Mass., E. H.
Warren; Mich., W. Brodie; Minn., John H.
Murphv : Mo., Isaac N. Love ; Miss., J. D. Dab-
nev; N. J., W. Perrv Watson; N. H., L. G.
Hill ; N.Y., E. D, Ferguson ; N. C.,W. J. Jones;
Neb., J. O. Carter; Ohio; W. S. Christopher;
Penna., W. H. Parish ; R. I., J. L. Collins ; S. C,
S. M. Orr ; Tenn., G. C. Savage ; Texas, A.Van
Gasken ; Va., L. Robinson; Vt., H. D. Holton ;

W. Va., ; Wis., W. T. Galloway ; U. S.

Army,G. Smart; U. S. Navy, J. L. Neilson ; U. S.
Marine-Hospital Service, W. H. Long ; Utah, J.
F. Bascom ; New Mexico, W, H. Ashley.

On motion, this Committee was instructed to
meet immediately.

Dr. Wm. Pepper, of Penna., then delivered the
Address in Medicine, which will appear in full in
The Journal.

Dr. A. L. Gihon, Chairman, read an Appeal on
behalf of the Rush Monument, which will be pub-
lished in the same issue with Dr. Pepper's ad-
dress.

The Permanent Secretar>' read a reference from
the Section on Gynecology, asking that the paper
by Dr. Storer on'" The M'edals of Dr. Rush," be
read before the General Session at this time. This
was granted.

On motion of Dr. M. L. Herr, of Penna., it
was agreed that one member of each County
Medical Society in the Union be appointed to
solicit funds for the monument. A recess was
taken to permit the members to make their offer-

98

SOCIETY PROCEEDINGS.

[July 20,

ings to the fund, whicli resulted in the collection
of $264.50.

The amendments to the Constitution and By-
laws being in order a motion of Dr. A. Garcelon,
of Maine, to postpone them until Thursday was
negatived. The amendment to strike out the last
clause of or paragraph of Sec. 7, relating to indi-
vidally afSxing names to the Constitution and
Regulations of this Association was adopted after
a full explanation of its purport by Dr. N. S.
Davis.

Vice-President Dr. F.Woodbury in the Chair.

Dr. Culbertson moved that the whole matter of
the other amendments be referred to the Board of
Trustees, with the Secretary.

On motion of Dr. J. B. Murdoch, Penna., this
was laid on the table.

The next amendment proposing many changes

read their report, showing the work done in pub-
lishing The Journal, the property on hand, etc.,
and that The Journal was now free from debt.

REPORT OF THE TRUSTEES FOR THE PUBLISH-
ING OF THE JOURNAL OF THE AMERICAN
MEDICAL ASSOCIATION, FOR THE YEAR
ENDING JUNE 30, 1889.

The trustees of the American Medical Associa-
tion for the publication of its Transactions in
Journal form, beg leave to make their annual
report.

The Journal, as is well-known to the mem-
bers, is now within a few days of having com-
pleated its twelfth volume and sixth year of pub-
lication. The wisdom of the change from an
annual volume containing simplj' its Transactions
to that of a weekly issue embracing the papers

in the Sections was taken up and Dr. N. S. Davis I read before the Association, and such other con-

moved to postpone all except the first paragraph.
After some further discussion, on motion of Dr.
Larrabee to lay this on the table and indefinitelj'
postpone, it was carried by a large majority. A
motion to reconsider this action was, on motion
of Dr. Gihon, laid on the table.

The amendment providing for a General Com-
mittee, or Council, was next considered. A mo-
tion by Dr. C. R. Earley, Penna., to indefinitely
postpone the entire subject was lost. After much
discussion by Drs. Davis, Larrabee, Murdoch,
Scott, Vaughan, Millard, Connor, Quimby, Edw.
Jackson and Baldy, the amendment was re-

jected

The Permanent Secretary- read the following j Association, to produce a first-class
communication from the Section on State Medi- 1 journal. The plant, or means placed at

tributions of interest as its editor may select, is
conspicuousl}- apparent, and has the fullest in-
dorsement of the Association.

It is observable that since the starting of The
Journal, the attendance at the annual meetings
j have been better, and the dues from absent mem-
j bers have been more generally paid, and thereby
! our income increased from less than $5,000 in
I 18S3 to over $15,000 in 1889. The report of the
Treasurer will show in detail the financial condi-
tion of the Association which is that of Thb
Journal. From the beginning of the enterprise
! it has been the desire of your Trustees, in addi-
tion to the publication of the Transactions of the

medical
the dis-

cine : posal of the Trustees, was at first very diminu-

Jicsolved, That the American Medical Association is of tive and tender, and had to be fostered with the
opinion that it is a duty devolving on all Nations to take greatest care and economy, that we might have a
measures to eradicate any plague centre from their terri- journal of any kind. The Trustees were ably

tory, that the existence of such plague centres is a menace
to all other Nations, and that our State Department be re-
quested to take measures through proper diplomatic
channels for the conveyance of this opinion to the Gov-
ernment deemed obnoxious to the opinion as herein
expressed.

On motion the action was accepted.
On motion the Association adjourned until
Thursdaj- at 10 a.m.

Third Day, June 27.

The President called the Association to order
at 10 A.M. Prayer was made by Rev. Jas. Coyle,
of Newport.

After announcements by the Committee, Sir
James Grant of Canada, and Dr. H. I. Bowditch,
were invited to seats on the platform.

Dr. Grant responded to the invitation by a
speech, in which he reviewed the valuable work
doTie by the members of the profession in the
United States. (See page 84.)

Dr. P. O. Hooper, of the Board of Trustees,

assisted in this delicate and arduous dutj- by the
' zeal and abilitj- of the editor — the father, patron
and friend of this Association. He has received
I our thanks, and deserves your hearty commenda-
tion for the very valuable services he has given to
its establishment.

From the small and uncertain resources availa-
ble at the beginning, this journal has now at-
tained a sound financial basis, and is to-day the
equal, if not the best in the country, and with
greater means at our di.sposal, and the .services of
a more complete corps of writers which can then
be employed, we expect to place it in the very
front rank of medical periodicals.

The Journal of the American Medical
Association is now honored and everywhere re-
spected, an-d its location coveted by various cities,
publishers and commercial interests.

It has won this high position bj- its just and
independent course, having no enemies to punish
or personal interests to ser\'e. In its course it has
been, is, and will continue to be loyal to the med-

1889.]

SOCIETY PROCEEDINGS.

99

ical profession and the best interests of the Ameri-
can Medical Association.

From the report of the acting editor for the
Journal year ending March 31, 1889, the Trust-
ees make the following extracts which concisely
presents the main facts :

Jlceily and Total Circulation. — At this date,
March 31, 1889, the regular weekly circulation of
The Journal is 4,633, of which 4,309 go to
members and subscribers, and 324 to exchanges,
foreign and domestic, and advertisers. The total
number printed each week is 5, 000 copies being 367
in excess of the number required for the regular
mail and express lists. An average of 75 are lost
by spoilage, as many more go for extra copies to
contributors, leaving on file about 200 copies
out of which to supply samples, and single copies
to complete files of members, when called for.
In addition to the regular weekly issues, an extra
edition of 20,000 copies was printed in April,
18S8, and distributed as sample copies to members
of the profession not previously receiving The
Journal, which made the total number of copies
of The Journal circulated during the year
275,000.

Receipts. — As all membership dues are paid to
the Treasurer of the A.Ssociation, only the money
paid for subscriptions, advertisements, reprints,
extra journals, etc., is received at the office of
publication. From the sources just named there
has been received at this office during the year
ending March 31, 1889: From subscribers, $2,-
182.53; from advertisements, $9,731,60; for re-
prints, $844.37 ; from sale of extra Journals,
Codes of Ethics, and Volumes of Transactions,
$77.75 ; for rent of part of printing office, $150 ;
and for bindery work for outside parties, $1,317.71 ;
making a total of $14,303.96, all of which has
been paid to the Treasurer of the Association
direct, or through the Treasurer of your Board.

Publication Expenses. — The total publication
expenses for the year ending March 31, 1889, for
office rent, materials and labor in printing office
and bindery, are $19,808.65; from which should
be deducted $1,317.71 cash received for work done
in the bindery for outside parties, and $150 for stor-
age use of part of printing office, leaving the
actual publication expenses of The Journal for
this 3'ear, $18,340.94.

Under the head of Editorial Expenses are in-
cluded the salary of the Editor, payments for
Foreign and Domestic Correspondence, the Re-
ports of Medical Societies, Lectures and Papers,
and for Assistant Editorial work. The total
amount drawn from the Treasury on account of
these items during the year ending March 31,
1889, is $4,534.38 ; of which $1,500 was paid to
the Editor for the first nine months of the year,
$333.33 for the month of January, 1889, and the
remaining $2,701.05 for the other items named.
It is thus .seen that the total current expenses on

account of The Journal, both publication and
editorial, for the year ending March 31, 1889, are
$22,875.32.

Expenditures on Account of Plant and Fixtures.
— In accordance with the recommendation con-
tained in my report for 1888, which were sanc-
tioned by your Board, $720.33 was paid for new
type, which enabled us to commence Volume XI,
July I, 1888, with an entire new typographical
dress and a better quality of paper. To facilitate
the work and economize the cost of folding, stitch-
ing, wrapping, etc., $500 was paid for a wire
stitching machine to complete the bindery part of
the office.

Property on hand. — The present property be-
longing to the Publication Department may be
stated as follows :

Printing office, type, fixtures, etc 11,477.94

Bindery 650.21

Business office — safes and furniture . . . 185.75

12,313-90
There are stored in the printing office, at the re-
quest of the Treasurer of the Association, 1,149
volumes of the Annual Transactions of the Asso-
ciation, issued during the j'ears prior to the es-
tablishment of The Journal, of estimated value
$2,870. About 25 copies of volumes five and six,
75 copies of volumes seven and eight, and 150
copies of volume nine, ten and eleven of The
Journal remain on hand, and 3,000 copies of a
cheap edition of the Code of Ethics.

S

^ ••

^ 5

"^ "S

■~ s

•S'^

>^>

..^^

1^

w

<

1^

H

r,"^-^

Cc; <3

>

^^

1'

•V^

A

S";^

<

« -is

Ph

s-^

S

^'^^

0

«s <<

> S-*

C^^

%J

^"S

■S «

i<l

^

■8 ? S S.
<^ i^ s" ^

N X 0 X

■<r to «-

1°

•sanssi
zS ni

S 1 1 !- i

•anssi
H0B3 ni

M X 0 a> ID
to "_ -o^ cK "5
w « to to to

■ssnssi
z5 ni

! ! ! ! t

anssi
UDEa UI

t % % % %

<

The Boston Medical and Surgical Journal.
The Medical News of Philadelphia ....

The Medical Record of New York

The New York Medical journal

lOO

SOCIETY PROCEEDINGS.

[July 20,

The present status of The Journal in regard
to the number of its pages, exclusive of adver-
tisements, and the actual amount of reading mat-
ter, in comparison with the four principal weekh-
medical journals published in this country, is
well shown in the foregoing table, prepared by
Mr. J. Harrison White, the business manager of
our printing and publication office.

A special edition of The Journ.\l, of 75,000
copies, was issued in May, and one addressed to
every physician in the United States and Canada.
The expense of this edition was fully covered by
the receipts from the advertisements obtained for
this special number, and left a slight balance in
the treasur>'. The good result of this enterprise
is already apparent at the office of publication.

At the beginning of the year the number of
pages of The Journal was increased from 32 to
36. This of course carried with it a considerable
increase of expense, but we are glad to be able
to state that we will close the year free from debt,
and are now in possession of a better plant for
producing an acceptable journal than at any for-
mer period.

All of which is respectfully submitted by the
Board of Trustees. J. M. Toner,

P. O. Hooper, \V. T. Briggs,

Leartus Connor, Jno. H. Hollister,
E, M. Moore, A. Garcelon.

On motion the report was adopted.

The Permanent Secretary read the following
from the American Social Science Association :

Resolved, That a committee of three be appointed by
the Presideut of this Association, to draw up a suitable
resolution, indicative of the sense of this body, upon
the necessity of a rigid demand on the part of our medi-
cal institutions for a more thorough general education
antecedent to the study of medicine; suggesting the
adoption of entrance examinations for those candidates
not possessing a collegiate or university degree, and fur-
thermore urging our medical colleges' so to extend the
course of study and increase their facilities that the
standard of scholarship may be on a par with like insti-
tutions abroad.

Resolved, That the same committee draw a resolution '
which may be presented to the legislative bodies of the
respective States, urging the necessitv of formulating
more stringent laws to guard against the further incor-
poration of bodies unqualified to properlj- teach the sci-
ence of medicine, and to take such steps that all the in-
corporated medical colleges be subject to a State super-
vision as to their methods and the standard of instruction.

Resolved, That a copy of these resolutions be presented
to the American Medical Association.

On motion of Dr. F. \Voodbur>' the communi-
cation was accepted.

Dr. P. S. Conner, Ohio, read the Address in
Surgery (see page 15).

On motion of Dr. Brodie thanks were offered
Dr. Conner for his address, and it was referred for
publication.

The Permanent Secretary read the

REPORT OF THE TREASURER.

I have the honor to report, as Treasurer, that

there is a balance in the Treasury of the Associ-
ation at this date of $2,845.65, as shown by the
itemized statement which will accompan}' this
report, and be published at length in The'Jour-
NAL of the Association for the information of
members.

There is nothing of special interest to report at
this time in connection with the financial relations
of the Association, except the statement, which
must forcibly address itself to all who have at
heart the onward progress of the Association, that
the Treasurj' has never yet, since the establish-
ment of The Journal ; or, indeed, at any time
during the twelve years in which I have had the
honor to occupy the position of Treasurer, failed
to respond to all authorized and legitimate de-
mands upon it for the interest and advancement
of the Association and the maintenance of its
now well established journal.

All of which is respectfully submitted.

Richard J. Dunglison, Treasurer.

Dr. Richard J. Dcnglisox, Treasurer, in account with the Amer-
ican :\Iedical Association ;
Dr. iSSS.
;May 9. To cash balance, as per report at Cincin-
nati meeting 52, 407. .S3

May 9. To amount received from delegates and

members at Cincinnati meeting 4.340.00

1SS9. ,
June 22. To amount of annual dues from mem-
bers to date 10,465.00

To amount received from office of publication

to date 16,585.81

' 533.798-64

Cr. iSSS.

May 10. By exchange and collection charged on
checks and drafts deposited at Farmers' and
Mechanic's Bank. Philadelphia 545-55

May 24. By postage and collection charges,

stamped envelopes and postal cards 104. 38

Maj' 25. By cash paid Dr. Richard J. Dunglison,
Treasurer, expenses of travel, expressage,
telegrams, etc 79.00

June I. By cash paid Dr. William B. .\tkinson,
Permanent Secretary-, expressage, postage,
traveling expenses, etc 161.78

June 5. By cash for postage, rental of P. O. Box,

envelopes, etc ' * ■ . . 22. Si

June II. By cash paid Dr. W. W, Dawson, Chair-
man Com. of .Arrangements, for rental of
hall, printing, etc 1,163.40

June 14. By cash paid William F. Fell & Co.,

printing, postals, slips, circulars, receipts. etc. 16.25

June 14. Bv cash paid Dunlap & Clarke, print-
ing drafts, cards, circulars, etc, 1.SS7-1S88. . . 29.50

June 19. By cash paid Geo. S. Davis, subscrip-
tion to Index Medicus. 1SS7-18S8 20.00

June 27. By cash paid to .\ltemus & Co. for sta-
tionery 9.00

July 2. By cash for collector's commissions, sta-
tionery, postage, etc, to date 53.73

July 19, By cash to Dunlap & Clarke, printing

cards, slips, circulars ; stamped envelopes. 21.25

Aug. 3. By cash to Dunlap & Clarke, printing

remittance blanks and postal receipts. . . . 10.25

Aug. 3. Bv cash paid collector's charges and
commissions, stamped envelopes, rental P.
O, Box. etc 46.64

Sept. S. By cash paid 1. 000 two-cent envelopes . 22.20

Sept. 13. By cash paid Wm. J. Domain, printing

credentials 4.95

Oct. 17. Bv cash to P. C. Merrj-, for hauling

books for Librarian at Washington 5.00

Oct. iS. By cash paid Wm. F. FclT& Co.. print-
ing postal cards, membership receipts,
drafts, etc 12.50

Oct. 20. By cash pai4 for postage, stationery,
collector's commissions, stamped envel-
opes, etc 60.64

1.SS9.

Jan. 19. By cash paid Wm. F. Fell & Co., print-
ing envelopes, cards, etc 16.25

March 20. By cash paid Ward & Barnitz. print-
ing postals, receipts, etc 4.75

March 30. By cash to Wm, F, Fell & Co.. envel-
opes, slip's, cards, etc 10.00

iSSg.]

SOCIETY PROCEEDINGS.

lOI

April 12. By cash paid Dr. C. H. A. Klein-

schmidt. Librarian, express charge on books, 8,70

May 6. By cash for postage, slatnped envelopes,
postals, rental of P. O. Box and collector's
charges 117-67

June 5, By cash for postage, telegrams, slips,

collector's commissions, etc 16.05

June S. By exchange and collection charges,
on checks and drafts deposited at Farmers'
and Mechanics' Bank, Philadelphia 42.37

June 24. By cash paid for publication expenses
of the Journal of the Association to June 15,
1SS9 22.322.5S

June 24. By cash paid for editorial work on the

Journal of the Association to June 15, 1SS9. . 6,527.79

June 25. Cash Balance 2,845.65

:S33.79B.64
This certifies that we have examined the accounts and vouchers

of R. J. Dunglison, Treasurer American Medical Association, for

the year ending June 24. 1SS9, and find them correctly cast and

properly vouched. Alonzo Garcelon,

\V. T. Briggs,
Newport, June 26, 1SS9. Auditing Committee.

Also the report of the Auditors.

The undersigned, Auditing Committee of the
American Medical Association, beg leave to report
that they have attended to the duty devolving
upon them and, after close inspection of the bills
for the publication of The Journal of the Asso-
ciation and other expenses pertaining thereto,
find that there has been paid into the Treasury' of
the Association during the year ending June 26,
current, the sum of $33,798.64, and that there
has been expended the sum of $30,952.99, leaving
an unexpended balance of $2,845.65, and that for
these expenditures the Treasurer holds bills duly
authorized and receipted.

Alonzo Garcelon,
W. T. Briggs,
Com. for Auditing Accounts.

On motion these were accepted.

The venerable George Bancroft, the historian,
having entered on the stage, he was presented to
the members, who arose to receive him.

Dr. P. O. Hooper, from the Committee on Nom-
inations, read the following :

REPORT OF THE COMMITTEE ON NOMINATIONS.

To the President and Me^nbers of the American

Medico I . -i ssocia tio n :

Your Committee on Nominations have the
honor to report that they met yesterday and or-
ganized by the selection of Dr. P. O. Hooper, of
Arkansas, as Chairman, and Dr, Henry D, Hol-
ton, of Vermont, as Secretary. After mature de-
liberation, they b}- ballot proceeded to the nomi-
nation of the following officers for the ensuing
year :

For President — E. M. Moore, of New York.

First Vice-President — J. W. Jackson, of Mis-
souri.

Second Vice-President — H. H. Kimball, of
Minnesota.

Third Vice-President — J. H. Warren, of Mas-
sachusetts.

Fourth Vice-President — T. B. Evans, of Mar3'-
land.

Treasurer — Richard J. Dunglison, of Pennsyl-
vania.

Permanent Secretary — William B. Atkinson,
of Pennsylvania.

Librarian — C. H. A. Kleinschmidt, of District
of Columbia.

To fill vacancies in Judicial Council caused by
expiration of their terms of office — N. S. Davis,
Illinois ; H. Brown, Kentucky ; Wm. Brodie,
Michigan; R. C. Moore, Nebraska; G. B. Gilles-
pie, Tennessee; T. A. Foster, Maine; J. B. S.
Holmes, Georgia.

To fill vacancies in Board of Trustees of Jour-
nal— P. O. Hooper, Arkansas; Alonzo Garcelon,
Maine ; Isaac N. Love, Missouri. For the unex-
pired term of E. M. Moore — W. W. Dawson, Ohio.

To deliver the Address on General Medicine —
N. S. Davis, Illinois.

To deliver the Address on General Surgery —
Hunter McGuire, Virginia.

To deliver the Address on State Medicine — Al-
fred L. Carroll, New York.

For Members of the Committee on State Medicine
— Alabama, Jerome Cochrane ; Arkansas, Edwin
Bentley; California, G. G. Tyrrell; Colorado, J.
Wood; Connecticut, J. C. Kenny; Dakota, F. P.
Kenyon ; District of Columbia, D. W. Prentiss ;
Delaware, L. Bush; Florida, J. Y. Porter; Geor-
gia, J. P. Logan ; Illinois, J. H. Ranch; Indiana,
F. W. Beard ; Iowa, A. B. Bowen ; Kansas, W.
L. Schenck ; Kentucky, J. N. McCormack; Lou-
isiana, J. J. Bland; Maine, T. J. Foster; Maryland,
T. A. Ashby ; Massachusetts, H. P. Walcott ;
Michigan, H. B. Baker; Mississippi, Wirt John-
son ; Missouri, H. H. Mudd ; Minnesota, Perry
H. Millard; North Carolina, T. F. Wood; Ne-
braska, J. O. Carter; New Jersey, I. N. Ouimby;
New York, T. M. Flandrau; New Hampshire, D.
S. Adams; Ohio, C. G. Comegys ; Oregon, W. D.
Baker ; Pennsylvania, W. T. Bishop ; Rhode Is-
land, H. R. Storer ; New Mexico, F. H. Atkins ;
South Carolina, H. T. Horlbeck ; Tennessee, J.
Berrien Lindslej' ; Texas, J. Sears ; Vermont, D.
F. Rugg ; W. Virginia, G. W. Baird ; Virginia,
— Ashton ; Wisconsin, J, T. Reeve ; Utah, F. S.
Bascomb ; U. S. Navy, W. D. Wolverton ; U. S.
Army, F. C. Ainsworth; U. S. Marine-Hosp. Ser-
vice, J. A. Kinyoun.

Committee 07i Necrology — Alabama, G. E.
Ketchum ; Arkansas, L. P. Gibson ; California,
R. H, Plummer ; Dakota, F. M. Crain ; Connec-
ticut, W. G. Brownson; District of Columbia, A.
N. Acker ; Florida, Neal Mitchell ; Georgia, P.
R. Courtleroy ; Illinois, D. W. Graham ; Indi-
ana, J. F. Hubbard; Iowa, J. B. Ingals; Kansas,
Chas. Gardner; Kentucky, H, M. Skillman; Lou-
isiana, J. R. Matas ; Maine, A. J. Fuller ; Marj--
land, F. S. Latimer ; Massachusetts, G. M. Gar-
land ; Michigan, G. E. Ranney ; Mississippi, —
Trimble ; Missouri, J. E. Kefft ; Minnesota, W.
W. Mayo ; New Mexico, W. R. Tipton ; Nebras-
ka, — Galbreth; New Jersey, J. D. Hough; New
York, John W. Brown ; New Hampshire, J. W.

I02

SOCIETY PROCEEDINGS.

[July 20,

Parsons; Ohio, S. P. Deahofer; Oregon, — Shack- '
elford ; Pennsj'lvania, J. B. Walker; Tennessee,
J. B. Murph}-'; Texas, W. Park; Vermont, E. R.
Campbell ; Virginia, M. L. James ; W. Virginia,
W. 1,. Wilson ; Wisconsin, — Mackie ; U. S.
Navy, W. T. Hord ; U. S. Army, J. R. Smith ;
U. S. Marine-Hosp. Service, Fairfax Irwin. ;

Committee to appoint Alternates in ease any Va-
cancies occur in the Number selected to give a Gen-
eral Address — Wm. Brodie, J. H. Murphy, J. T.
Morris.

Your Committee name as the place of next
meeting Nashville, Tenn., and the time of meet-
ing as the third Tuesday of May, 1890.

Chairman of Committee of Arrangements — W.
T. Briggs.

Assistant Secretar}' — G. C. Savage, Nashville.
(Signed) P. O. Hooper, Pres.

Henry. D. Holton, Sec.

On motion, the report was unanimously adopt-
ed and these officers were elected for iSgo.

Dr. Culbertson, from the special committee on
transportation of members to the sessions of the
Association, reported a resolution making it the
duty of the Permanent Secretan,- to secure from
all railroads or other means of travel the lowest
passenger rates for the sessions of the Association, i

After discussion this was adopted. •

On motion of Dr. Frank Woodbur}- the follow- \
ing preambles and resolution were unanimously
adopted :

\Vhere.\S, It is of the utmost importance that the
people of this country should etijo}- the same advantages
from the advances in materia medica, chemistry and phar-
macy that are possessed by the people of Europe and other
favored nations, and

Where.\S, The patent laws of the United States ap-
pear to be so construed as to protect the foreign manu-
facturers and purve^'ors of chemical products, and to
discriminate against domestic manufacturers b\- creating
monopolies in the supply of certain new and valuable
drugs; therefore be it

Resolved, That the .\merican Medical Association
hereby most respectfully petitions the Congress of the
United States to instruct the appropriate committees to
investigate this subject, to take testimonj- of any such
discrimination, to compare the legislation on this subject
of the leading Governments of Europe and the practical
working of our own laws upon copyright, trade-mark,
and any other protection afforded to foreign manufactur-
ers of drugs in frequent use or to be used in the treat-
ment of the sick, and to report such action as it may
deem advisable to correct any abuses or injustice to Am-
erican citizens, if they find such abuse or injustice really
exists.

The following was offered by the Section on
Ophthalmology :

Resolved, That the Ophthalmological Section respect-
fully desires the .Association to authorize this Section to
use what influence it can command to induce the Census
Committee of the United States for 1890 to extend the
tables relative to the blind and to tabulate to the greatest
extent possible the causes of blindness.

On motion this was adopted.
The Section on State Medicine offered the fol-
lowing :

This Section has adopted the following Report
of the Committee on Uniform Medical Legislation
in the United States, and recommend that it be
adopted, and that the Secretary of the Association
transmit a copy of the Report to the Secretary of
each State Medical Society, with the recommen-
dation that each Society exert itself to secure the
enactment of a law embodying the provisions of
the Report.
Gentlemen of the Section on State Medicine :

Your Committee on Uniform Legislation have
the honor to submit the following :

That, in our judgment, the best interests of
the public will be subserved by the enactment of
efficient medical legislation in everj- State in the
Union,

That for the convenience of the profession and
the stimlating effect on medical education in this
countrj' it is advisable to secure uniformity of
legislation in the essential features of all Medical
Practice Acts.

This Committee, therefore, begs to recommend
as follows — that in future medical legislation the
essential features of the enactment be as follows :

That all persons commencing the practice of
medicine in any of its branches shall possess a
license from the State Board of Medical Exam-
iners.

That all candidates for a license shall submit
satisfactorj' documentary evidence that he or she
is a graduate in medicine of a medical institution
in good standing with the said Board and having
a curriculum possessing at least the following
requirements :

First. — An entrance examination to test the
student's fitness to become a practitioner. This ex-
amination shall include at least an examination in
English grammar, composition, geography, history,
arithmetic, algebra, physics, and the natural
sciences ; together with at least one of the follow-
ing languages : Latin, French, or German, pro-
vided, however, that graduates of reputable col-
leges may be exempt from said examination.

Second. — Before granting a degree of M.D. or
M.B., candidates for same shall have attended at
least three full and regular courses of medicine
of not less than six months' duration each.

All candidates for a license shall undergo an

examination by the said Board of Medical E.^am-

j iners upon the branches usually taught in medi-

I cal colleges. Said examination shall be both

scientific and practical, but of sufficient severit}^

I to test the candidate's fitness to practice medicine

and surger3'.

; Said Board of Medical Examiners shall isstie a
! license to only such persons undergoing an exami-
nation as may be deemed suitable persons to prac-
tice medicine. Said Board may refuse or revoke
a license for the following named cau.ses, to-wit :
chronic and persistent inebriety, criminal abortion,
or gross unprofessional conduct.

1889.]

SOCIETY PROCEEDINGS.

103

All licenses shall be recorded and made a
matter of public record with the County Clerk,
or Clerk of District Court, in the county wherein
resides said person.

Said Board of Medical Examiners shall be ap-
pointed by the Governor, for a period not exceed-
ing five years, the members thereof to be chosen
from among the reputable practitioners of medi-
cine of the State of not less than five years' resi-
dence.

On motion, the report was adopted.

The same Section offered the following :

It is recommended by the Section on State
Medicine that the Committee on Collective Inves-
tigation of Disease, at present included in the
Standing Committee on Meteorology, be dis-
charged, and that the Committee on Meteorology
be continued, with the direction to report to the
Section on State Medicine at the next annual
meeting of the Association.

On motion, this was adopted.

Dr. Frank Woodbury offered the following,
which, on motion, was adopted :

Whereas, The Americau Pharmaceutical Association
has appointed a Committee of Conference and sent a
delegation to this Association,

Resolved, That this Association extends a cordial greet-
ing to the representatives of the American Pharmaceuti-
cal Association, and invites them to a seat upon the
platform, and

Resolved, That a Committee of Conference be appoint-
ed to meet the Committee of the American Pharmaceuti-
cal Association, for the consideration of subjects of mu-
tual interest and benefit.

Resolved, That this Committee report on the second
day of the next annual meeting of this Association the
result of their conference, with such recommendations
as they may deem advisable in the premises.

The Permanent Secretary read the following :

Yotir Committee on Dietetics beg leave to re-
port : The special topic referred for investigation
has been entertained and partially discussed at
this session, but not so fully as to warrant a re-
port at this time that will completely satisfy all
the requirements of the subject. We therefore
report progre.ss and ask that the Committee be
continued.

(Signed) E. A. Wood, Chairman.

The report was received and the Committee
were continued.

Dr. A. L. Gihon ofiered the following amend-
ment to the By-laws :

That the first da)- of the meeting of this Asso-
ciation shall be on the first Wednesday of May
or June, respectivel}', instead of Tuesday.

Laid over tmtil next meeting.

The vSection on Practice of Medicine offered a
resohition, that the President appoint three dele-
gates to attend the Convention to revise the Phar-
macopoeia, which meets in May, 1890. This was
adopted.

The Association adjourned until Friday at
10 A.M.

Fourth Day, JxmE 28.

The President called the Association to order
at 10 A.M.

Prayer was made by Rev. D. A. Jordan.

Dr. Storer in making the final annotmcements,
took occasion to thank the Association for the
many kindnesses they had shown the committee.

The Permanent Secretary read the. report of the
Librarian, which will appear in a future issue,
with a recommendation that the usual appropria-
tion of $10 be made for the Index Mcdicus.

On motion of Dr. Davis the report was ac-
cepted and the appropriation was made.

The Address on State Medicine was then de-
livered by Dr. W, H. Welch, of Maryland. (See
page 73.)

On motion of Dr. J. B. Hamilton the address
was referred for publication, with thanks to the
author for his verj' able, instructive and entertain-
ing paper.

The President appointed as the committee to con-
fer with the Social Science Association Drs. C. G.
Comegys, Ohio ; J. B. Hamilton, U. S. Marine-
Hospital Service, and A. M. Owen, Marjdand.

By request of the Section on State Medicine
the Committee on Foeticide was discharged.

The President appointed as the committee to
confer with the American Pharmaceutical As-
sociation : Drs. G. E. Frothingham, Mich.; J. C.
Culbertson, Ohio; Frank Woodbury, Pa.; Isaac
N. Love, Mo.; F. C. Shattuck, Mass.

As the delegates to the Convention for revision
of the Pharmacopoeia: Drs. H. A. Hare, Pa.;
N. S, Davis, Jr., 111.; Elmer Lee, Mo,

Dr. X. C. Scott, Ohio, ofiered an amendment to
the By-laws abolishing the Committee on State
Medicine inasmuch as the Section on State Med-
icine occupies the entire ground.

This will lie over till next j-ear.

On motion of Dr. N. S. Davis, the President
was requested to appoint a committee to take
charge of the procuring excursion rates, and to
select the most feasible route to the Tenth Interna-
tional Medical Congress in Berlin. Committee :
Drs. W. H. Pancoast, Pa., J. B. Hamilton, D. C,
A. N. Bell, N. Y., A. H. Beidler, Md.; N. S.
Davis, 111.

The Permanent Secretary read the following
names as appointed to attend the British Medical
Association in Etirope during 1889 : Drs. A. J.
Fuller, Me.; E. Cutter, N. Y.; P. O. Hooper,
Ark.; J. H. Knight, Ct.; I. N. Love, Mo.; J. M.
Mathews, Ky.; W. C. Wile, Ct.; W. F. Hutch-
inson, R. I.; A. N. Owen, Ind,; I, N. Quimby,
N. J.; J. W. Jackson, Mo.; F. J. Lutz, Mo.; S.
E, Solly, Col.; J. F. Noyes, Mich.; J. M. French,
Ohio; A. Segur, N. Y. ; D. A. Hengst, Pa.; J.
Taber Johnson, D. C; R. H. Plummer, Cal.

To the Canadian Medical Association, Dr. P.
S. Conner, Ohio.

I04

DOMESTIC CORRESPONDENCE.

[July 20,

To the International Medical Congress to be
lield in Berlin in 1890: Drs. J. B. Hamilton, D.
C; J. F. Noyes, Mich.; F. Woodburj-, Pa.; W.
W. Keen, Pa.; A. J. Fuller, Me.; E. Cutter, N.
Y.; X. C. Scott, Ohio; W. H, Pancoast, Pa.;
W. F. Waugh, Pa.: E. H. M. Sell, Pa.; J. Taber
Johnson, D. C; J. M. French, Ohio; N. S. Davis,
111. ; A. P. Clarke, Mass. ; Chas. S. Wood, N. Y. ;
A. H. \Vilso;i, Mass.; James Collins, Pa.; R. H.
Plummer, Cal.

On motion of Dr. J. B. Hamilton, it was re-
solved that the American Medical Association
hereby expresses its profound sympathj- with the
unfortunate citizens of the city of Johnstown, Pa.
and vicinit}', and especially with the members of
our profession therein residing, and that as a
mark of our sympathy the treasurer be instructed
to remit the dues for the ensuing year of any
member of this Association living in said place.

Dr. J. M. Toner submitted his report as Chair-
man of the Committee on Necrology.

OFFICERS OF SECTIONS.

The Sections reported their officers as follows :

Practice of Medichic, etc. — J. H. Musser, Pa.,
Chairman ; H. McColl, Mich., Secretary-.

Surgay and Anatomy. — B. A. Watson, N. J.,
Chairman; J. B. Deaver, Pa., Secretarj\

Obstetrics and Diseases of Women. — W. W.
Potter, N. Y., Chairman; J. Hoffman, Pa., Sec-
retary.

State Medicine.— lo^^ B. Hamilton, D. C,
Chairman ; F. S. Bascum, Utah, Secretary.

Ophtlialmology. — S. C. Ayres, Ohio, Chairman;
E. J. Gardner, 111., Secretary.

Laryngology and Otology. — ^John O. Roe, N. Y.,
Chairman ; Frank H. Potter, N. Y., Secretary,

Diseases of Children. — Isaac N. Love, Mo.,
Chairman ; E. F. Brush, N. Y., Secretarj-.

Medical fiirispnidence. — T. B. Evans, Md.,
Chairman ; L. Crothers, Ct., Secretary.

Dermatology and Svphilography. — I, E. Atkin-
son, Md., Chairman;' W. T. Co'rlett, Ohio, Sec-
retary.

Oral and Dental Surgery. — ^J. L. Williams,
Mass., Chairman; E.S.Talbot, 111., Secretarj-.

W. B. Atkinson, M.D., Secretary.

Dear Sir : — It is with great regret that I am compelled
to decline the office of Chairman to the Section of Der-
matology and Sj'philography to which I have been elect-
ed. Deeply grateful for the high honor paid me by the
Section, I remain, your very obedient servant,

June 27, 1S89. ' I. E. .'\TKiNSON.

Several Sections reported their minutes and
papers, which were referred to the Trustees for
publication.

On motion of Dr. W. L. Schenck, it was

Resolved, That the thanks of the .Association are ten-
dered to Dr. n. R. Storer, Chairman, and the members
of the Committee of Arrangements ; to the Profession of
Newport and of Rhoile Island for the courtesies so lib-
erally extended during the session ; to His Honor, Mayor
Thomas Coggeshall, and the City Council ; to Rev. Dr.

Thayer, Right Rev. Bishop Clark, Rev. Jas. Coyle, and
Rev. D. .\. Jordan ; the Trustees of the Newport Hos-
pital ; the Newport Historical Societj- ; the Redwood Li-
brary ; the People's Library ; the Rev. Rabbi Mendes ;
the Trustees of the Chauning Memorial Church ; Mr. H.
Bull, Jr., for the use of the Opera House : the Business
Meu's Association ; Capt. J. Waters, Asst. Sup't Third
Life Saving Station ; Commander C. F. Goodrich, U. S.
Navy ; Commander F. J. Higginsou, U. S. Nav}' ; Col.
John Meudenhall, U. S. Army ; to His Excellency, Her-
bert W. Ladd, Governor of Rhode Island ; the Rhode
Island Medical Society ; Hon. Geo. Bancroft, who gave
400 roses for every lady accompanying the delegates ; the
Medical Faculty of Harvard University : and to Lewis
Brown, the Postmaster of Newport.

Dr. W, H. Pancoast offered a vote of thanks to
Sir James Grant, M,D., of Canada, for his admira-
ble address and desire to express our pleasure in
having him with us. We will always welcome
cordialh- our British Medical brethren.

This was carried by a rising vote.

Sir James Grant replied to the sentiment.

The President elect having been called awaj',
his installation was necessarily postponed.

President Dawson then arose and declared the
Association adjourned to meet in Nashville, the
third Tuesdaj- in May, 1890,

W. B. Atkinson,

Permanent Secretars'.

DOMESTIC CORRESPONDENCE.

LETTER FROM IsT:W YORK.

(from our own correspoxdext.)

Dr. facobi reads some Azotes on the Baking of
Bacilli, at the Academy of Medicine — Dr. fohn C.
Peters reports for the Committee on Croton Wafer
Nuisances — Mr. R. H. Robertson exhibits and de-
scribes the plans of the New Academy Building — ■
CommeJicement Exercises at the College of Physi-
cians and Surgeotis — The Presidency of the Board
of Health— The Election of Dr. E. M. Moore, of
Rochester, N. Y., as President of the American
Medical Association, received with enthusiastn.

It was not expected that there would be any
scientific exercises at the last meeting of the
Academy of Medicine before the summer vaca-
tion, but on account of special circumstances and
the importance of the subject. Dr. Jacobi was
given the privilege of reading some "Notes on
the Baking of Bacilli." It will perhaps be re-
membered, in this connection, that a few months
ago Dr. Louis Weigert's hot air inhalation appa-
ratus was exhibited at a meeting of the Section
on Practice of the Academy, and a very rose-col-
ored accotnit given of the wonders accomplished
by it. Having stated that of late the inhalation
of drj- hot air in pulmonar>- tuberculosis had at-
tracted considerable attention. Dr. Jacobi made
some remarks stronglj' condemnator\- of all pat-

1889.]

DOMESTIC CORRESPONDENCE.

105

€nteci apparatuses and processes in medicine; and
then went on to say that Weigert's apparatus,
which has been patented, was quite imperfect in
its mechanical construction and, in addition to
its other objections, was sold at a very high price.

He stated that the attention of the profession
was first directed to the use of drj- hot air in !
phthisis b3' Dr. Louis Halter, in an article pub-
lished in two numbers of the Berliner Kliiiische
Woclicnschrift m September, 188S, and accompa-
nied hy a representation of an apparatus which
he had devised. Halter's attention was first drawn
to the matter by the exemption of lime-kiln work-
ers from tuberculosis, and his obser\-ations, ex-
tending over a period of fifteen j-ears, were made
in Westphalia, where this disease was very prev-
alent among the general population. The air
about the ovens is quite Axy and verj' hot, the
thermometer usualh' ranging from 122° to 158° F.
Such air must, therefore, be for the most part free
from tubercle bacilli, which, as is well known,
perish at a temperature of from 140° to 149° F.
The air about the lime-kilns is also greatly rare-
fied, and it has the eifect in the case of newcomers
of increasing the body temperature 2.5^ above the
normal, while the pulse is raised to 120 to 160,
and the respiration to 20 to 80. Old hands, how-
ever, perspire \Qxy freely, and feel perfectlj- well.

Another paper on the inhalation of dry hot air
in phthisis was also published in the Berliner
Klinische Wochenschrtft in September, 18SS, by
Dr. E. Krull, and this was also accompanied by
a representation of an apparatus devised bj- the
author. It was not until December of the same
year that Dr. Louis Weigert published an account
of his apparatus in the New York Medical Record,
and in his communication he made no mention
whatever of the articles of Drs. Halter and Krull.
About the same time he also exploited his appa-
tus in the public press, proclaiming himself wor-
thy to be considered the equal of Koch by reason
of his great invention, by means of which con-
sumption was entirel)- curable.

Dr. Jacobi then went on to say that he had ex-
perimented with the Weigert apparatus to a con-
siderable extent in his wards at Bellevue Hospital,
and that the results had not been at all satisfac-
tory'. It was true that, in manj- of the cases,
more or less improvement was noted while it was
being used; but it was a well established fact that
everj- patient coming to the hospital with phthisis,
except the disease is in its last stages, improves
for a time after entrance, on account of the nutri-
tious diet, rest, freedom from care, etc. He found
by repeated obser\'ations that the temperature of
the air to be inhaled from the apparatus was al-
ways many degrees cooler Xyy the time it had
passed through .the tube conveying it to the
mouth of the patient than it was when it left the
cylinder where it was heated. In addition, the
temperature of the air was further reduced in the

pharynx and trachea, and when the proportion-
ately small amount remaining finally reached the
great volume of the blood and was diffused over
the extended surface of the lungs, it was still
more cooled down. In fact, the expired air was
warmer than the inspired air. When it was re-
membered, furthermore, that the bacilli were lo-
cated and multiplied deep in the tissues, it seemed
hardlj- probable that they were disturbed at all ;
and it was not even likeh- that the soft lung tissue
could be heated above normal, while neither the
pulse or the general temperature of the bod^-
showed any alteration. It was evident, therefore,
that in order to destroy the bacilli something more
was required than the inhalation of hot air in an
ordinan,' room. The temperature of the apart-
ment in which the inhalations were given ought
to be at least 108°. The men working at the
lime-kilns mentioned by Halter were subjected to
a temperature varj'ing from from 106° to 158°.

Both the hot inhalations and the hot room, Dr.
Jacobi said in conclusion, would find their contra-
indications in all cases where the patients were
weak or liable to hsemoptysis, and could onlj- be
emploj-ed with safety, therefore, where the patient
was comparatively robust. He believed, conse-
quently, that this method of treatment should be
resorted to only in the verj- earliest stage of phthis-
is. In the cases in which he had used the hot in-
halations, other causes, as he had mentioned,
would account for the improvement where an)'
improvement was noted. In a few he found it
difficult to control the cough excited by the treat-
ment, and in two instances it caused so much vom-
iting, with other disagreeable S3-mptoms, that the
patients were decidedly relieved by the discontinu-
ance of the inhalations.

Dr. John C. Peters, chairman of a committee
appointed at the last meeting in regard to Croton
water nuisances, reported that the committee had
made an earnest appeal to the Department of
Public Works, which, it seems, is legally respon-
sible in the matter, for the prompt suppression of
all nuisances existing along the Croton water
shed. The inhabitants of a considerable part of
three counties are apparently' constantly engaged
in polluting the water-supply of New York, and
attention has been emphaticallj' directed to the
abuse in the report published b}' the State Board
of Health last winter ; a thorough investigation
having been made during the latter part of last
year, in response to an application by Mayor Hew-
itt to this Board.

A similar investigation was made in behalf of
the City Board of Health in 1884. There was
much discussion at that time as to what should
be done about the matter, and legislation has
since been obtained to enable the public authori-
ties to put a stop to the nuisances. It was not
reassuring to find, when the result of the inves-
tigation of the State Board of Health was pub-

io6

DOMESTIC CORRESPONDENCE.

[July 20,

lished, that the nuisance was not only unabated,
but had gone on steadily increasing with the
growth of villages, the multiplication of summer
resorts, and the increase in industries in the val-
leys of the Croton district. Where Mr. Lucas,
who made the former investigation, found 1,879
houses draining into the streams which fed the
Croton in 1884, Mr, Brown, the engineer for the
State Board of Health, found 2,843 i" 1888.
Barns and barnyards have also multiplied, and
the refuse of a growing population and an in-
creasing number of domestic animals, together
with the foul waste of mills and factories, is
poured into the Croton water in a constantly
swelling volume.

The State Board of Health followed its inves-
tigation bj^ formulating ' ' Rules and Regulations
for the Sanitary' Protection of the Croton River
and its Tributaries, " but as it had no legal au-
thority to enforce these rules, nothing whatever
has been done about the abatement of the nui-
sance. A determined effort is therefore to be
made to induce the Commissioner of Public
Works, who alone, under the existing laws, has
the power to do so, to take such action as will
remove the present sources of pollution and keep
the water-suppl}' pure in the future.

On this occasion Mr. R. H. Robertson, the
architect, who, by the way, is a son-in-law of
Prof. T. M. Markoe, exhibited and described the
plans of the new Academy building, which is to
occupy a lot 75 feet wide and 100 feet in depth on
Forty-third St., near Fifth Avenue. It will be
five stories in height, with a gable story, and is
to be constructed of brick and a handsome red-
dish-brown stone known as Longmeadow stone.
On the first floor in front are to be a smoking-
room 36 by 26 feet and other smaller rooms, and
in the rear the large assembh- room, 57 by 42
feet, and a handsome dining-room, 31 by 26 feet.
These two rooms will be separated by a rolling
partition, so that they can be thrown into one at
any time when required for large meetings or a
largely attended dinner.' One and a half stories
will be taken up by this part of the building, and
the rooms will be 26 feet in height. The half-
storj' in front, 1 1 feet in height, is to be used for
committee-rooms, etc. On the next floor will be
the reference librarj- and the stack-room, occup}'-
ing a story and a half, with three reading-rooms,
of le.ss height, in front. The full capacity of the
stack-room will be for 230,000 volumes, to accom-
modate which there will eventuallj- be three tiers
of stacks. At first, however, but a single tier
will be required by the library. The next floor
will be taken up by four section rooms, each with
an anteroom and .specimen or apparatus room,
and accommodating respectively 160, 225, 225
and no persons. In the top ston,-, which will
not extend over the entire area of the building, •
will be a microscope room and librarian's apart-

ments, and the rest of the space will be devoted
to an open deck, which will probably be fitted
up as a summer garden. After the meeting there
was a social reunion, with a collation, and the
loving cup was pas.sed merrily around.

At the recent Commencement of the College of
Physicians and Surgeons the graduating class
numbered 166, the largest in the historj' of the
College. Professor James W. McLane, through
whose instrumentality the munificent gifts of the
Vanderbilts to the institution were mainly secured,
has been selected for the Presidencj^, made vacant
b}- the death of the lamented Dalton, and Prof.
T, M. Markoe appointed Vice-President of the
College.

Much indignation was felt by the profession at
the appointment by Mayor Grant, a short time
since, to the Presidency of the Board of Health,
of Mr. Charles G. Wilson, a man without expe-
rience and, so far as known, utterly without
knowledge in sanitarj' matters, in the place of
Mr. Bayles, an expert, and one who has filled the
duties of the position in the most admirable man-
ner. This feeling found voice in a resolution in-
troduced at a recent meeting of the Academy of
Medicine by Dr. Walter Mendelson, to the effect
that, in the opinion of the Academy, the appoint-
ment to the Presidency of the Board of Health of
any one not specially qualified is fraught with
possibilities of the gravest danger to the public
health ; and furthermore, that the Academy, hav-
ing at heart the public good, urges the Mayor to
reconsider the appointment and, after due con-
sultation with those acquainted with the duties of
the office, make a new appointment better suited
to the important nature of the department.

In the preamble it is set forth that the Board
of Health is a department of the City Govern-
ment in which every member of the community
is most personally and vitally interested, and one
where it is absolutely necessary for true efficiency
that the presiding officer be acquainted with san-
itary science and have a knowledge of the laws
of health and of disease ; that the medical pro-
fession, as guardian of the health of the commu-
nitj', is being brought into daily contact with the
workings of the Board of Health, and therefore
especially interested in its eflSciency ; and that the
Mayor of the City of New York has appointed to
the Presidency of the Board one whose previous
experience nowise justifies the belief that he is at
all fitted to assume the grave responsibilities of
the office intrusted to him.

It was deemed best before submitting the reso-
lution to the vote of the Academy, that it should
be referred to the Council for mature considera-
tion, and therefore no definite action will probably
be taken in the matter before autumn. There is,
however, a growing feeling that the possibility of
the appointment of an utterly incompetent Presi-
dent of the Health Department of a city like New

1889.]

MISCELLANY.

1 07

York is an outrage upon the community, and it
is probable that urgent efforts will be made to in-
duce the next Legislature to amend the present
law in such a way that no one can be appointed
to this position who is not a doctor of medicine
or an expert in sanitary science. As the law now
stands, strangely enough, no physician is eligible
to the Presidency, and the great medical profes-
sion of New York is entitled to but one represent-
ative as Commissioner in the Board of Health; so
that our medical men feel that it is time that they
should claim some right to proper recognition in
a body with which their profession has so much
to do and with the interests of which it is so
closely identified.

The election of Dr. E. M. Moore, of Rochester,
as President of the American Medical Association
meets with much enthusiasm here, and, aside from
the fact that nowhere in the profession could there
be found one more eminentlj' qualified by natural
gifts and special culture to fill the position with
dignity and grace, it is felt that the selection is in
some sense a recognition of the loyalty of that
portion of the New York profession which has
always stood true to the National colors, and of
which Professor Moore is one of the most distin-
guished ornaments. In this connection it may be
stated that the continued prosperity of our State
Association, of which Dr. Moore was the second
President, is suflBcientlj' attested by the last ex-
cellent volume of Transactions, recently issued
under the admirable editorship of Dr. Carroll ;
while the New York County Medical Association
has never been so flourishing as at present, about
a hundred new members, including man}' promi-
nent physicians, having been added within the
last four months. p. b. p.

MISCELLANY.

Dr. John S. Billings and the Eleventh Census.
— Through an oversight the followingcircular to the pro-
fession, issued by the Superintendent of the Eleventh
Census, was omitted at the proper date. The attention
of our readers is especially directed to the instructions
contained therein: "The various medical associations
and the medical profession will be glad to learn that Dr.
John S- Billings, Surgeon U. S. Army, has consented to
take charge of the Report on the Mortality and Vital
Statistics of the United States as returned by the eleventh
census. As the United States has no system of registra-
tion of vital statistics, such as is relied upon by other
civilized nations for the purpose of ascertaining the ac-
tual movement of population, our census affords the only
opportunity of obtaining near an approximate estimate
of the birth and death rates of much the larger portion
of the countr}-, which is entirely unprovided with an}-
satisfactory system of State and municipal registration.
In view of this, the Census Office, during the month of
Ma}', this \'ear, will issue to the medical profession
throughout the country- ' Physicians' Registers ' for the
purpose of obtaining more accurate returns of deaths
than it is possible for the enumerators to make. It is

earnestly hoped that physicians in every part of the
country- will cooperate with the Census Office in this im-
portant work. The record should be kept from June i,
1S89, to May 31, 1S90. Nearly 26,000 of these registra-
tion books were filled up and returned to the office in
1880, and nearly all of them used for statistical purposes.
It is hoped that double this number will be obtained for
the eleventh census. Physicians not receiving registers
can obtain them by sending their names and addresses to
the Census Office, and, with the register, an official en-
velope which requires no stamp will be provided for
their return to Washington. If all medical and surgical
practitioners throughout the country will lend their aid,
the mortality- and vital statistics of the eleventh census
will be more comprehensive and complete than they have
ever been. Ey-ery physician should take a personal pride
in having this report as full and accurate as it is possible
to make it. It is hereby promised that all information
obtained through this source will be held strictly confi-
dential. Roberts. Porter, Sup't of Census.

Medical Society of Virginia. — The twentieth an-
nual session of this Society yvill convene in Roanoke, Va.,
Tuesday, Sept. 3, 1S89, at 8 p.m. Special attention is
called to the following resolution adopted 1884 :

"Resolved, That the Secretary be instructed to send
out a notice to each member of the Societj- two months
in ady-ance of tlie day of meeting calling for the titles of
any papers to be read before the Society — said titles to be
returned to the Secretary at least five yveeks before the
day of session — failure in which will relegate any papers
to the last day of the session ; that the Secretary shall
classify- such titles according to subjects, and, in publish-
ing his programme, assign all papers on or pertaining to
the same classification (such as Surgerj-, Diseases of
Women, etc.) to be read the same day, specifying the
day, yvith a limit of one-half hour to each paper; and fif-
teen minutes for each discussion, unless this time is ex-
tended by a two-thirds vote of those present."

The subject for general discussion is " Croupous Pneu-
monia," Dr. B. L. Winston, of Hanover C. H., Va.,
Leader. Parties preparing papers on this subject should
notify the Secretary. Circular announcement yvill be is-
sued about a month hence. Send applications for Fellow-
ship, with name and post-office in full, name of college,
and date of graduation in medicine, date of passing ex-
amination successfully' before Medical Examining Board
of Virginia, name of a Felloyv yvho recommends the ap-
plicant, and ;y2.oo initiation fee, to the Recording Secre-
tary, Landon B. Edyvards, M.D., Richmond, Va.

The Medico-Legal Society has issued the following
circular:

New York, June 20, 1SS9.

Dear Sir: — The recent session of the International
Congress of Medical Jurisprudence was successful bey-ond
the most sanguine expectations of its promoters. It per-
fected a permanent organization and provided for the se-
lection of an additional Vice-President from each State
and Territory of the American Union, and from each for-
eign province. State and country who had members in
the organization who took an interest in the success of
the movement.

Future meetings were authorized to be called by the
executive officers, a list of yyhom is hereyvith sent you.

The expenses of publishing all the papers read at this
Congress, w-ith a record of its transactions and the pro-
ceedings at the banquet, will fill a large volume, the ex-
pense of which it is estimated yvill be about f 700. The
executive officers were authorized to elect additional
members into the organization, the only expense of
which is the enrolling fee of $3, which entitles the mem-
bers to the Bulletin free.

Will you unite in this movement with a view of mak-
ing it International, and will you suggest a suitable name
for Vice-President from your State, Territory, province

io8

MISCELLANY.

[July 20, 1889.

or country. If this effort is received with favor by the
members of the Medico-Legal Society, active, corres-
ponding and honorary alone, without counting others, it
will at once provide for the publication of the transactions
and the papers read before the Congress, and lay on firm
and sure foundations the International work of promot-
ing the advancement of medical jurisprudence, not alone
in the United States of America, but throughout the civ-
ilized world.

Your cooperation in this effort is earnestly solicited in
your locality, and \-our name will be laid before the ex-
ecutive officers for enrollment as a member on receipt of
the enrolling fee, which can be sent to any officer of the
body.

The officers elected by the Congress, held June 4 to 7,
18S9, in New York, were as follows: President — Clark
Bel], Esq., of New York. Vice-Presidents — Chief Justice
Sir John C. Allen, of New Brunswick; Chief Justice Ed-
ward F. Bermudez, of Louisiana; Dr. Bettincourt Rodri-
gues, for Portugal; Gov. Biggs, of Delaware; Dr. Daniel
Clark, of Toronto, Canada; Ex-Chief Justice Noah Da-
vis, of New York; Dr. Edward J. Doering, of Illinois;
Prof John J. Elwell, of Ohio; Judge W. H. Francis, of
Dakota Ter.; Dr. W. W. Gedding, of Washington, D. C;
Dr. Eugene Gris.som, of North Carolina; Dr. Carl H.
Horsch, of New Hampshire; Judge Locke E. Houston,
of Mississippi; Dr. Charles H. Hughes, of Missouri; Dr.
W. W. Ireland, of Scotland; Prof Robt. C. Kedzie, of
Michigan; Dr. Norman Kerr, of England; Dr. Jules Mo-
rel, of Belgium; Dr. Jennie McCowen, of Iowa; Dr. Con-
nolly Norman, of Ireland; Prof John J. Reese, of Penn-
sylvania; Judge H. M. Somerville, of Alabama; David
S'tewart, Esq., of Maryland; Theo. H. Tyndale, Esq., of
Massachusetts. Secretary — Moritz Ellinger, Esq., of New
York. Assistant Secretaries — Dr. Frank H. Ingram, of
New York; Dr. Wm. J. Lewis, of Connecticut; J. F. Wal-
ters, of New York.

The President was empowered and directed bv the Con-
gress to appoint additional Vice-Presidents for the vari-
ous States, Territories, provinces and countries, which
will be done during the summer vacation. Members of
the Congress receiWng this circular, who have not sent
their enrolling fee, will please do so, and circulate this
among those who take an interest in the science.

Your earlj- response is requested to either of the under-
signed. Clark Bell, President,

Moritz Ellinger, 57 Broadway, New York.

Surrogate's Office, New York City.

Mississippi Valley Medical Association. — At a
meeting of the General Committee, at Newport, it was
decided to change the date of meeting of this .Association
to September 10, 11, and 12, 1889. This promises to be
the largest and most interesting meeting in the history of
this Association. A large attendance of representative
men from all parts of the United States has been as-
sured.

LETTERS RECEIVED.

Dr. O. D. Haven, .-Mleghenv, Pa.: Dr. Henrv W. Elmer,
Bridgeton, N. J.; E. M. DePuv, Washington; Dr. S. L.
Holley, Nanticoke, Pa.; Dr. C' Park, Oquakee, 111.; Dr.
F. B. Schulz, Cape Girardeau. Mo. ; Jerome Kidder Mfg.
Co., New York, Dr. C. A. Harvev, New York; Dr. Rich-
ard J. Dunglison, Philadelphia; Dr. J. A. Dibrell, Jr., Lit-
tle Rock, Ark.; Dr. W. N. Miller. Pittsburgh, Pa.; Dr.
Charles Disen, Minneapolis, Minn.; Dr. W. VanHook,
Chicago; Dr. I. H. Ellis, Bethany, Mo.; Malted Milk Co.,
Racine, Wis.; Dr. James E. Morgan, Washington; Dr.
Wm. C. Dabney. White Sulphur Spriugs, Kv. ; Dr. Joseph
Price, Philadelphia: Dr. N. P. Daudridge. Cincinn.iti, O.;
W. L. Minter, Louisville, Ky.; Medical Herald Co., St.
Joseph, Mo.; Dr. G. K. Dickinson, Jersev Citv, N. J.; J.
F. Widman, McGregor, la.; Dr. J. F. Page, Powersville,

Mo.; Dr. Thos. Cosgrove, Auburndale, O.; Dr. F. G. Al-
bright, Lancaster, Pa.; Dr. W. H. Landis, Woodland,
Mich.; Dr. G. W. H. Kemper, Muncie, Ind.; Dr. Horace
M. Starkey, Chicago; Dr. J. C. Hoag, Chicago; Galvano
Faradic Mfg. Co., New York; Dr. G. R. Wells, Gold
Hill, Col.; Dr. A. L. Hummel, Philadelphia; Dr. J. W.
Long, Bryan, O.; Dr. J. T. Jelks, Hot Springs, Ark.; Dr.,
A. P. Brown, Fort Worth, Tex. ; Dr. Joseph Eastman,'
Indianapolis, Ind.; Dr. David Barrow, Lexington, Kv.;
Dr. J. B. Murdoch, Pittsburgh, Pa.; G. H. Mitcheir&
Co., Cedar Rapids, la.; Dr. W. T. Lusk, Brooklyn, N. Y.;
Dr. A. M. Owen, Evansville, Ind.; Fred. D. Van Horen,
New York; Dr. Gersham H. Hill, Independence, la.; Dr.
H. R. Storer, Newport, R. I.; Dr. Albert F. Stifel, Wheel-
ing, W. Va.; Dr. W. I. Haddens, St. Joseph, Mo.; Pub-
lishers' Commercial L'nion, Chicago; Dr. A. R. Stewart,
Toledo, O.; Dr. J. G. Truax, New- York; Dr. G. F. Smolt,
Nickerson, Kan.; Dr. J. W. Muenich, Jefferson, Wis.

Official List of Changes in the Stations and Duties of
Officers Serving in the Medical Department, U. S.
Army, from July 6, i88g, to July 12, iSSg.

By direction of the acting Secretary of War, the retire-
ment from active service this date, by operation of law,
of Col. Thomas A. McParlin, Surgeon, under the pro-
visions of the Act of Congress approved June 30, 18S2,
is announced. Col. McParlin will repair to his home.
Par. 2, S. O. 157, A. G. O., July 10, 1889.

Major H. O. Perley, Asst. Surgeon U. S. Army, is or-
dered to accompany troops from Ft. Wayne, Mich., to
Gognac Lake, Mich., to encamp there with the Michi-
gan State troops from August S to 13, 1889. Par. i, S.
O. 154, Hdqrs. Div. of the Atlantic, July 9, 1889.

Capt. H. O. Perley, Asst. Surgeon U. S. .A.'rmy, is granted
fourteen days' leave of absence, to commence about
July 14, 1SS9. Par. 2, S. O. 154, Hdqrs. Div. of the At-
lantic, July 14, 1889.

Col. Andrew K. Smith, Surgeon U. S. Armj-, promoted
to Surgeon with rank of Colonel, to rank from JUI3' 10,
1889. Vice McParlin, retired.

Lieut. -Col. Francis L. Town, Surgeon U. S. Army, pro-
moted Surgeon, wtth rank of Lieut-Colonel, to rank
from July lo, 1SS9. Vice A. K. Smith, promoted.

Capt. W. C. Gorgas, Asst. Surgeon, is granted leave 01
absence for one month, to take effect on the arrival of
a medical officer to relieve him. Par. 2, S. O. 84,
Hdqrs. Dept. of the Missouri, July 3, 18S9.

By direction of the Secretary of War, Capt. Andrew V.
Cherbonnier, Medical Storekeeper, will, in addition to
his present duties, take charge of the office and per-
form the duties of acting Assistant Medical Pur^-eyor
in St. Louis, Mo., during the absence of Capt. George
T. Beall, Medical Storekeeper. Par. 2, S. O. 151, A.
G. O., Julv 2, 1889.

Official List of Changes in the Medical Corps of the U. S.
Naiyfor the Week Ending July /j, iSSg.

Asst. Surgeon S. Stuart White, ordered to the Naval
Hospital, Brooklyn, N. Y.

Medical Inspector C. H. White, detached from the
" Trenton " and wait orders.

P. A. Surgeon Ernest Norfleet, detached from the " Tren-
ton," and to the "Monocacy."

P. A. Surgeon H. E. Ames, detached from the " Mono-
cacy, proceed home and wait orders.

Snrgeon G. E. H. Harmon, detached from the "Constel-
lation " and to the Naval .Academy.

Asst. Surgeon C. H. T. Lowndes, detached from the
" Constellation " and to the Naval Academy.

Surgeon H. P. Harvey, detached from the " Vandalia "
July 7, proceed home and wait orders.

Asst. Surgeon S. Stuart White, detached from the "Tren-
ton July 7, 18S9.

/07

THE

Journal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.
PUBLISHED WEEKLY.

Vol. XIII.

CHICAGO, JULY 27, 1889.

No. 4.

ORIGINAL ARTICLES.

THE TREATMENT OF SALPINGO-
OVARITIS BY ELECTRICITY.

Being a paper prepared for the Gynecological Section of the A nierican

Medical Association Meeting at Ne'u*port,Jiinc zj, 18S9.

BY GEORGE APOSTOLI, M.D.,

OF PARIS.

The electrical treatment of fibroma which I
originated has made great strides despite the rail-
ings of charlatans and incompetent persons ; it
is not necessary- to refer to this subject again, be-
cause it is a child that will grow of itself, and is
amply able to take care of itself. To-day I in-
vite your attention to a subject of equal inter-
est, I mean the treatment by electricity of sal-
pingo-ovaritis, and I sincerely hope that it maj-
have the same useful future, more restricted per-
haps, because at present it is restricted to a cer-
tain number of cases, but in any case worthy of
^•our consideration.

Salpingo-ovaritis is a disease which has long
been recognized, but under names which I have
changed verj- often : Phlegmon, pclvic-pcri-
loni/is, lymphangitis, adcno-lymphangitis, cellu-
litis, peri-mctritis, para- metritis, peri- uterine,
phlegmasia, etc.; all of these titles being used to
picture a disease originating in the lymphatics,
in the cellular tissue, or in the peritoneum, ac-
cording to the special pathological views of the
individual describing the malady. Laparotomy'
had the advantage of fixing the diagnosis pre-
cisely, by demonstrating that lesions of the ovarj-
and of the tube were almost constant factors, and
that these inflammations almost always took
origin in the lining membrane of the uterus, and
from there spread to the adnexa, the cellular tis-
sue, and the peritoneum. At the commencement
of my practice I fell into the common pathological
error, which I hasten to correct to-day : But one
fact is beyond dispute, and that is that the condi-
tions which I then treated 2.^ phlegmon, and peri-
mctritis, and which concealed a salpingo-ovaritis,
does not militate in the least against mj- claim to
priority in the electrical handling of the disease
under discussion.

Since 1882 I have treated all cases that come to
my clinic by electricity, whether sufiTering from

tumors, from endometritis, or peri-uterine phleg-
masia. Look for a moment at the thesis of my
assistant, Dr. L. Carlet, which appeared in July,
1884,' and which I myself revised thoroughly :
"One pole (the negative) is X.h.2X_oi dentil? ition
par excellence : it is suitable, therefore, not only
for tumors, but for sub-acute peri-uterine inflam-
mations (circumscribed), without fever, which are
connected with the uterus, and which considera-
bly disturb its functions," Farther on, j-ou maj-
read with profit the clinical histories of twenty
cases' of peri-uterine phlegmasia, complicating
uterine tumors, which were treated with electric-
itj\ I quote as follows, (page 1 10) . " This ob-
ser\-ation is of the greatest importance, because it
shows the value of intra-uterine galvano-caustique
in moderate doses, in causing a resolution of sub-
acute peri-metritis. ' ' Further on I wrote : ' 'This
obser\-ation (page 117) should be of great impor-
tance, since it shows, first, that intra-uterine gal-
vano-caustique, badh- done, or made undulj- pain-
ful, may set up multiple accidents, and here, the
peri- uterine phlegmasia is clearly due to the last
application. On the other hand, this obser\-ation
also proves, that hysterometry, badly done, is
dangerous, but when well done is never so, even
in the sub-acute stage of peri-uterine phlegmasia;
this same malady, indeed, has been treated with
uterine faradization (that is by another form of
hysterometry), during the convalescent stage of a
phlegmon of the broad ligament, which resulted
in a complete cessation of symptoms after a very
short treatment."

From 1884 to 1887, my experience has enlarged
coincidentlj- with greater skill, boldness in oper-
ating, and at the Dublin Congress (August,
1887), I discussed the question under an entirely
new caption. (See Bulletin general de Thera-
pl'utique, of September 30, 1887, and British Med-
ical Journal, of November 19, 1887). To-da3' the
names have changed, but the ideas are the same,
and I propose giving jou the results of my
electrical treatment. I shall speak no more of
peri-metritis, but of salpingo-ovaritis, whether
complicating a pelvic peritonitis or not. The atti-

1 Du traitement ^lectriqvie des tumeurs fibreuses de Viiterus
d' apres la m^thode du Dr. Apostoli par le Docteur Lucien Carlet.
Pans. Octave Doin. Editeur. 1.SS4.

= See obser\-ations (op. cit.) on pages 74. 81, 85, 94, 108. 114, 120,
123, 124, 151, 169, 196, 205, 214, 216, 225, 227, 232. 236. 241.

no

SALPINGO-OVARITIS.

[JUI.Y 27,

tude of those doctors who occupy different and
opposing ground, is very curious, and may,
briefly, be described as follows : the large number,
following in the footsteps of a wise ancestry,
when confronted with asalpingo-ovaritis, exclaim,
" Do not touch it." They ignore all intra-uterine
interference, relying upon poultices and revulsives.
Their success is variable. The cavity of the
uterus is, for them, a ncili me fangcre, which they
religiously avoid. Others, on the contrary', com-
prising a small number of surgeons, anxious of
statistical fame, open the abdomen of every
woman having an undue sensitiveness of the
adnexa, either for exploration or castration.
Here the abuse cries out for reform, and if under
some circumstances, the ser\'ices of the surgeon
are indispensable, j^et here, one may justly ex-
claim with indignation, that in many cases, surg-
ery, out of selfishness, consigns a woman to a fu-
ture of sterility. The true path, gentlemen, lies
between the two extremes. If on the one hand,
doctors are over-timid, and count too largel}-
upon nature to cure certain diseases, which al-
most never, are spontaneousl}' cured, on the other
hand, surgeons commit a fault quite as repre-
hensible, by hast}- operations ; for we know now
that castration sometimes kills, and does not
always cure, forgetting that, clinically speaking,
these cases are frequently curable by more simple
and conservative means, without causing an irre-
parable physical and moral shock to the woman.
From the very commencement, despite the
prejudice from all sides, my treatment of these
cases has been absolutely and entirelj^ the intra-
uterine electric. This idea, at first theoretic, is
to day a fixed fact, thanks to pathological investi-
gation which demonstrates that almost all cases
of peri-uterine phlegmasia or salpingo-ovaritis,
have their starting point in an endometritis, which
is often the posthumous witness of the secondary
lesion of propagation, cleanse the uterus, make
use of intelligent intra-uterine antisepsis, cure the
endometritis, and provoke healthy intra-uterine
derivation — such are the general considerations
that have guided me on to such results. These
are the reasons why, at the very first, I swept
away the existing prejudices against an interfer-
ence with the uterine cavity, and why I went at
once to the bottom no matter what might be the
extent of the phlegmasia. It is true, I associ-
ated, in this therapeusis, faradization with gal-
vano-chemical caustique. Faradization, in the
form of a current of tension, calms the nervous
S3'stem, diminishes excitability and relieves pain ;
but, of itself, is often insufficient to arrest the
acute phlegmasia. The dynamic action in the
commencement of inflammatory conditions is
purely calmative, and will aid in the resolution of
old exudates. I have associated three orders, of
procedure, which, in inverse order of merit, are
faradism, intra-uterine galvanism and vaginal j

peripheric galvano-puncture. I will briefly sum
up my views of each.

1. Faradization, under the form of a current
of tension, made by the long thin wire, calms the
nervous system, moderates its excitability, as-
suages or cures pain, but is often powerless to
arrest an acute phlegmasia ; its action is purely
dynamic, and it acts, as opium acts, during earlj-
inflammatory stages, but is powerless to arrest the
evolution of inflammatory processes. The cur-
rent (faradic) of tension is the only one tolerable
and indicated in acute and subacute forms. A
current of quantity is less efficacious and less
tolerable, except in rare cases of chronic exudates
where, in acting upon the interstitial circulation,
it aids reabsorption to a certain extent. The elec-
trode should generally be the bipolar, to better
localize the electric action, either in the vagina
or in the uterus. All other things being equal,
the uterine application is by far the most useful.
The application should be in moderate doses
without shock, and more gentle as the inflamma-
tion is more active. The seances should be daih'
at first, lasting from five to twenty minutes, and
the dose progressiveh* augmented as the patient
can bear it.

2. Galvanization, or rather intra-uterine chem-
ical caustique, is much more powerful than fara-
dization, and will often be sufficient of itself in
cases of ovaro-salpingitis. It is a most excellent
way of changing in part or in whole the entire
lining membrane of the uterus, and of setting up
peripheric changes by derivation. The faradic
current excites the nervous and muscular systems
after the manner of a mechanical force, by inter-
ruptions and shocks. The galvanic current, how-
ever, is a physical and chemical force, at once
caloric and trophic, and brings each of its factors
into action separately or together as desired. All
binarj- compounds and those of greater complica-
tion will tend to decomposition, and this decom-
position, called electrolysis, will be in proportion
to the electric energ}- given out, and to the length
of time of the application. This interstitial
breaking up of the elements, which will be pre-
ceded b}' a different orientation in the polarization
of the organic molecules, tends, on the one hand,
to bring around the positive pole the acids and
oxygen, while the bases and hydrogen go to the
negative pole. This serious molecular action
ought to be sufficient for an intelligent theon,- of
the effects of the galvanic current, but recent ex-
periments which we have made place these facts
upon an indisputable basis. My friend Laguer-
riere and myself have found that the galvanic
current sent through culture media of pathogenic
microbes is germicidal , thus confirming what I
said long ago, that this current was antiseptic,
and would attenuate or sferili:e certain conditions
of germ change. Applied in a given region the
galvanic current acts locally and generally ; each

1889.]

SALPINGO-OVARITIS.

Ill

pole has its undivided caustic action — the one
acid, the other basic. The current is felt in the
interpolar zone, engendering trophic changes, and
tending to the resolution of certain pathological
conditions.

The doctor of to-day who has not kept apace
with the advance of gynecological science, lauds
to his utmost the curette, which first saw the light
in France, but has long since fallen into desuetude
in the laud that originated it. Without wishing
to discredit a surgical procedure of value in cer-
tain conditions, the superior advantages of the
intra-uterine galvanic current are beyond dispute.

(a.) It is simple and easj- of application, re-
quiring no assistant, and may be used b\' anj- one,
no matter how little experience he has in gyne-
cology.

(b.) Being but slighth- painful, chloroform is
not needed, this being only demanded in certain
cases of puncture.

(r.) It is valuable among working women, as a
short period of repose alone is necessary- after the
application, instead of hours and perhaps davs in
bed.

(d.) It can be gradually and gentlj- applied bj'
progressively increasing the strength, and is less
brutal than the curette.

(e.) It is not contraindicated in an 3- acute case
of inflammation — the sole caution being to use
extra care, and to increa.se the strength only as
the patient is able to bear it.

( /'.) It is an agent which, instead of being
blind, obeys in a precise and mathematical man-
ner the hand applying it ; that is to say, one can
measure and administer it and at the same time
have an exact record of the amount of cauteriza-
tion produced, to which three things conduce :
the general intensity made use of the densit}'
of the active electrode, and the duration of the
application.

i g-. ) It is an active force, which will produce
an active result localizable at will, and which
may be concentrated upon any part of the uterine
lining membrane desired.

(/;.) It is absolutely harmless if proper antisep-
tic or aseptic precautions are made use of.

(i.) According to the intensit}' and duration its
action can be varied, and also according to the
active pole made use of ; it may be made acid by
using the positive pole, and basic by using the
negative pole.

(/.) Apart from the curetting action of the
chemical galvanism, which one can easil}- see,
there is a more profound action trophic and vital,
and which is propagated along the whole organic
circuit between the two poles. Thanks to this
last consideration, above all in the treatment of
salpingo-ovaritis, this chemical galvanism has a
power far above surgical curetting, chiefly in
reaching the uterine parenchyma and adnexa.

(X-.) If surgical raclage often results in frequent ;

returns of the disease, causing anatomical and
functional troubles which it hoped to combat, I
can aSirm that these results are much less fre-
quent by the electroh-tic treatment, which may
require several seances to produce a lasting effect,
but which good results, as I have had reason to
observe in my clinic, last for manj- years after the
cessation of all treatment.

The operative technique is already- sufiiciently
well explained in my various brochures upon the
electric treatment of fibroma and endometritis. I
shall content mj^self with giving j-ou merelj' the
salient features of the treatment of ovaro-salpin-
gitis. The positive pole always causes less con-
gestion than the negative, but the latter is more
valuable to promote resolution. The positive pole
should be used generally in the commencement,
and once having passed the first stage of tolera-
tion, the negative pole should be substituted. The
dominant preoccupation which should make us
cautious in treating salpingo-ovaritis, and which
is sometimes difficult of recognition, is the fear of
finding ourselves in the presence of a pyosalpinx,
which a large dose of galvanism would aggravate;
so, when in doubt, begin ver\- gentlj- with a mild
current to test the susceptibility of the uterus and
peri-uterine tissues, then increase with the patient's
tolerance and according to clinical indications.
One ma}' begin with 20 to 40 milliamperes. If
the intolerance is great, respect it and do not in-
crease; if well tolerated increase to 100-150 mil-
liamperes. Here clinical diagnosis must be called
in to differentiate between hysterical intolerance,
that need not be heeded, and an inflammatorj' in-
tolerance which must be respected. The sittings
should not be too frequent. In the initial treat-
ments they are frequently followed with a reaction
more or less intense, which ma\' last several Aa\s;
generall}' we should wait until calm is reestab-
lished. Sometimes the seances may be given
once or twice a week, sometimes only every fif-
teen days. The same reasons must guide the
doctor as to the length of a seance ; sometimes
they should last three minutes and sometimes five
to eight minutes.

3. I now come to the third division, the most
efficacious of all, the penetration with the galvanic
current of one of the vaginal cul-de-sacs at the
nearest point of the inflamed region. I mean
vaginal galvano-puticlure. There are two clinical
indications, the one of choice, the other of neces-
sity. The indication of choice presents itself when
one finds himself in presence of a salpingo-ovaritis
which has not been sufficiently' ameliorated bj' the
intra-uterine galvanism. It is necessary then to
penetrate the mass in the point the nearest possi-
ble to the disea.sed spot, in order to lose nothing
of electric force, which now should serioush- con-
cern itself with the suffering point. Theoretically
the application, well made, should be most effica-
cious, and no doubt rests in my mind that such is

112

SALPINGO-OVARITIS.

[July 27,

the case, for the reply of all the patients who have
submitted to this plan is that the punctures were
much more painful but much more efficacious, be-
cause often one puncture gives more relief than
many simple intra-uterine applications. The in-
dication of ?uressi'(r for galvano-puncture is when
a fluctuating tumor impinges upon the vagina,
and which should be drained antiseptically through
the vagina.

Already many years ago I gave the rules for the
essentials of galvano-puncture. I will only now
cite the chief points :

(a.) Here, as in all electrical treatment, be it
faradic or galvanic, one should precede everj-thing
with thorough antisepsis, preceding and following
ever}' operation with an antiseptic vaginal irriga-
tion, either of sublimate, carbolic acid, creoline
or naphthol. Between the seances we will do well
to close the vaginal cavity with iodoform gauze
(or sublimate or salol gauze), to insure perfect
asepsis, as well as to prevent sexual congress,
which should be suspended.

(k) With the preceding electrical treatment it
is not necessar}- to remain in bed. I exact from
my patients only one or two hours of repose after
galvano-caustique, without denying, however,
that a longer period might be beneficial. Galva-
no-puncture, however, requires at least two or
three days of rest in bed after each puncture.

(c.) The trocar carrj-ing the current should be
the smallest possible, but of sufficient resistance
not to be easily broken. Steel is the best, because
it penetrates easily.

(d.) The chief point is the depth of the punc-
ture. A slight puncture of a half centimetre, as
an average, suffices to make a door of entrance for
the current in the region which it is to traverse.
Deeper punctures do not suffice any better to at-
tain such an end; on the contrary, as I have seen,
they ma}' be dangerous. I proscribe all punctures
over I centimetre.

(f.) Where make the puncture ? Questions of
choice and necessity here come up. The choice
is to puncture as near as possible the diseased
portion, but necessity forces us to avoid at all
cost the anterior cul-de-sac on account of the blad-
der. The lateral, and above all the posterior re-
gions are the most favorable for the puncture. I
make them oftenest in the posterior cul-de-sac, in
the middle of the pouch of Douglas, directing the
axis of the instrument toward the uterus in order
to avoid the rectum.

(/.) This operation, much more painful than
galvano-caustique, is often tolerated by certain
women, but in others chloroform will be required.

{g^) I never use a speculum in this operation,
which can only be well and delicately carried out
as follows : One fixes at first the exact length of
the puncture, by turning the screw and advancing
the steel point to the required length beyond the
celluloid, then, having fixed with the index finger

the exact point to be punctured, and having made
sure that there is no arterial pulsation, one slides
the celluloid up to the point, which serves as
the conductor for the trocar, which is then plunged
in.

(A.) The number of punctures demanded is va-
riable. Some cases of hydro- and catarrhal sal-
pingitis 3-ield to one puncture, some require three
or four, and tubercular tubes even more.

Generally these cases require much longer peri-
ods of intermediate repose than cases of galvano-
caustique, because at their commencement they are
often followed b}- a severe reaction, which may
; last many days. The application should not be
\ renewed until all of the symptoms have disap-
peared.

(z.) As to intensity and choice of poles I repeat
what I said just now when speaking of intra-
uterine galvanization. The intensity will var\^
from 20 to 50 milliamperes. To go beyond this
is to go beyond the point of tolerance, and chlo-
roform should be used. To create a temporar\'
vaginal fistula 100 to 250 milliamperes will be
required.

\j.) The puncture should generally be positive
at first, because it is more tolerable and less ex-
citing than the negative. This latter is employed
when a more powerful action is demanded. Es-
pecially in presence of a fluctuating tumor point-
ing into the vagina, in which a fistulous tract is
to be made and vaginal drainage established, is
the negative pole demanded.

(k?) Should febrile excitement arise, all treat-
ment is to be suspended. One may think himself
in the presence of a pyosalpinx, if it points into
the vagina, and a puncture is not contraindicated;
but if it is high up, not accessible, and far from
the vaginal cul-de-sac, a deep puncture, which
might cause an evacuation into the cavity of the
peritoneum of the sac, is to be avoided. It is here
that surgerj- must step in to earn,- out its legiti-
mate functions.

My clinical experience, which is now seven
years old, has given me many cases of salpingo-
ovaritis, which I hope later on to tabulate. I shall
content myself now with some results of my treat-
ment. Every salpingo-ovaritis will generally be
suitable for appropriate electrical treatment, and
this should be the conservative method of choice;
it is sovereign in catarrhal salpingitis, only calm-
ative in tubercular salpingo-ovaritis, and in cer-
tain pus tubes may be of great service. What-
ever electric treatment is made use of, it should
be continued until the patient pronounces herself
cured of her symptoms, and until an examina-
tion has satisfied us that the anatomical change
is considerable. Surgical interference should never
be resorted to until after all electrical resources
have been exhausted. Castration, which morally
and physically mutilates a woman after an incur-
able fashion, and only cures radically in a fourth

1889.]

SALPINGO-OVARITIS.

"3

or fifth part of the cases, should be onl3- an oper-
ation of necessity, never of choice, and should be
regarded as a last resort. Electrical consen-ative
therapeusis, harmless, easily appled by any one,
and which does not pretend to cure every case of
salpingo-ovaritis, finds its greatest triumph in
rendering a subsequent conception possible, as I
have seen in several of my patients. I will not
harrass you with the details of all of the cases
that have been to me for treatment, but will con-
tent myself with giving you full details of two
typical cases, in one of which there were two
subsequent conceptions, the other remarkable
clinically, and though long it is full of interest,
demonstrating that electricity, persisted in and
rightly used, may be of the greatest value in the
different troubles that maj' beset the same patient.

COMPLETE piSTORY.

Madame Sophie Edinger, aet. 34 years, living
at 5 Rue de I'aqueduc, Paris, presented herself at
the clinic of Dr. Apostoli, August 17, 1886.

Previous His/orv. — Nullipara, neither pregnan-
cy nor miscarriage. Born in Lorraine. Has lived
at Paris for seventeen and a half years. Mother
died at the age of 48 in consequence of a profuse
uterine haemorrhage, the cause of which was un-
known. Menstruation easily established at the
age of II. Since its appearance it has been of
the following regular type : Occurring at fixed
interv^als, the flow has lasted on an average six
days, and has been painless; it has always been
very abundant, and often accompanied by the ex-
pulsion of clots. At 13 and at 17 years of age,
without an appreciable cause, the periods were
suppressed for about two or three months, with-
out other morbid phenomena. Slight, intermit-
tent leucorrhoea.

Of a rather delicate and lymphatic temperament,
the patient had several of the diseases of child-
hood, eczema of the head, and frequent attacks
of gastritis which often caused vomiting of the
food. At 28, a light attack of rheumatism, lo-
calized in the two arms, which lasted one week.

Married at 29 years of age. From the begin-
ning of her marriage her health has been disor-
dered. The most striking phenomena from the
first were the menstrual troubles characterized by
an increase in the quantity of the flow, by its i
more frequent occurrence, and by pain preceding
the flow for one or two days and disappearing as
soon as it was established. Her married life, j
then, was marked for five years by the appearance
of a true dvsnicnorr/ina, very intense, which has
persisted until to-day, and which often obliged
her to go to bed. Usually the pain disappeared
suddenly on the appearance of the flow.

Since her marriage her general health has also
been disordered; she began to grow thin, and her
appetite became capricious. This condition per-
"^isted for three years, during which time she

worked, though with difficult}^ For two years
past (1884- 1 886) her condition has become pro-
gressively much worse. The pain, formerly in-
i termittent and premenstrual, has become almost
constant, interfering with the walk, making
standing impossible, and localizing itself as a
continuous dragging or tension in the right iliac
region, radiating posteriorly to the lumbar region,
and anteriorly to the right groin, involving fur-
ther the entire corresponding thigh as far as the
knee. This pain has increased greatly, without
changing the condition topographically, at the
time of the periods most of all, obliging the pa-
tient to take a forced rest.

For some months after the marriage the sexual
relations were verj' painful. Then the pain dis-
appeared, to reappear again two years ago with
much greater intensitj', finally making all sexual
relations impossible. Intercourse also provoked
and increased the pain in the right iliac region.
The patient has never, up to this time (1S86),
had an)^ pain in the left iliac region. For eight
months the patient scarcely left her bed, attacked by
pain so intense as to cause her to cry out involun-
tarily; this was accompanied by almost daih' vom-
iting of sometimes alimentary, sometimes bilious
matter. She grew thin more rapidly and her ap-
petite became more and more perverted, while the
digestion became more painful. The abdomen
was extremely sensitive, and the pain was always
localized on the right.

She was also decidedly constipated. The men-
struation was at times transformed into a verita-
ble metrorrhagia, an almost constant flow with an
inter\'al of only one week between the periods.

The patient was treated regularly hy Dr. Man-
det, who applied the usual clas.sic treatment of
emollients, milk rUgime, opiates, revulsives upon
the abdomen, etc. It was at the instance of her
physician that she came to consult us, on account
of the total lack of success of the most varied and
assiduous treatment that had been instituted.

Actual Conditio7i August ij, rSS6. — The patient
is humble, impressionable, ner\'ous, but not hys-
terical, so feeble, and suffering to such a degree,
that she had to be brought to the clinic in a car-
riage and assisted upstairs. She is emaciated,
without color, and exhibits a state of considerable
sufi'ering. On palpation the abdomeii is painful,
and sensitive in the two iliac fossae, especially in
the right. For a year it has been impossible for
her to remain erect without an abdominal support.

The internal examination is difficult on account
of an excessive sensibilit}' of the uterus, and es-
pecially of the cul-de-sac. An inflammatory ex-
udate entirely surrounding the uterus constitutes
a single mass, adherent to the sacrum, to each
side of the pelvis, and enclosing the uterus.

An examination shows at times in the middle
of this total cellulitis, which envelops the uterus,
a plane, subadjacent, more resistant and fibrous.

114

SALPINGO-OVARITIS.

[July 27,

which indicates the presence of an interstitial '
uterine fibroid, localized especially at the right
and anteriorly.

Diag7iosis. — Peri-uterine and subacute inflam-
mation with interstitial, subadjacent fibroid, and
ovarian salpingitis. Pronounced retroversion.
Sound measures 7 centimetres.

Treatment. — August 21, 1886. First, intra-
uterine negative galvano-eaustic, 100 milliamperes,
for five minutes. Two hours after the treatment
.the patient returned home.

September 9, 1886. — Patient reports that she
has had a flow lasting twelve days, which began
the day after the first treatment, and which has
greatly fatigued her. This flow is probably due
to the first operation (treatment), which was
wrong. This was negative and ought to have
been positive. . This flow was accompanied bj- an
increase in the vomiting already existing. In
order to calm the patient, she was given an intra-
uterine, bi-polar faradization of tension, ivith the
Jijie wire, for five minutes, andstarting with to-daj',
in order, hereafter, to carry on this treatment sim-
tultaneously with the treatment of the uterus, tlie
bi-polar galvanisation of the pneumo-gastrics was
begun, to alleviate the gastric phenomena, the
most serious of which is the vomiting.

This galvanization is given at a dose of 5 to 12
milliamperes, for fiv^e to fifteen minutes each time.

September 21. — V\xs\. positive, intra-ulerinegal-
vano-caustie (made with the object of arresting the
hsemorrhage), 175 milliamperes, five minutes.

Sept. 30. — Second positive galvano-caustic.

Sept. 30. — Third positive galvano-caustic —
idem — 150°, five minutes.

The last period occurred Sept. 22, and lasted
six days. The vomiting of food, which was in-
cessant, and almost dailj^ before the beginning of
the treatment, has been overcome at the onset by
the galvanization of the pneumo-gastrics, which
has not only put her in a condition to tolerate
the milk which she had been ordered to take, at
the clinic, but also has again given her an appe-
tite, almost unknown before.

October 7. — Re-commencement of the negative
galvano-caustic in order to accelerate the absorp-
tion of the exudate. Second negative galvano- 1
■caustic, 80°, five minutes. j

October 12. — -Third negative galvano-caustic,
So°, three minutes.

It was necessary to discontinue the treatment
after a sitting of tliree minutes, on account of the
Trial an caur of which the patient complained.
Strength is restored, the stomach performs its
functions much better. Since the beginning of
the treatment she has never vomited on the days
of treatment, and in the interv'als has vomited but
Tarely. For fourteen days there has been entire
absence of vomiting. She begins to walk more
easily, and with less pain, but still sufiers when
.sitting. The constipation persists. She has con- 1

stant numbness in the right leg. She is still
obliged to keep her bed almost all the time, and
onlj' leaves it to come to the clinic.

October 14. — Fourth negative galvano-caustic,
100°, five minutes.

October 19. — Fifth negative galvano-caustic,
100°, five minutes.

Has had her menstrual period since this morn-
ing, but with much less pain. The complexion
is clearer and the expression better.

October 21. — Menstruation continues; flow
abundant, but there is no menorrhagia.

October 26. — Vomiting again on the 23d and
24th. Fifth negative galvano-caustic, 100°, five
minutes.

November 4. — Sixth negative galvano-caustic,
150°, five minutes, badly borne.

November 6. — Seventh negative-galvano caus-
tic, 60°, five minutes.

November 9. — Eighth negative-galvano caus-
tic, 60°, five minutes.

The vomiting has quite ceased ; only a slight
nausea remains. The appetite and digestion are
always better on the days of treatment : the day
following she is sometimes not quite as well.
There is an equal improvement on the part of the
abdomen : it is less sensitive on pressure, and
swells only when she is tired from walking. For
fifteen days she has been able to sit up part of
the day.

November 11. — Patient is menstruating and (a
fact most characteristic in favor of her improve-
ment) she has sulfered much less than usual, and
has not had to go to bed. She has been able to
walk alone without support, a thing which for-
merly was impossible in this condition. She de-
clares herself completelj' transformed,

November 11. Eighth galvano-uegative, 90°,
five minutes. An internal examination shows an
appreciable change. The half of the exudate has
disappeared, and on the right it has left bare the
sub-adjacent fibroid, the diagnosis of which is
emphasized to-day. The uterus begins to be
movable, and can be slightly displaced.

November 20. — Ninth galvano-negative, 100°,
five minutes.

November 27. — Tenth galvano-negative, 80°,
five minutes. Since the beginning, each treat-
ment is followed by an antiseptic vaginal injec-
tion, after the method of Van Swieten, and a tam-
pon of iodoform gauze is left in the vagina.

November 30. — Patient has just had a return of
her former painful symptoms, without an appre-
ciable cause. This lasted eight days, and was
marked by a reappearance of the old vomiting.
Galvanization of the pneumo-gastrics, which pro-
duced immediate relief The weight is increas-
ing ; without the clothing it is 118 pounds.

December 2. — Amelioration of the abdominal
pain. No vomiting since November 30. Elev-
enth galvano-negative, 80°, five minutes.

1889.]

SALPINGO-OVARITIS.

115

December 4. — Twelfth galvano-negative, 60°,
five minutes. The patient is becoming more in-
tolerant of the action of the galvano-caustics, but
each time she feels greatly relieved by it, and
sleeps better the night following.

December 23. — Thirteenth galvano-negative,
So°, five minutes. Patient feels well. The gas-
tric troubles have disappeared ; she walks better,
but is still unable to do her housework.

December 28. — On account of the intolerance
which begins to be manifested for the galvano-
caustic which, at the beginning, was well borne
at 100°, and now is somewhat painful at 60° or
80°, and in order to hasten the cure — which maj'
be considered as still in the rough — both anatom-
ically and symptomatically, the galvano-punc-
tures are begun.

First vaginal negative galvano-puncture at a
depth of one centimetre in the right-lateral cul-
de-sac, with a filiform trocar of steel, at 200°
milliamperes, five minutes. Patient under the
influence of chloroform. Vaginal injection of sub-
limate solution 1-1200 before and after the seance,
vaginal tampon of iodoform gauze. Patient re-
mained at the clinic for six days without leaving
her bed. Vomiting appeared the evening of the
day she was treated and the following day, and
was relieved b}- the galvanization of the pneumo-
gastrics.

Menstruation occurred December 31, ten or
twelve days in advance, of average quantit}-,
though rather less than formerh-. For the first
time since her marriage the menses appeared with-
out pain and without the formation of clots. A
complete calm has followed the appearance of the
menses. The patient has eaten with a good ap-
petite and has recovered her power to sleep, which
she had lost for a long time. In a word, she feels
as if she were transformed, and she seems to have
derived more benefit from this first puncture than
fram all the preceding galvano-caustics.

Januarj- 4, 1887, — The patient left the clinic
to return home. Since then her health has con-
stantly improved. The following is a statement
of the typical modifications which have been pro-
gressively determined from the 4th to the 22d of
January, 1887 :

1 . Walking has become much easier. The pa-
tient is able to come to the clinic without the
companion hitherto necessary. She is much less
fatigued than formerly by the jolting of the car-
riage.

2. Slje is able now, for the first time, to do her
housework, discontinued eighteen months ago.

3. Digestive functions good. She has more
appetite, while the nausea and vomiting have
ceased.

4. Parallel transformation, anatomically speak-
ing. On examination the peri-uterine sensibility
is less acute. The retrogression of the exudate
makes rapid progress.

5. Restoration of all the functions, and notably
considerable diminution of the abdominal pain.

Ever\- two days she has had an antiseptic vag-
inal injection, and the tampon of iodoform gauze
has been changed.

January 22. — Second negative, vaginal galvano
puncture, to the right, at a depth of i'- centime-
tres ; made this time without chloroform. The
pain limits the intensity to 50 milliamperes, eight
minutes. The patient did not remain at the clinic
but returned home the same evening. Slept well
and did not suffer. The menses appeared the
next day, five days in advance, and for the second
time without pain and less profuse.

Januan,- 25. — Antiseptic vaginal injection.

Januarj' 29. — Walking is still easier, patient
finds herself "very light."

February- 10. — The orifice made by the last
puncture is closed. Third negative, vaginal gal-
vano-puncture, at a depth of one centimetre, 60°,
five minutes, without chloroform. Antiseptic in-
jection, and vaginal tampon of iodoform gauze.

February 12. — Patient suffered for some hours
after the last puncture, although she was able to-
go home that evening. She was rather more
tired than after the previous punctures, and at-
tributed this to the fact that the operation was
done without chloroform.

Februarj' 13. — For the first time in eighteen
months the patient has had sexual intercourse,
which was effected without too much pain.

March 5. — Galvano-puncture without chloro-
form was attempted. Patient was unable to tol-
erate it, and after some seconds the application
was discontinued. Nausea and efforts to vomit
rendered the continuation impossible and unbear-
able.

March 8. — The evening following this aborted
puncture there was a recurrence of the abdominal
pain. The next day, March 6, menstruation be-
gan, for the first time in her life eight days late.
Unlike the three last periods, the flow has been
more abundant, painful, and accompanied by the
expulsion of clots. The question arises, in view"
of the recent sexual relation and of the delay in
the menstrual function, so abnormal, if this, as
seems probable, was not a miscarriage? There
was also a renewal of the digestive disturbance,,
but without vomiting.

March 19. — Fourth negative galvano-puncture^
in the posterior cul-de-sac, under chloroform, 150°,.
five minutes.

March 22. — Patient remained in bed at the
clinic 24 hours. She suffered a little after this
puncture, but found herself again ver\- much im-
proved. From this date the patient, who has had
three times a week antiseptic vaginal injections,
and tampons of iodoform gauze, finds herself
again progressively improved. One month after,
the orifice made by the puncture had not closed.
The uterus begins to be easily movable.

ii6

SALPINGO-OVARITIS.

[July 27,

April 20. — For the first titae in j-ears the pain
seated in the plane of the right iliac bone, and
radiating posteriorly and anteriorly, has disap-
peared. Continued anatomical improvement.

Maj- 3. — On examination the fibroid appears
to-day very^ clearh^ marked, and the inflammatory^
exudate can only be perceived on deep pressure.
The mobility of the uterus increases. Fifth gal-
vano-puncture (negative) in the right lateral cul-
de-sac, at a depth of one centimetre, 150°, five
minutes, under chloroform.

May 5. — Patient vomited the evening of the
treatment and the day following, due probably
to the great amount of chloroform absorbed. She
remained 24 hours at the clinic. Since the punc-
ture the amelioration has been on the increase.
Patient has continued to come to the clinic three
times a week for the galvanization of the pneu-
mo-gastrics, and to have the iodoform tampons
changed.

June 4. — The following is a statement of the
actual condition :

1. Patient has just taken a long walk without
fatigue.

2. All spontaneous pain in the right groin has
disappeared.

3. Menstruation in April and in May occurred,
after a delay of two to four daj'S, icit/iout pain,
and less profuse, lasting five to six days. Slight
malaise at the end of the periods,

4. The complexion is better, she has more col-
or, and has lost the former deathty hue.

5. She feels transformed, strength recovered,
and says she is able to work.

6. The constipation has disappeared. Patient
has a daily movement of the bowels.

7. The patient, comparing the benefit from the
galvano-caustics with that from the punctures,
aflSrms that the benefit from the latter is verj'
much greater, especially from the punctures made
under chloroform, at a higher dose, which proves
that the efiect increases with the intensity, other
things being equal.

8. Patient has never been as well as at present
since her marriage.

9. The sexual relation is not ver>' painful,

10. From an anatomical point of view the ex-
udate has been reduced three-fifths. The patient
remains under observation, and it is probable
that no new interference will be necessars-, since
she believes herself nearly well from every point
of view, and capable of leading the active life of
a tradeswoman.

June 7. — -Patient weighs 119 pounds. (In De-
cember she weighed 118 pounds.) Dr. Apostoli
made a futile attempt to pass the sound. This
was painful and could not be completed. In the
evening the patient had a bloody discharge, which
was certainlj- provoked bj- the attempt to pass
the sound. This discharge continued almost
without interruption from the 8th to the i6th of

June ; it was neither accompanied nor preceded
by abdominal pain.

June 18. — The discharge has been arrested
since the i6th, since which time there has been
an offensive return of the pain in the right iliac
fossa.

June 21. — The old gastric disturbance reap-
peared the da}- before yesterday ; the patient vom-
ited, and was obliged to come to the clinic for
the galvanization of the pneumo-gastrics. Walk-
ing is again diSicult, and the countenance is once
more depressed in consequence of the relapse,
which can only be attributed to the sound. With
the single object of calming the patient, a first
vaginal faradization was immediately given, using
the large bi-polar vaginal sound, the extremity
of which was applied against the right lateral
cul-de-sac, the most painful part. Application of
a current 0/ tension, with the fine wire, ivith slight
intensity, for fifteen minutes.

The acute pain disappeared immediately after
the treatment, the expression became better, and
walking easier. Patient continued to be relieved
during the evening and somewhat the next day :
on the third day there was an offensive return of
the old symptoms.

June 23. — Third vaginal faradization, identical
with the first, lasting ten minutes, with the same
amount of relief.

June 24. — Third faradization, ten minutes.

June 25. — Fourth faradization, ten minutes.
Since the 2 2d the amelioration of the pain has
been progressive, and parallel with this the gas-
tric trouble, which alwaj's occurs with the pain,
has been relieved. The patient has not vomited,
indeed, since the 2 2d ; the digestive functions are
re-established, walking is eas}-, and sleep good.

June 30. — In order to bring about the complete
resolution of the remainder of the old exudate,
a sixth negative, vaginal galvano-puncture was
made to-day, to the right posteriorly, in the most
prominent portion of the fibroid, 180°, five min-
utes. Depth of puncture, one centimetre. Pa-
tient chloroformed. Remained at the clinic 24
hours without any incident worthy of note, and
returned to her home the next day.

July 2. — No loss of blood. Patient suffered
verj- little after the puncture. She had a little
nausea, but did not vomit. Antiseptic vaginal
injections, and tampons continued.

July 12. Menstruation continued from the 4th
to the 7th, moderate in quantity, without clots,
and without pain either before or during the flow
Since the cessation of the menses the patient has
suffered for three days, and has had a return of
the gastric trouble. The abdominal pain is bet-
ter to-day. Intra-uterinc faradization, with the
fine wire, for five minutes, badly borne. Galvan-
ization of the pneumo-gastrics continued.

From July 19 to August 20 the patient contin-
ued her visits to the clinic regularly three times

1889.]

SALPINGO-OVARITIS.

"7

a week. Bi-polar vaginal faradizations with the
fine 'ivirc have sufficed for treatment. Thus .she
has had seven successive sittings of five to eight
minutes each, the result of all of which has been
to increase progressively her hien-etre, and to re-
lieve all abdominal pain. One month after the
last puncture the orifice made by it had not closed,
but the patient was able to continue her occupa-
tion, in spite of the presence of a temporary vag-
inal fistula, thanks to the antiseptic precautions
which have been carefully observed. Conjointly
■with the vaginal treatment the galvanization of
the pneumo-gastrics has been carried on, accord-
ing to the indications and, as usual, each seance
has been followed b\- an immediate alleviation of
all the gastric disturbances.

October 16, 18S7. — Patient has been so well
that she suspended her visits to the clinic after
the 28th of August. She walks easilj', does not
suffer, and has no pain during sexual intercourse.
Her sleep is good, she eats well, and digests eas-
ily. The abdomen is no longer painful, even
when she is tired. She is scarceh- sensible of a
slight dragging the first day of her menstrual pe-
riods. Total absence of leucorrhoea.

January 12, 1888. — Excellent health since the
last visit. Patient lias worked constanth- and
been able to do really hark work since October,
and this without interruption during her periods,
which last on an average six daj's. On palpa-
tion, one finds absolute insensibility of the abdo-
men. On internal examination, the uterus is
found to be movable, the peri-uterine exudate is
almost entirely absorbed, and there is marked
■diminution of all sensibility, even with deep
pressure.

January 26, 1888. — Same good condition. The
journeys which .she is constantly obliged to take,
€ven during menstruation, do not fatigue her.

April 16, 1889. — Of her own accord the patient
has discontinued all visits to the clinic since Jan-
uary, 1888. She comes to-day by special request.
Her health has remained perfect in ever>- partic-
ular, and she believes herself radically cured, be-
cause ail the functions are normal. She has not
been indisposed for a single day, and has contin-
ued her fatiguing work without interruption.

Actual Condition, April 16, rSSg. — Complexion
fresh and of good color, giving every evidence of
health. Walking very easy. Erect position not
at all painful. Menstruation is always regular.
It occurs on a fixed day, without delay. The
quantit}' diminishes progressively. Formerly the
flow continued six days, at present it lasts but
three or four days. There are no clots. There
is complete absoice of pre-vtenstrual dysmenorrhira.
She feels only a little tired, and slight abdominal
pain before the appearance of the flow. She is
always able, even during her menstruation, to
work easily and without fatigue. Vesical func-
tions normal ; no constipation ; complete absence

sexual relations are rather pain-
the two iliac fossae are not at

of leucorrhoea :

ful. Palpation
all painful.

Internal Examination. — Neck in normal posi-
tion. Uterus movable, without appreciable sen-
sibilit}-. Absence of pain on touching the cul-
de-sac, but a deep exploration causes rather acute
pain in Douglas' pouch, vers- little laterall}-. The
uterus is easily displaced laterally, but on raising
it it is found to be slightly adherent to the sa-
crum.

With a deep touch the right ovarj- can be felt,
also the right Fallopian tube, which no longer
seems to be inflamed. The rectal examination
confirms what has been determined by vaginal
examination. All efforts to pass the sound —
even a verj- small sound — are futile. The sound
is arrested \>y an almost complete atresia of the
external orifice.

A'ota Bene. — This absence of dj-smenorrhoea.
which is coincident with a considerable degree 01
uterine atresia, is a new fact, which, with the ad-
dition of those which I already possess (in all a
ver)- large number) stands in favor of the thesis
which I have sustained for a long time, the fre-
quent independence of dysmenorrhoea, and uter-
ine atresia, and confirms this proposition ; Dys-
menorrhoea is almost always of ovarian origin, vety
rarely of uterine origin. The patient affirms again
to-day that, judging without appeal, the respective
results of the different treatments that she has
undergone, she has derived the greatest benefit
from the galvano-punctures, although more pain-
ful and often scarceh- to be endured without
chloroform.

In order to get all possible information on the
origin of the disease, I saw the husband to-day
(April 23, i889\ for the first time, who stated
that he had, in 1878, while in the armj% a mani-
fest gonorrhoea, characterized by pain on urina-
tion, and a discharge 5?^/ _^tv/ <»;•«. He claimed to
have been rapidly cured of this disease bj- the
usual treatment. Five years after this he mar-
ried, and it is possible that in spite of his state-
ment he had still, at this date, an unknown gon-
orrhoea, which must have been the point of de-
parture, as is usual, of the peri-uterine accidents
of his wife.

SECOND OBSERVATION- ; SUMMARY.

Madame Marie Elien, domestic, aged 22 years,
presents herself at the clinic of Dr. Apostoli June
9, 1885 ; unipara.

Antecedents. — No hereditary- antecedents, ha-
bitual good health, no diseases of infancy, men-
struated at 17 years of age, scantily during two
days on an average, and without pain. Married
at 21 years, pregnant immediately after, prema-
turely confined in seven months, after a fall on
March 13, 1S85. Immediate consequences appar-
ently good, and probable commencement of the

ii8

SALPINGO-OVARITIS.

[July 27,

present malady six weeks later at the time of the
menstrual return. Profuse metrorrhagia, which
has existed a month, and acute pains in left side
of abdomen, work impossible, sexual relations
very painful. Has kept the bed for a month with
fever. Gastric troubles.

Diagnosis. — Endometritis. Double prolapsus
of the uterine annexes, and left ovaro-salpingitis.
Uterus bound down.

Trcatinoit. — First galvano-cauterization, intra-
uterine, negative, 100 milliamperes, five min-
utes.

June 13. — Improvement as to the pain. Metror-
rhagia continues.

June 16, — First galvano-puncture, vaginal,
negative, made in the posterior cul-de-sac, with a
fine steel trocar, to the depth of one centimetre,
without anaesthesia, 80 milliamperes, five min-
utes. Rather lively reaction the same evening of
the operation, which became calmed in the night,
and after which she was better. Continuation of
the metrorrhagia.

June 1 8. — Disappearance of the pains — has not
kept the bed since the beginning of the treat-
ment.

June 23. — Expulsion of a slough last evening
and considerable diminution of the retro-uterine
exudate, as well as of the vaginal sensibilitj',

June 30. — The same good condition.

July 4, — Marked improvement.

July g. — All flow has ceased.

Jul}' II. — Second galvano-puncture, vaginal,
negative, in the posterior cul-de-sac, to the depth
of one centimetre, 100 milliamperes, five min-
utes, without anaesthesia, and without a sojourn
at the clinic — only rested two hours, the same as
at the first time.

August 4. — No inflammatory reaction as a re-
sult of her last puncture. She has been able to
endure easily a journey into the countn,', from
which she has just returned after an absence of
three weeks.

August 8. — Same good condition. Third gal-
vano-puncture, vaginal; negative, 50 milliamperes,
five minutes.

Sept, 12. — Improvement persists. Walking is
more easy.

Sept. 17. — Fourth galvano-puncture, vaginal,
negative, 50 milliamperes, five minutes.

Sept. 22. — Fifth galvano-puncture, vaginal,
negative, 50°, five minutes.

Sept. 29. — Offensive return of the pains under
the influence of a great fatigue and the renewal
of the sexual relations in spite of our injunctions
to the contrary. Fresh metrorrhagia.

Oct. 6. — All is quieted, the flow is arrested,
and she does not suffer.

Oct. 13. — The improvement conitnues, the pos-
terior puffiness has almost disappeared, and she
can be considered as cured.

Oct. 22. — Another galvano-puncture made

solely for the purpose of perfecting the cure.
Sixth and last galvano-puncture, vaginal, nega-
tive, made as the preceding ones, to a depth of
one centimetre, without anaesthesia, and with the
aid of a small steel trocar, after having taken all
the precautions possible for vaginal antisepsis be-
fore and after each treatment. No sojourn at the
clinic, repose only for two hours. All of these
gal vano- punctures, although painful, were in
general well tolerated, and were not followed by
any inflammatory reaction,

Oct. 30. — She is very well, she is cured symp-
tomaticallj- and anatomically, all the exudate has
disappeared ; but the uterine annexes remain
prolapsed, a deep and quite forcible vaginal pres-
sure is necessarj^ in order to provoke sensibility.
She ceases all treatment spontaneously.

Jan., 1886. — Beginning of a second pregnancy,
during which she can continue her work without
interruption.

August 30. — Premature confinement at about
seven months without appreciable cause, expul-
sion of a dead foetus, immediate results good,
almost immediate resumption of her work.

Oct. 6. — Same good condition as a year ago.
The uterus can be displaced laterally, but pre-
serves still some posterior adhesions. Defecation,
previously painful, is easy and causes no longer
sensitiveness. To resume, a year after cessation
of treatment the patient remains cured. Symp-
tomatically and anatomically she remains very
much improved, her health is perfect in ever>- di-
rection and the sexual relations, impossible before
the treatment, provoke no longer any sensitiveness.

Januan,-, 1887. — Commencement of a third co7i-
finemeni, which developed normally.

Oct. 21.— Normal confinement at term, and re-
sults of the lying-in good. Resumption of her
domestic work almost at once. Nurses her
child.

May 12, 188S. — She has not kept the bed a
single day, and has not lost the benefit of her
treatment, same anatomical condition, same pro-
lapsus of the uterine annexes, especially the left,
without any inflammation.

August. — Commencement of a fourth normal
confinement, during which she worked constantl3\

April 28, 1889. — Confinement at term. Se-
quelae of the lying-in excellent, no pains in the
abdomen, no leucorrhcea, was able to recommence
her work on the tenth day.

June 8. — Is verj- well, all her functions are
normal, she nurses her child.

Local Examination. — On pressure, a slight
ovarian pain in the left iliac region is obser\'ed,
the uteEus is normal, very movable laterally, but
cannot be lifted without a little difficulty, on ac-
count of the posterior adhesive bands, same pro-
lapsus of the annexes, more pronounced on the
left, with one tube in the recto-vaginal wall, wo
signs of salpingo-ovaritis.

1889.]

THE ETIOLOGY OF LEPROSY.

119

To resume, the treatment, composed ol 07te gal-
vano-caukrization and of six galvano-pundures,
had an immediatel}' favorable result, symptomat-
ically and anatomically, which sun'ived four
years after, and which permitted the evolution of
three consecutive confinements, of ivhich two were at
term.

OBSERVATIONS ON OVARIAN SALPINGITIS ;
SUMMARY.

Woman, aged 34, multipara, scrofulous. Until
the age of 29 menstruation regular, abundant,
and without dysmenorrhoea. Married at 29.
Sudden appearance immediately after of an in-
tense, premenstrual dysmenorrhcea. Sanguinous
:flow and frequency of periods increased. Same
unfortunate condition for three years, making
work often difficult. For two years progressive
aggravation of the local condition : continual
abdominal pain, walking almost impossible, daily
vomiting, suspension of sexual relations because ,
so painful, beginning of an almost continuous
metrorrhagia, unsuccess of all classic treatment.
After remaining in bed for eight consecutive
months almost all the time, the patient presented
herself at clinic August 17, 1886.

Complete peri-uterine inflammatory exiidate,
li'ith subadjaccnt fibroids, tend tight ovarian sal-
pingitis.

From August 21 to November 23, 1886, thir-
teen negative, chemical, intra-uterine galvano-
caustics of 60 to 150 milliamperes, five minutes
each, with two galvano-positives at the begin-
ning, to arrest the existing metrorrhagia, and, in
addition, bi-polar galvanization of the pneumo-
gastrics three times a week.

Marked anatomical retrogression and consider-
able symptomatic amelioration. In order to per-
fect the cure, from December 28, 1886, to June.30,
1887, six negative, vaginal galvano-punctures
at a depth of one centimetre, posterior and to the [
right ; two, without chloroform, at an average of i
60 milliamperes, five minutes each, and four, with
ansesthesia, of 150 to 200 milliamperes of five min-
utes each. Amelioration more marked and rapid '
under the influence of the galvano-punctures.
Some vaginal and intra-uterine faradization of
tension, with the fine wire, were practiced to alle-
viate the pain, and, simultaneously, galvanization
of the pneumogastrics, which were always victori-
ous over the gastric troubles.

Suspension of all treatment in Augu.st, 1887.
At this date the patient declared herself symp-
tomatically cured. Walking easy, riding well
borne, difficult work tolerated even during the j
periods, entire disappearance of all spontaneous !
pain, increase in strength, better health than for j
several years, menstruation regular, disappear-
ance of all dysmenorrhoea. Anatomically the
retro-uterine inflammatory exudate has almost
<lisappeared.

From August, 1887, to March, 1889, all the
functions have been normal and the cure has re-
mained well defined.

THE ETIOLOGY OF LEPROSY.— A CRITI-
CISM OF SOME CURRENT VIEWS.

Rt'ad in the Section on Dermatoloiiy and Syphilogfaphy at the Fortieth

Annual Meeting of the American Medical Association held

at Nezoport, R. I. .June, /S89.

BY P. S. ABR.\HAM, M.A., M.D., B.Sc, F.R.C.S.I.,

OF LONDON', ENG.,

LECTURER ON PHYSIOLOGY AND HISTOLOGY, WESTMINSTER HOS-
PITAL MEDICAL SCHOOL ; CLINICVL ASSISTANT HOSPITAL
FOR DISEASRS OF THE SKIN, BLACKFRIARS ; .AND
LATE CURATOR OF THE MUSEUM AND MEM-
BER OF THE COURT OF EX.4MINERS,
ROYAL COLLEGE OF SUR-
GEONS IN IREL.AND.

Putting to one side, for the present, the bacil-
lus, which all pathologists agree is to be found in
every leprous neoplasm, the suppo-sed etiological
factors of leprosy which have been most consid-
ered of late years, are three, viz., (i.) Heredity.
(2.) A diet offish. (3.) Contagion.

The theory of heredity has had immense sup-
port, both lay and professional, and it is curious
to obser\'e how loth some medical authors are to
set themselves free from its trammels, or to ques-
tion its influence in propagating the disease, even
though many of the facts which they themselves
adduce seem obviously to lead to quite another
conclusion. As Mr. Jonathan Hutchinson points
out, ' the fact of leprosy occasionally appearing in
healthy immigrants, and just as severely as if such
persons belonged to leper families, is enough to
prove that hereditariness goes for little or nothing
in its causation. It is indeed idle to deny the
liability of leprosy to attack individuals who have
not the slightest hereditary taint.

In a recent paper," my friend. Dr. Blanc, who
has in late years seen probably more cases of
leprosy in the United States than any one ob-
server, shows that in forty-two cases treated by
him, twelve were natives of foreign countries
(seven German, one Austrian, one English, one
Irish, one French, one Italian), and of the re-
mainder, eighteen were the children of foreign
born parents (chiefly German and Irish), "from
which we conclude, ' ' he says, ' ' that if the dis-
ease is hereditary^ it must be derived from a va-
riety of foreign sources ; and if acquired then it
seems to attack the children of immigrants as
often as those of the older native families." What
evidence can be stronger against heredity?

An important paper on the Heredity of Lep-
rosy has latelj^ been published by Dr. G. A.
Hansen,^ who made a journey to North America
last year to see what had become of the Norwe-
gians who had gone there as lepers or had de-

iClinical Lecture on " Leprosy, its Cause," etc.— Med. Press and
Circular, Nov. 4, 18S5.

-"Leprosy in New Orleans." N. O. Med. and Surg. Journal iS,S.S
iVirchow's Archiv., Vol, CXIV. 1888.

I20

THE ETIOLOGY OF LEPROSY.

Duly 27,

veloped leprosj- after their arrival in the new
world, and to study this question of heredity in
particular. With the help of Dr. Hogh, of Min-
neapolis, and Dr. Grunwold, of Minnesota, he
was able to find out that about 160 Norwegian
lepers had been established in the states of Wis-
consin, Minnesota, and Dakota. Many of them
are married, and several have left a good many
descendants. There are, in addition, many other
Norwegian immigrants who are either descended I
from lepers, or have leprous relations in Norway. |
There is, therefore, in those districts, consider-
able material for the inheritance of leprosy. Of |
the 160 leper immigrants only thirteen are left, j
which he himself saw, and besides these there are
perhaps three or four others. All the rest are dead . '
Of all their descendants whom he has seen as far
as the great grandchildren, not one has become a
leper. This is, in short, the result of his inves-
tigations : and he saj's there can be only one ex-
planation, viz., that leprosy is not inherited.

The Fish Theory. — In reference to this old
theory', Mr. Hillis wrote in 188 1 that it "may
now be laid aside as obsolete :" and it is, I be-
lieve, almost universally discredited by the medi-
cal men in Norway, as well as in even,' other
part of the world where leprosy is rife. Never-
theless, one who is justly regarded as one of our
highest British authorities is still, it seems, an
ardent believer in the view that the disease is
contracted by the eating of fish, more especially
fish which has been somewhat decomposed, or
has been salted.'

Those who oppose this theory may well point
out that while numbers of people in Scandinavia, \
in Africa, and in other countries, habitually re-
gale themselves with imperfectly cooked or de-
composed fish, and do not get leprosy, numbers of
those who do acquire the disease are not aware of
ever having eaten anything of the kind. (This
negative argument is apparently at least as good
as that largely relied on b}' the anti-contagionists,
who infer that because many persons who come
in contact, or even live with lepers, do not be-
come lepers, therefore the disease cannot be con-
tagious under any circumstances.)

If, indeed, it must be through 07ie particular
article of diet, in all parts of the world, that the
germ of leprosy is introduced into the system,
why may v.'e not select something which everj^-
one must swallow at some time or other, such as,
for instance, bad water? Filters and other pre-
cautionary measures are, at an}- rate, not par-
ticularly fashionable in leper countries.

We really have no direct arguments against a
possible dietetic origin for leprosy, /. r.,at least by
means of contaminated food; and the view of D.
Liveing promulgated in his Gulstonian Lectures
so long ago as 1873,' viz., that the di.sease may

be " propagated by the inhibition of the excre-
tions of those affected, much in the same way as
typhoid fever or cholera," may j-et come to the
front and secure further support.

The Contagion Theory, — Although clear and
distinct instances of the direct communicability
of leprosy from person to person are few and far
between, and, from the nature of the disease, its
latency and uncertain prodromata — difficult to
prove, it appears to me that we cannot now deny
its " contagiousness " in the sense that untainted
individuals may occasionally become affected with
the disease after being in close relation with
lepers. As far as I can see there is no getting
over Dr. Hawtrey Benson's case," and as that
careful physician remarks, "to ignore the evi-
dence of contagion in this case, where the cir-
cumstances are so simple and so well authenti-
cated, is indeed to strain scientific caution to its

utmost limit, if not beyond it The

proof of contagion afibrded by this case possesses
a force little short of that of a mathematical dem-
onstration." I agree with him that " one such
fragment of positive evidence carries more weight
than a vast accumulation of negative evidence."
In 18S5, in his lecture on leprosj-, Mr. Jonathan
Hutchinson is reported to have said, "of course,
if you are prejudiced in favor of its contagious-
ness, you can produce instances apparently in
favor of it, especially if you reject a thousand
negative facts in favor of one fact which seems to
support it. I submit that no one who will read
a record of the facts can ever believe that conta-
gion can take place." There are other authori-
ties, too, who, having made up their minds on
the subject many j-ears ago, are "of the same
opinion still ;" several, however, have seen rea-
son to modifj' their views. Until a few years ago
most of the Norwegian phj'sicians di,sbelieved in
the contagion of leprosy. Dr. Hansen, however,
the discoverer of the bacillus, boldly asserted its
infective character ; and I found last j'ear that
Dr. Sand, of Trondhjem, and Dr. Kaurin, of
Molde, have both come round to his way of
thinking. The veteran Dr. Danielson, however,
is still of the old opinion — for, as he told me, "in
all his long experience with the disease he had
never met with one single instance of contagion."
Dr. Nickoll also has no belief in the contagion of
leprosy, nor indeed in its heredity. Dr. Kaurin
now considers that leprosy is not transmitted by-
heredity, although like A'irchow and many-
others, he admits that there may be hereditary-
predisposition to contract the disease. He in-
formed me that he had seen several cases, besides
the one he has published, which point to direct
contagion. Dr. Sand is of a similar opinion ; and
I learnt from him that he has known of two cases
of servants — one at the Molde asylum, and one

4 Mr. Jouathan Hutchinson, 1. c, p. 417.

5 "Elephantiasis Groccorum, or the -True Leprosy," 1873. p. 93.

^'Dublin JonrnallMcdical Science, 1877, p. 562, and letter in Brit-
ish Medical Journal, lApril 13. 1S89.

1889.]

THE ETIOLOGY OF LEPROSY.

at Bergen — having contracted the disease while
in attendance on lepers. He knows, too, of many
other instances which can be, at an}- rate, most
satisfactorily explained by the theory of conta-
gion.

Dr. Phillippo, of Jamaica, gave me, last year,
his opinion as follows : " It is communicable by
contagion. This has always been the opinion
amongt most of the laity, and, with some reser-
vation, amongst manj' of the medical profession.
Of late years I have known some most undoubted
cases of contagion, and yet there have been many
instances of relatives who have for j-ears lived in
dail)' intercourse of the freest kind, as parents
and brothers and sisters, who have not suffered,
and a small number of those who undoubtedlj-

have I know of cases where there

was no hereditarj' disease in which one member
of a family has taken it from another. In one
case, the husband, a European, took it from the
wife. In him it ran a rapid course, and he died
before her, though she had it for years before him.
I know of cases in which this disease has been
taken from outsiders, and have heard of others in
which it has been taken from the wet nurse."

It is interesting to observe that Dr. Phillippo is
one of those authorities mentioned by Dr. Gavin
Milroy" as being opposed to the view that leprosy
is contagious.

Dr. A. R. Saunders (M.D., Lond., F.R.C.S.
Engl.), one of the leading practitioners (for 14
years) of Kingston, Jamaica, has recently in-
formed me that he has no doubt whatever as to
the contagiousness of lepros}-, and that he has
under his care at the present time in Jamaica
several cases which can only be explained by the
theory of contagion. He ridicules the idea of a
fish diet having anything to do with the disease.

Dr. Blanc, of New Orleans, states in the paper
quoted, his belief, after a studj- of these forty-two
and other cases, " that leprosy may be communi-
cated from a leprous to a non-leprous person by
means of a specific virus, which acts like a spe-
cific poison of syphilis, depending upon thin or
denuded surfaces for its absorption, and which
remains potent, very probably, for an indefinite
period of time."

The doctors in the Sandwich Islands are all
(and have been, with one exception, Dr Fitch,
report, Honolulu, 1886), believers in the conta-
gion of leprosy ; as are man\' of those at the
Cape, in India, in the West Indies, and else-
where. Dr. G. H. Fox, of New York," indeed
says, " Now it is generally admitted by those
who have most carefully studied the facts of the
case that leprosy is a contagious disease." He
further remarks that " granting leprosy is conta-
gious, we are forced to admit that it is so only to

1885.

7 In his report on Leprosy in the West Indies. 1875, p 30.

8 In his " Remarks on the Treatment of Leprosy," New York,

a verj^ limited extent." Most people will concur
in this.

Some of the ablest observers are still keeping
their minds open on the question. Dr. Beaven
Rake writes that he has met with no case of con-
tagion in Trinidad, but that he can bring forward
many negative instances. His inoculation ex-
periments on animals, too, have been so far un-
successful-— as were those which were formerly
practiced on the human subject in Norway, in
Mytelene, bj- Bargilli. and more recenth- in Sicilj-
b\' Profeta. Even Arning's experiment on the
convict at Honolulu, is, in Dr. Rake's opinion,
not conclusive. This man, Keann, was inocu-
lated September 30, 1884, b}- Dr. Arning, " after
having previously made a most searching inquiry-
as to any leprous taint in his famih', and a close
examination of his own bodj-," which examina-
tion, says Dr. Arning, " satisfied me that, as far
as I am able to judge, no trace of the disease
could be found on him at that time.' Dr. Beaven
Rake's valuable "Report on the Trinidad Leper
Asylum for 1888," has just been kindly sent to
me by the author. In it, in reference to this in-
oculation, he says, " When, however, we come
to examine this question dispassionateh*, what
do we find ? A man living on an island infested
with leprosy was inoculated three years' ago with
the disease and has now developed it. But in
that time he may have acquired leprosj- in a
dozen different waj-s, in air, food, water, etc., or
it maj' have been in his family. True, the man
was ascertained as far as possible to come of a clean
family, and he has been isolated in goal since the
inoculation. Still, anyone who has attempted to
take the statement of lepers will appreciate the
value of familj- histon.-, and in a country where
leprosy is rampant are we sure that it can be shut
out bj- four walls ? I repeat what I said in my
last report, that an experiment of this, kind, to
be scientifically perfect, must be performed in a
country free from leprosy, and in an individual
who has never left that country, and whose im-
mediate ancestors have always stayed at home.'*

Mr. C. Macnamara, then of Calcutta, discuss-
ing in 1866 the Indian Reports on Leprosj- in an
able article in the Indian Medical Gazette, stated
in addition to other arguments in favor of the
view of its contagiousness : "(i. A large pro-
portion of the civil surgeons in this presidency
believe, from personal obser\-ation, that the dis-
ease is contagious. (2.) The instances quoted
from this report can only be explained by sup-
posing the disease to be contagious."

Any opinion, however, which was favorable io
contagion prior to the j-ear 1867 went for nothing,
for in their celebrated and authoritative Report
of that year, the Royal College of Physicians of
London, made the sweeping statements, so often
quoted, that: "The all but unanimous convic-

9 Appendix to Report on Leprosy, Honolulu, 1886, p. 43.

122

PUBLIC HEALTH.

[July 27,

tion of the most experienced obser\'ers in differ-
ent parts of the world is quite opposed to the be-
lief that leprosj' is contagious or communicable
by proximity or contact with the diseased. The
evidence derived from the experience of the at-
tendants in leper asylums is especially conclusive
on this point. The few instances that have been
reported in a contrarj- sense either rest on imper-
fect observation, or they are recorded with so
little attention to the necessary details as not to
affect the above conclusion," More than 250
replies to the interrogatories of the College Com-
mittee had been received from medical men and
others located in the various leper centers, and a
large majority of these were undoubtedly in the
negative with regard to the communicability of
leprosy from person to person. Some 32 or so, on
the other hand, gave a more or less affirmative
answer in reference to the question ; and several
qualified men actually cited cases in support of
their views ; e.o-., amongst others. Drs. Aquart, of
Grenada ; Manget, of British Guiana ; Regnaud,
of Mauritius ; Jackson, Harris, and Messrs. Mac-
namara, and Rose, of India. On looking over
the report, it is difiScuIt to see why the opinions
of these gentlemen, many of whom had been for
years in charge of lepers, should have been, ap-
parently, considered so unreliable and worthless,
in comparison with the others. The College, it
seems, did not modify its views for years ; but in
1887 we learn that " the committee are quite
aware that there is much difference of opinion
respecting the communicability of leprosy, and
that manj' colonial practitioners and inhabitants
do not concur in the views expressed by the
College in their Report in 1867.'°

There is indeed, as the Committee now admits
(April 7, 1889), "increasing evidence respecting
the communicability of leprosy ;" and it seems
to me that we cannot ignore the cases reported,
and the opinions formed upon them, by such
qualified observers as \'andyke Carter in India,
Petersen and Miinch in Russia, Besnier, Vidal,
Leloir, and Cornel in France, and by many others
of large experience and of high repute in all parts
of the world.

In point of fact, however, any circumstances
-whatever — however strong they may be — which
apparently lend support to the contagion theor\%
so long as they occur in a country in which lep-
rosy is prevalent, are liable to be laid aside with
some such "begging-the question" remark as,
that "after all it onh' amounts to this, that a per-
son has become a leper in a place where the dis-
ease is endemic ! "

In conclusion, I venture to express the opinion

— after a .somewhat extended study of the subject

— that, with the facts at present at our disposal,

it appears to be a pure assumption, unsupported

.by valid evidence, to say that leprosy can on/y
. 9

'■'Vide "Leprosy Committee Report," R C. P., July 15, 1SS7.

gain a footing in the human body per unam viam.
Dr. Gavin Milroy, the secretary of the commit-
tee which scouted the idea of contagion, said, after
his visit to the West Indies, that "leprosy ap-
peared to him to be neither more nor less conta-
gious than scrofula." We have no reason to as-
sume that it may not be introducible in as many
ways, although, perhaps, with much greater dif-
ficulty. The problem will, possibly, be full}'
solved when we know the whole life history of the
microbe which is characteristic of the disease.

THE AMERICAN MEDICAL ASSOCIA-
TION AND ITS RELATIONS TO
PUBLIC HEALTH.

Read in the Section on State Medicine, at the Fortieth A nnual Meeting
of the American Medical Association. June 27, 18S9,

BY N. S. DAVIS, M.D., I..L.D.,

OF CHICAGO, ILL.

Although the primary and potent influence
that prompted the movement that resulted in the
assembling of the Convention of delegates in the
city of New York, May, 1846, to effect a perma-
nent National organization of the profession of
the United States of America, was the desire to
elevate the standard of professional education and
thereby increase the usefulness and honor of the
profession ; j-et even that preliminary' Convention
did not pass without initiating important meas-
ures having a direct bearing on the interests of
public health.

On the second day of that Convention, May 6,
1846, Dr. John H. Griscom, of New York City,
offered the two following resolutions, which were
adopted without opposition :

"Resolved, That a Committee of five be appointed to
consider the expeiiieiicy. and if deemed expedient, the
)itode of recommending and urging upon the several
State Governments the adoption of measures for a regis-
tration of the births, marriages and deaths of their sev-
eral populations.

"Resolved, That Mr. Lemuel Shattuck, of Boston ; Drs.
Jarvis, Dorchester, Mass.; Emerson, of Philadelphia ; T.
R. Beck, of Albany, N. Y.; and C. A. Lee, of New York,
be a Committee to prepare a nomenclature of diseases,
adapted to the United States, having reference to a gen-
eral registration of deaths, to report to a future Conven-
tion."

By vote, the mover of the resolution was added
to the Committee, as Chairman.

To constitute the Committee under the first
resolution, the President of the Convention ap-
pointed Drs. J. H. Griscom, Alonzo Clark, Charles
A, Lee, and James Stewart, of New York ; and G.
Emerson, of Philadelphia.

At the adjourned Convention, assembled in
Philadelphia, Mays, 1847, both these Committees
made able reports, that received the cordial sanc-
tion of that body. The report by the Committee
on Registration of Births, Marriages and Deaths,
contained a brief and pointed appeal addressed

1889.

PUBLIC HEALTH.

125.

to the several State Govemments, in favor of
the enactment of such laws as would secure a
general and uniform registration, and indicating
the benefits to be derived therefrom. It also
recommended the appointment of a Standing
Committee to take general charge of the subject
and annually report progress to the Association.
It further recommended that the several State
Medical Societies aid in urging the matter upon
the Legislatures of their respective States. These
recommendations were adopted, and after the
Convention had resolved itself into the American
Medical Associatjpn they were persistently prose-
cuted until there are but few States in the Union
without laws of more or less efiiciency on the im-
portant subject of vital statistics.

The important bearing of this movement made
at the threshold of this National organization
upon the interests of public health is more fully
appreciated when we remember that it is only by
a reliable registration of deaths and their causes
in the population of any city or country that we
are enabled to locate such deaths and compare
their ratio to the population in one locality with
another. This gained, the way is open for a care-
ful comparison of the conditions of the soil, water,
air, food, and personal habits, in the localities in
which diseases and deaths prevail most, with
those in which their ratio is lowest. And thus
indication for the sanitarj- improvements come
into the mind with all the clearness and force of
well ascertained facts.

The Standing Committee to take general charge
of the subject of registration, or vital statistics,
as recommended in the report to which I have
alluded, appointed by the Convention and ap-
proved by the Association after the completion of
its organization, in May, 1847, consisted of the
following members, viz.: Drs. J. H. Griscom, C.
A. Lee, A. Clark, and John D. Russ, all of New
York ; and G. Emerson, of Penna.; R. D. Arnold,
of Georgia ; and Mr. Lemuel Shattuck, of Mass.

Probably the first attempt to make a general
investigation concerning the hygienic and sani-
tary condition of the whole countrj^ was made bj^
the Medical Department of the National Insti-
tute, at Washington, D. C, in 1845, when a Com-
mittee was appointed, consisting of Drs. James
Wynne, Thomas Sewall, J. M. Thomas, Marcus
Buck, and Dr. Baile, of the U. S. Navy. This
Committee from time to time issued circulars ad-
dressed to members of the profession and others
in different parts of the country soliciting infor-
mation regarding the condition of the public
health and the causes supposed to be capable of
affecting it, in their respective localities.

At the second meeting of the American Medi-
cal Association, held in Baltimore, 1848, two
members of the Committe, Dr. James Wynne,
Chairman, and Dr. J. M. Thomas, attended as
delegates from the Medical Department of the

National Institute, and presented a memorial, not
only calling attention to the subject, but inviting
the Association to appoint a committee to take
charge of the further prosecution of the work.
In their memorial it was stated that many replies
to their circulars had been received and much
information of more or less value obtained, but
not suflBcient to justify the publication of a for-
mal report on so important a subject.

The memorial was received and referred to s
Special Committee for consideration. At a sub-
sequent stage of the meeting the Committee re-
^ ported, recommending the appointment by the
(President of the Association of a "Committee
'on Hygiene," to consist of twelve members, and
I with power to fill vacancies in their own num-
bers. [See Transactions of the Association, 1848,
pp. 38, 42, and 43.] The recommendation was-
adopted, and the President announced as mem-
bers of the Committee on Hygiene, Dr. James
Wynne, of Baltimore ; Dr. Isaac Parrish, of Phil-
adelphia ; Dr. Charles P. Gage, of Concord, N. H.;
Dr. Peter C. Gaillard, of Charleston, S. C; Dr.
:john M. Thomas, of Washington, D. C; L. P.
' Yandell, of Louisville, Ky.; Dr. John P. Harrison,
of Cincinnati ; Dr. Edward H. Barton, of New
Orleans ; Dr. Albert Smith, of Peterboro, N. H.;
Dr. John H. Griscom, of New York ; Dr. J.
[ Curtis, of Lowell, Mass. ; and Dr. Turner, of New
i Orleans.

Another subject of importance, and at least in-
directly affecting the public health, received
prompt attention at the same annual meeting,
namely, the adulteration and deterioration of
drugs. A long and very important paper on the
subject was presented by Dr. T. O. Edwards, of
Ohio, a member of the National House of Repre-
sentatives,' which was responded to by a memo-
rial to Congress urging the passage of proper
laws for preventing the importation and sale of
adulterated and worthless drugs.

It is thus seen that during the first year after
the completion of its organization this Association
i had entered actively upon the work of promoting
1 the public health in three directions, viz. : the
securing of reliable registration of births, mar-
riages and deaths ; 2. the direct investigation of
the causes of disease and the means for their
removal ; and 3. the securing of drugs of stand-
ard quality and purity. This third line of work
was prosecuted so efficiently that Congress soon,
enacted the necessarj- laws for the proper inspec-
tion of all imported drugs, and they have con-
tinued in operation until the present time.

At the second annual meeting of the Associa-
tion, which was held in Boston, May, 1849, the
Committee on Hygiene, composed of twelve
members, as already stated, made a brief general
report on the subject of drainage, street cleaning,
water supply, building and ventilation, nuisances,

' See Trancactions 1S48, pp 3S and 311.

124

PUBLIC HEALTH.

[July 27,

and disinfectants, and special reports on the sani-
tarj' condition of the cities of Portland, Concord,
Boston, Lowell, New York, Philadelphia, Balti-
more, Charleston, New Orleans, and Louisville ; on
the use of disinfectants in the Nav3% and on the in-
fluence upon health of the introduction of tea and
coffee in large proportion into the dietar\- of chil-
dren and the laboring classes, making in all 224
pages of the volume of Transactions for that year.
These special reports and papers present a
great variet}- of facts and observations of the
iighest importance, and to students of sanitary
science they afford the best indication of the
status of sanitary interests in this countr)- half a
centurj- since that can be found on record. This
is especially true regarding the special reports on
Boston and Lowell, bj' Dr. Josiah Curtis ; on
Philadelphia, by Dr. Isaac Parrish ; on Baltimore,
by James Wynne ; on Charleston, by Dr. P, C.
Gaillard, and on New Orleans, by Edward H.
Barton. The report of Dr. Curtis gives a ver}-
interesting history of the sanitary- measures and
public hygiene of Massachusetts from its early
Colonial settlement to the time he wrote, 1848,
including a valuable summary- of its vital statis-
tics.

In addition to the full reports from the Com-
mittee on Public Hygiene, the Standing Commit-
tees on Medical Sciences, and on Practical Medi-
cine, in their reports at the same meeting of the
Association, gave many facts of much interest
relating to public health, particularly in connec-
tion with the appearance of Cholera in New York
and in New Orleans in December, 1848, and other
epidemic diseases in various parts of the country.

The next annual meeting of the Association
■was held in Cincinnati, Maj-, 1850, when the
Chairman of the Committee on Hygiene, the late
Dr. Josiah M. Smith, of New York, presented
one of the most interesting and valuable reports
on the ' ' Sources of Typhus Fever and the Means
Suited to their Extermination," that I have ever
read. Regarding human or animal excretions as
the chief source of typhus and typhoid fevers, he
gives a very complete exposition of the composi-
tion aud quantity of the excretions from the human
body, iucluding the exhalations from the skin
and the lungs, and of the extent to which the
•walls, furniture and air of rooms, as well as the
soil and water, may become so contaminated as
to develop and propagate the essential causes of
continued fevers. Besides this report of the
Chairman, two .special reports were made by
other members of the Committee. One was
made by Dr. Edward Jar\-is, of Dorchester, Mass.,
on the "Sanitary- Condition of Massachu-setts
and New England," and is an excellent supple-
ment to the special report of the previous year,
by Dr. Josiah Curtis. The other was by Dr.
J. C. Siinonds, on the " Hygienic Characteri.stics
of New Orleans," and is a fitting complement to

the report of Dr. Barton the previous year. At
the same meeting of the Association in the report
of the Standing Committee on Practical Medicine
and Epidemics, made by Drs. J. K. ^Mitchell, R.
LaRoche, and Francis West, we have a very able
and detailed account of the great cholera epi-
demic of 1849, and embodying facts worthj- of
the careful study of investigators and practitioners
of the present time.

The annual meeting of the Association for 185 1
was held in Charleston, S. C, at which further
reports were made by the Standing Committees
on Public Hygiene, and on Practical Medicine
and Epidemics. It was at that meeting that the
' Standing Committees were abolished and a large
number of Committees appointed to report on
special subjects. The several States of the Union
were divided into eight groups, and a Committee
of three was appointed for each group, to report
on the prevalence of epidemics and their causes.
In the reports of these Committees at the meeting
of 1852, in Richmond, Va., may be found valu-
able information concerning not only the epi-
demics, but also of the topography and general
sanitary condition of the districts where the epi-
demic diseases prevailed, in most of the Eastern,
Middle and Southern States.

At this meeting, also, a vigorous movement
was commenced for improving the sanitary condi-
tion of ships carrj-ing emigrants across the seas,
and for compelling them to have on board compe-
tent surgeons to render proper care of such pas-
sengers as need their services. An able committee
was appointed aud instructed to memorialize
Congress on the subject, and to enlist the influ-
ence of the several State Medical Societies in the
same direction.

At each subsequent annual meeting, until 1859,
the Committees on the Topograph}-, Epidemics,
and Vital Statistics of the several States and
large cities made reports of such extent and value
that they occupy not le.ss than one-third of the
pages of the several volumes of Transactions for
those years. Experience had been demonstrating
from year to year the impossibility of hearing in
detail such an amount of material in the General
Sessions of the four days allotted to each animal
meeting, and hence the larger number of these
reports, as well as those made regarding other
departments of medicine, were read by title onh'
and referred for publication.

To remedy this defect, the eminent sanitarian
who is at present presiding over this Section of
State Medicine, in the annual meeting of 1859,
moved to .so amend the By-laws that the General
Sessions ot the Association during the annual
meeting should be limited to the morning of each
day, and the afternoon should be devoted to
meetings in a specified number of Sections. The
plan was earnestly supported by the writer of this
report and adopted by the As.sociation.

1889.]

PUBLIC HEALTH.

125

It provided for five Sections, namely : i, Anat-
•oru}- and Physiology. 2. Chemistry and Materia
Medica. 3. Practical Medicine and Obstetrics.
4. Surgery. 5. Meteorology, Medical Topog-
raphy, Epidemic Diseases, Medical Jurisprudence
and Hygiene.

These Sections were first organized and entered
upon their practical work at the next annual
meeting, which was held in New Haven in iS6o.
They have been rearranged and added to from time
to time until their number has been doubled.
But through all the changes thej- have invited,
received and caused to be published valuable con-
tributions relating to the public health every
year. So true is this, that the annual volume of
the Transactions of this Association from 1847 to
1882 contain the materials for a more complete
history of the more important epidemic diseases
that have prevailed in different parts of this
country during the last half-century, with a
■sj-nopsis of what had been put on record previ-
■ously, than can be found elsewhere. Accompany-
ing the numerous papers relating to epidemic
•disease is to be found a large amount of imforma-
tion concerning the topograph}-, soil, water and
meteorology of almost every State in the Union.
The same series of volumes contain papers and
reports from many of the most eminent members
of the profession on almost every question re-
lating to personal and public hj'giene and vital
statistics, whether in the city or in the countr}-,
•on board of ships, or in camps, prisons, or asy-
lums ; not even omitting the consideration of
foods and drinks. And through it all there is
•evidence of a constant and ever increasing de-
mand upon the various legislative bodies, State
and National, for the enactment of such laws and
municipal regulations as would remove all those
unsanitary and destructive influences resulting
from density of population and neglect of cleanli-
ness, ventilation, drainage and water-supply. All
these eSbrts in the National body were reflected
"back through their delegates to the State and more
important local societies. The effect upon the
legislative bodies has been slow, but constantly
■cumulative. At the date of the organization of
this Association, Massachusetts was the only
State having a law for the registration of births,
marriages and deaths, which had been enacted in
1842, and had been imperfectly- executed. Until
that period even the statistics of mortality were
chiefly obtainable only from the records of the
-various cemeteries belonging to the larger towns
and cities. Twenty-five years later Dr. Joseph
ISI. Toner, in a statistical report on Boards of
Health of the United States, records the existence
and regular organization of Boards of Health in
more than one hundred cities and towns, and
State Boards in seven States, namely, Massachu-
setts, Rhode Island, Virginia, Louisiana, Cali-
fornia, Michigan and Minnesota. (See Proceed-

ings of Am. Public Health Association, Vol i,
p. 499, 1S73.) Laws for the registration of vital
statistics had been enacted in a larger number of
States, and much influence had been gained both
in the profession and outside of it, in favor of the
establishment of a National Health Bureau. In-
deed it was this rapidlj- increasing number of
health boards and sanitary measures under the
diverse legislation of many States that led di-
rectly to conferences among the Health Ofiicers
engaged in practical work, for the purpose of
securing greater harmony of action. These,
commenced in 1872, led in the following year,
1873, to the permanent organization of the Ameri-
can Public Health Association, and its subsequent
career of usefulness. Later in the same year the
severe epidemic of cholera prevailed throughout
the Southwestern States, followed b)- an equally
destructive epidemic of yellow fever in 1878-79,
both of which served to greatlj- increase the
action of legislative bodies, whether National,
State or municipal, on sanitary measures. A
National Board of Health was organized under a
law of Congress, and although it proved of tem-
porary duration it was followed by such an en-
largement of the powers and duties of the U. S.
Marine-Hospital Service as makes it, in some de-
gree at least, a National health department, with-
out the name. And State and local Boards of
Health have become organized in nearly all the
States and commercial cities of the countrj^and are
annually increasing in their eSiciency and harmony
of action. In the accomplishment of these results,
this Association with its constituent organizations,
the State and local Medical Societies, has been
not onlj- the primary and chief force in moving
legislative bodies to action on measures for pro-
tecting and improving the public health ; but it
has been steadily accomplishing an equally im-
portant work in educating the profession itself to
a better appreciation of the nature and impor-
tance of preventive medicine, or sanitary science.
And so far from having completed its work in
either of these directions, it has only made a fair
beginning, and improved its methods and imple-
ments for more efiicient progress.

A knowledge of the causes of disease, their
modes of development, the conditions under
which they are capable of maintaining an active
existence, and their modus operandi in the human
system, must constitute the basis of preventive
medicine and the only reliable guide to the adop-
tion of such sanitary measures as will practically
limit the prevalence of diseases and permanently
lower the ratio of mortality wherever they may
be instituted. That knowledge, which consists
in the simple discovery or identification of the
specific cause of a disease and its a.s3ignment to
its proper scientific position among the myriads
of organic germs, or in the long list of chemical
products, is not sufficient for the successful prose-

126

MEDICAL PROGRESS.

[July

cution of measures for the protection of the public
health. Such identification is but a single item,
though a very important one, in the series of
facts needed for a successful warfare against the
enemies of human health and life. Everj- living
pathogenic germ must have its own pabulum or
food and certain phj'sical conditions of tempera-
ture, moisture, etc., for its development and
propagation ; and experience has shown that in
a majority of instances measures for the removal
of the pabulum, or for controlling some of the
essential conditions, are more efficient in prevent- '
ing its development than any measures for the
direct destruction of either the living germ or the
chemical ptomaine. 1

Therefore it becomes as necessarj- for the sani- j
tarian to identify the materials in the soil, the i
water, the air, and in the living body, capable of I
feeding pathogenic germs or entering into the
formation of ptomaines, as to discover the specific
disease-producing agent itself. To cover the
whole field of investigation successfullj- it is i
necessarj' to have the cooperation of all classes
of workers in the profession. The carefully re-
corded obser\-ations of the general practitioner
and of the specialist in their direct dealings with
diseases and injuries, fixing the dates of their
occurrence, progress and results, are as necessary
to the proper understanding of the causes of dis- \
ease and the conditions under which thej- are :
developed as is the most skillful work in the la-
boratories of the microscopist and the chemist.

It is only by the cooperation of observers occu-
pying difierent standpoints of observation that \
the investigation of etiological subjects can be
made complete, Consequenth- there is no medi- ,
cal organization in our countr}- better adapted
for the prosecution of such work than this Asso-
ciation, with its Sections covering all departments
of medical science, and its Journ'.\l through
which the work of each becomes quickly dis-
tributed to the whole.

I trust, therefore, that this Section will not
only continue a vigorous prosecution of inves-
tigations pertaining to the public health and pre-
ventive medicine, but will also so systematize
the work as to render it more reliable and com-
plete.

MEDICAL PROGRESS.

Phlegmonous and Gangrenous Processes
IN Diabetes. — Although the occurrence of pur-
ulent and gangrenous processes as the result of
diabetes has been known for a long time, yet but
little is known regarding the etiologj-, diagnosis
and treatment of these processes. Formerly their
etiology was sought in a specific action of sugar
upon the tissues. Since Konig it is universally

believed that especially diabetic phlegmon is the-
result of an infection the same as other phleg-
mons. As regards diabetic gangrene, Schiiller is-
of the opinion that it is caused b}' acute arterio-
sclerosis and previous inflammations induced by
pus-cocci. For the diagnosis of diabetic phleg-
mon the following points seem to be of impor-
tance : Development from an insignificant injurj',
its combination with gangrenous processes, and
its obstinacy.

Regarding the diagnosis of diabetic gangrene, its
occurrence in still robust, relatively not old peo-
ple, consequent upon some slight injur}' or in-
flammation, and its painfulness, are significant.

Concerning the treatment of phlegmonous and.
gangrenous processes. Max Schuller (Berlin
Klin. Wochenschrij't, Xos. 47, 48, 49, 1888), ad-
vises an early surgical inten.'ention, and warns-
against delay for the purpose of a previous gen-
eral diabetic treatment : he considers local, sur-
gical, especially antiseptic treatment at the begin-
ning as more important than the former. The
greatest stress must be laid upon the treatment of
the phlegmon itself, and its rapid and easj' spread-
ing must be fought against energetically with ex-
tensive incisions, draining and rinsing, and baths-
with antiseptic fluids, even more energetically
than in common phlegmons in patients not affect-
ed with diabetes. In diabetic gangrene the con-
ditions are more unfavorable. Local treatment
must likewise be strictly antiseptic. If the phy-
sician succeeds in this way in obtaining a line of
demarkation or in confining the gangrene, the
part affected must be removed from the healthy
portion with strictest antisepsis ; if the gangrene-
can not be checked, at least the patient's life maj'
be saved, as Konig has shown, \>y antiseptic am-
putation.

From a prophylactic standpoint the author ad-
vises the strictest attention to even the slightest,
injuries, in view of the great vulnerability of dia-
betic patients and their tendency to phlegmonous
and gangrenous processes. — Wiener Medicinische
Wochenschrift, No. 17, 1889.

Regarding Gl.\ndular Xerves. — In exam-
ining the tongue of a rabbit after injection with
methyl-blue, Retzius (Verb. d. Biolog. Vereins,
of Stockholm, I, No. i) found in the vicinity of
the papilla foliata the little glands in that region
overspun with ner\'e fibres colored a beautiful
blue. Alongside the glands he saw little nerve-
trunks whose axis-cylinders were blue, and from
these single fibres branched off that ran toward the
alveoli of the gland to divide again into branches-
there. These nerve fibres were varicose and so-
thin that they had to be regarded mostly as end
fibrilli. They surrounded the alveoli of the gland
in all directions like nooses, lay evidently close-
upon the membraua propria, and formed a rich
network closely surrounding the alveoli. Iiii

1889.]

MEDICAL PROGRESS.

127

some alveoli it seemed to Retzius that these fibres
ended in cells, but he could not discover them
entering these cells.

Through this observation we have progressed
a step in the important question of the glandular
nerves, inasmuch as we have here the last branch-
es of the glandular nerves on the alveoli of the
glandular cells, and these nerve-fibres proved verj'
abundant and fine. — Ccniralblatf fur Physiologic,
No. 2, 1889.

On the Indications and Prognosis of the
Operative Treatment of Abdominal Tu-
mors.—In a paper published in Orvosi Hefilap, No.
48, 1888, W. Tauffer, of Budapest, sa3's :
" Everv^ movable ovarian tumor, of at least the
size of a fist, if diagnosed with certainty, should
be removed, and the sooner the better. Ovarian
tumors located between the ligaments, deep in
the pelvis, are so dangerous to approach (because
of their close proximitj' to large vessels, the
urethra, etc.,) that their removal should be post-
poned until, rising from the pelvis, thej' begin to
distend the abdominal walls and have thus be-
come more accessible. Neither youthful or ad-
vanced age, nor malignant character of the tumor,
kidney or heart affections, tuberculosis, extensive
adhesions, acute peritonitis or a purulent character
of the swelling should be considered an obstacle
to the operation if the life of the patient appears
to be endangered, and an improvement by the
operation seems possible."

Despite these comprehensive views on the indi-
cations for operation, Tauffer lost of 172 ovario-
tomies (in ten of which supra-vaginal amputation
of the uterus was necessary because of compli-
cated conditions) only eighteen, /. t\, ten (4 per
cent.), seven of these (4 per cent. ) from sepsis.

The indication for ovariatomy Tauffer puts as
follows: I. Pathological changes in the position
of the ovaries if causing acute symptoms and not
curable otherwise. 2. Complete absence on de-
ficient development of the uterus with normal
ovaries, if ovulation causes intense pain. 3. Such
diseases of the uterus as influenced bj- ovulation,
heal after cessation of the latter (like intra-mural
and some subserous myoma, fungus growths of
the endometrium constantlj' returning, membra-
nous dysmenorrhoea, many retroflexions not to
be cured in any other way, etc.). 4. Chronic
inflammation of the ovaries and their surround-
ings in cases where the entrance of blood accom-
panying evolution keeps up and constantl}- re-
news the inflammation. 5. Such acute diseases
of the ner\'es as seem to be connected with ovu-
lation and menstruation.

The thirty- ovariotomies and salpingotomies
made b}^ Tauffer passed off" without a fatality.

The radical treatment of tumors of the uterus
he considers indicated : i. In dangerous hsemor-
rhages which cannot be cured in any other way.

2. In symptoms of pressure which endanger the
life of the patient, for instance, considerable push-
ing upward of the diaphragm, horizontal position
of the heart, pressure on the large vessels, danger
of incarceration, unbearable pains, etc. 3. If the
tumor is growing rapidl3-. 4. If anj' compli-
cation dangerous in itself exists, or the vitality of
the patient is sinking. Each of these conditions
indicates the advisability of an early operation.
In fifty-one cases of hysterotomy Taufl"er had
twelve with fatal results, /. c, a mortality of
22.2 per cent. Regarding the treatment of
the pedicle, Tauffer is a partisan of the extra-
peritoneal method. In thirty-five other cases,
only explorative incisions were made, or after
opening the abdomen such adhesions of malig-
nant tumors to the peritoneum or the intestinal
walls were found as to make extirpation impos-
sible ; of these thirtj'-five cases, twenty -one ter-
minated fatally sooner or later, whilst fourteen
were cured by the operation.

Finally TauflTer mentions seven laparotomies
with the following indications : Ancient irreme-
diable inversion of the uterus ; ileus caused by
carcinoma of the intestines ; twice extra-uterine
pregnancy at the end of the pregnancy ; twice
hydronephrosis, and once loosening of adhesions
which held the uterus in a retroflected position. —
Ccntralblat fiir Gymikologic, No. 20, 1889.

A Case OF Hemisystoly. — Dr. Dehio demon-
strated before the Medical Faculty of Dorpat
sphygmographic courses taken from the radial
arterj' and the neck veins of a patient with heart
disease, in whose case there had been diagnosed
an insufficienc}' of the mitral with grave com-
pensatory disturbance and secondary' relative in-
sufficiency of the tricuspid valve in consequence
of the dilatation of the right ventricle. Pa-
tient suffered from grave engorgements in the
course of the great circulation, general dropsj^
ascites, hydrothorax, orthopnoea, and during the
last week of his life the well-defined s}'mptoms of
hemisystoly of the heart, 80-76 contractions of
the heart per minute could be distinctl}- counted
by the aid of the stethoscope, but on the radial
artery, as also on the carotid, just half as many
pulsations (40-38) could be felt, so that there
were two systolic and two diastolic tones for each
perceptible arterial pulsation. Besides the sj'sto-
lic tones systolic murmurs could b^ plainly heard
at the apex and at the lower end of the sternum.
Simultaneously pulsation was plainlj- noticeable
at the veins of the neck. Pulsation in the liver
could not be established because of the ascites.
The tracing upon the radial arterj- shows conclu-
sivelj- that this was a case of alternating pulse, a
low pulse-wave between two high ones being dis-
tinctly visible in the descending portion of the
cur\-e ; to be sure, this spot had become so small
that the palpating finger could no longer feel it.

128

MEDICAL PROGRESS.

[July 27,

The tracing from the neck veins, on the other
hand, show plainly two positive pulse-waves fol-
lowing each other rapidly, and separated by a
longer pause from the next pair (pulsus bigemi-
nus). The first wave of each pair corresponds
with the perceptible radial pulse, the second is
also in the neck veins, clearly shorter and almost
always lower than its predecessor ; only during
expiration, when the obstruction in the neck veins
became especially severe, the second wave was for
a few days just as high as the first of the twin
waves, or even a little higher.

This observation confirms the view advanced by
Friintzel that the so-called hemisystoly of the
lieart must be regarded as the highest stage of the
pulsus bigeminus, during which the second wave
of the twins becomes so small that it is no longer
perceptible in the arteries of the great circulation.
That the right ventricle produces alternately a
strong and a weak pulse-wave the same as the
left ventricle and isochromally with the latter, is
demonstrated by the curves exhibited. A hemi-
s^-stoly as understood by Leyden, where the two
ventricles act independently from each other, so
that the right one within a given time contracts
twice as often as the left, certainlj- did not exist
in this case. — S/. Petersburger Mcdicinische Wocl.i-
£7isckri/t, No. 18, 1889.

A Case of Heart Thrombosis in Myocardi-
tis Fibrosa after Scarlet Fever, and Im-
bedding OF A Portion of the Left Vagus in
Callus Connective Tissue. — Sommer reports
in the Charitc Annaloi, 1888, the case of a boj-
10 years old who, nine weeks after recovery from
scarlet fever, was taken with symptoms which led
the author to suppose a hasmorrhagic nephritis
with disease of the heart muscle. Later on sjmip-
toms of consolidation above the left lung, oedema
of the legs and constantly diminishing diuresis
occurred, and the heart symptoms became promi-
nent. The examination of the heart when the
boy was first received showed an extending of dul-
ness toward the right, extending 2 cm. bej-ond
the sternal line. The apex beat lies in the sixth
intercostal space. In the course of the disease
the pulse became alternating, greatly accelerated,
1 36-1 44-1 50, easily suppressible. I3eath ensued
•with symptoms of heart failure. At the post-
mortem the heart was found to be greatly enlarged,
both ventricles being much dilated with numerous
parietal thrombi. The myocardium was largely
replaced bj- den.se connective tissue. Embolic in-
farcts in lungs, spleen and kidneys. No neph-
ritis. The left vagus is surrounded by coarse
fibrous tissue which originates from ca.seous and
■calceous lymphatic glands. The microscope
showed numerous granular cells, indicating de-
generation in the compressed portion of the vagus.
Supported by the investigations of Wasilief re-
:garding the trophic relation of the vagus to the

heart muscle, Sommer supposes the changes in
the heart to have been caused bj- the scarlatina
and the partial degeneration of the left vagus. —
Ccntralblait fi'ir Klinische Median, Xo. 20, 1889.

Formation of Ptomaines and Toxines by
Pathogenic Bacteria. — In a report to the Royal
Academy of Sciences in Berlin, L. Brieger calls
attention to the interest which attaches to the
alkaloids produced by pathogenic bacteria, and
makes public the results which he obtained by
examination of the cultures of typhus bacteria on
freshh- peptonized blood albumen. He found in
it neuridin (C H;,Nj), which is isomeric with
cadaverin ; furthermore, mydin (C,Hii^O). which
he had found so far onh- once in preparing human
bodies. This ptomaine forms a picrate (melting-
point 195°) cr\-stallizing in broad prisms, a chlor-
hydrate cr\-stallizing in colorless little plates, an
easily soluble chloro-platinat ; it reduces a gold
solution immediately, as also a mixture of chlor-
ide of iron and c\-anide of calcium and iron.
The free base has a strong alkaline reaction, and
the smell of ammonia. Besides these two pto-
maines the author obtained several times an ex-
tremely poisonous toxine which causes severe
purging, sometimes also blood}' urine, but has
not been examined yet accurately. The author
calls attention to the surprising circumstance that
no ptomaine causing inflammation or necrosis
could be separated from the typhus cultures.
Finally he mentions that milzbrand bacilli have
' an ox}-idizing effect and produce some methyl-
guanidin from creatin ; but this occurs only when
these bacilli are cultivated in bouillon containing
I peptonized blood albumen ; in pure bouillon cul-
\ tures another ptomaine originates which is not
I well known yet. — Centralblatt fiir Physiologie,
No. 3, 1889.

Thrombosis of the Cavernous Sinus. —
' Prof. Nothnagel recently related a case of
which the diagnosis was thrombosis of the cavern-
ous sinus. (/?(■:'. Gai. dc Clin, et dc The rap., No.
j 26). The patient, aged 70, three years ago suf-
fered from severe pain on the right side of the head,
resembling neuralgia of the fifth nerve. Later there
occurred diplopia and strabismus, which after-
wards was succeeded by immobility of the eyeball,
; There is now closure of the right eye, cedema of
I the upper eyelid and right cheek, increase of tem-
perature of that side of the face, and attacks of tic
douloureux; ansesthesia involving the same region
and also the tongue, conjunctiva, and cornea ; vas-
cular injection of the conjunctiva ; intense keratitis
I and iritis. These .symptoms referable to involve-
l ment of the fifth nerve and all the ocular nerves
suggested a localized lesion at the base of the brain
and were most likely due to cavernous thrombosis,
caused probably by localized chronic meningitis
rather than a tumor. — The Lancet, July 6, 1S89.

1889.]

EDITORIAL.

129

Journal of the American Medical Association

PUBLISHED WEEKLY.

Sttbscription Price. Including Postage.

Per A>'num, in Advance $5.00

Single Copies 10 cents.

Subscription may begin at any time. The safest mode of remit-
tance is by bank check or postal money order, drawn to the order
of The Jourx-^l. When neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
letters.
Address
JOURNAI, OF THE AMERICAN MEDICAL ASSOCIATION,
No. 65 Wabash Ave.,

Chicago. Illinois.
All members of the Association should send their Annual Dues
to the Treasurer, Richard J. Dunglison, M.D., Lock Box 1274, Phila
delphia, Pa.

London Office, 57 and 59 Ludgate Hill.
SATURDAY, JULY 27, 1889.

THOM.\S KEITH ON FIBROIDS OF THE

UTERUS.

In the present number of The Journal will
be found a very comprehensive article by Dr.
Apostoli , of Paris, on ' 'The Treatment of Salpingo-
ovaritis b\- Galvanism." In this connection it is
very interesting to notice the high estimate in
which Apostoli's treatment of fibroids of the
uterus is held by so eminent an abdominal sur-
geon as Mr. Thomas Keith, as advanced bj^ h^™
in an article in the British Medical Journal, of
June 8, 1889.

Dr. Keith, in the beginning of this article,
deals with the assertion advanced hy many of
the opponents of electricity, to the effect that
Apostoli's method is nothing but the revival of an
old process, by giving the information that he
was an assistant of Sir James Simpson at the time
the latter was experimenting with the " so-called
' discussion ' of uterine and ovarian tumors, ' '
and that now he "doubts if any electricit}- got
into the body at all b}- the old methods, and, if
this did so happen no good could have come of
it for the interrupted current was always used."

Since those days he has carefuUj- watched the
many attempts to introduce electricity for the treat-
ment of uterine tumors, but there was nothing to
encourage him to try any of them. Drs. Kimball
and Cutter certainly cured some, he thought, but
he has too lively an impression of the risk of in-
serting large needles through the abdominal wall
into the tumor to think of adopting that method.
Dr. Keith's watching brought its reward, however,
for he says :

"The only treatment not surgical worth speaking
about that I have seen do any good, and which at the
same time, is one free from danger to life if the treat-
ment be undertaken by one who has respect for a strong
electrical current, is that brought before us by Dr. Apos-
toli. If any one should have held on firmly to hvsterec-
tom)- it is myself, for my results after it are better than
any other. I have, however, thrown over all surgical
operations for this new treatment, and the longer I fol-
low it the more am I satisfied

" To the surgeon, no doubt, hysterectomy is the good
and simple plan. He may have his bad quarter of an
hour at the operation, but then he has practically done
with the case, and he gets his result quickly, sometimes
more quickly than he cares for. If the patient
recover there is pleasure all around ; if things go badly
and the patient die, he bewails his bad luck, as it is
called, .... waits a little, and then, though rather
unwillingly, does another. He resents any other treat-
ment than that by the knife. He especially resents
Apostoli's treatment of fibroids bj' electricity, for the re-
sult is long in coming ; it is a slow treatment, requiring
great patience, great tenderness of manipulation and

much thinking But with patience the result

is certain There is no mutilation, a thing

abhorent to most women It puts a woman

with a fibrous tumor, who suffers much, into the position
of a woman with a fibrous tumor who does not suffer or
may be even unaware of its presence. It does not bring
about the disappearance of the tumor, or it does so very
rarely, but the size is lessened more or less — one-half,

one-third, two-thirds Tension is taken off

everywhere, all around, and bladder irritabilitj' from
pressure, a common cause of distress, is relieved. In a
word, the woman is made well, her whole life is changed.
All this can be done without danger to life, and if there
be pain during the time the current passes the fault is in
the operator. What more does a reasonable woman who
has suffered much desire or need ?

"What have those to offer in place of all this who
have so bitterly opposed this treatment, who with unlim-
ited material stand aside and will not take the trouble to
investigate the matter for themselves, but wait till some-
one else does it for them, who make onlj- an outcry if by
chance they hear of any accident during the progress of
the treatment of any case, and who go frantic over the
rumor of a death, or worse still, who proclaim they know
of deaths that never happen ? These men have absolutely
nothing whatever to offer in the bad cases, and only hj-s-
terectomy in such tumors that will come out more or less
easily, so as to be treated by the extra-peritoneal method
of operating. I have seen not a few cases of bad bleed-
ing fibroids since I came to London, almost everj-one had
consulted one or other surgical authority on the subject of
operation. These were invariably told that nothing
would do them any good but the removal of the tumor ;
but in their special case the local difficulties were too
great, or thev had let their strength go down too far for
such an operation. The ver\- feeble and bad cases, with
masses of tumor blocking the pelvis, with absence of cer-
vix, and opened-out broad ligaments, would seem to be

I30

INSANE ASYLUM INVESTIGATIONS.

[July 27,

let alone. Hysterectomy then, at best, would appear to
be a most doubtful remedy for a certain number of cases,
and these not of the worst sort. On the other hand, the
worse the case, the more feeble the patient, the greater
the loss of blood, the more marked is the result of elec-
trical treatment. Given a woman with a large bleeding
fibroid, blanched almost to death from years of haemor-
rhage, and see her some months after this treatment is
completed, you would scarce!}- recognize her, the im-
provement is so great." ....

In an experience with his method in the treat-
ment of a large number of cases, Dr. Keith has
to mourn the loss of but one life, and of this he
says :

" I do not say that the treatment was of itself the
cause of death, which, I am satisfied, need not have hap-
pened; and in this I am borne out by the opinion of the
patient's brother, a medical man

" The old spirit that at one time would have no abdom-
inal surgery still unfortunately lingers amongst us. Elec-
tricity in any form, when applied to the cure of disease,
is set down as pure quackery by many medical men, sim-
ply because thej- know nothing about it, and won't take
the trouble to learn for themselves what to many is rath-
er a hard study

"What I now plead for is that, for a time, all bloodj- !
operations for the treatment of uterine fibroids should |
cease, and that Dr. Apostoli's treatment, as practiced by 1
him, should have a fair trial. Those who have hitherto ;
most resisted the introduction of electricity are the sur- 1
geons who are the best competent to carry it out. They
are accustomed to manipulate in the pelvis, and they will
not make mistakes in the diagnosis, or make them as
seldom as it is possible to do. Hysterectomy, remember,
which is performed ever\- day for a complaint that rarely
of itself shortens life, kills every .fourth or fifth woman
who is subjected to it. This mortality must cease; it is
not a question of surgery, it is a question of humanit}-.
Every time that any disease can be cured without resort-
ing to a bloody operation such as hysterectomy, progress
is made in our art, and there is a gain to humanity, while
surgery is the better for being purged of a deadly opera-
tion. It may seem strange to some that after the results
I got in hysterectomy — results that almost made it justi-
fiable— I should now begin to throw stoues at the opera-
tion instead of trying still further to improve upon it;
and but for Dr. Apostoli, I would now be doing so. I
would give something to have back again those sixty-four
women that I did hysterectomy for, that I might have a
trial of Dr. Apostoli's treatment upon them; and I would
give something never to have had the wear and tear of
flesh and spirit that these operations cost me, for in
scarcelj- one of them was the operation simple.

" I have said my say, and it must not be forgotten that
the opinion here expressed as to the value of Dr. Apos-
toli's treatment is not that of an unsuccessful surgeon,
but is the deliberate opinion of one who was the first to
lower to a minimum the mortality that so long followed
abdominal surgery, and who, by the best results in hyster-
ectomy— results that Dr. Playfair is pleased to call almost
phenomenal — still retains the position."

INSANE ASYLUM INVESTIGATIONS.

Recent events, too familiar to our readers to
call for special mention, have set in motion one
of those periodical waves of popular distrust in
regard to the treatment of the insane in public
institutions, which from time to time sweep over
our country, leaving behind them some wrecked
reputations, but too often, accomplishing little
but destruction. While the excitement lasts the
innocent are apt to sttffer with the guilts- ; when
it subsides things settle back into ver}- much
their former condition. We do not propose, at
present, to discuss particular cases, but to sug-
gest some general considerations which it seems
to us well to bear in mind when such charges are
made.

In the first place, there is no class of cases in
which the maxim that a man is to be held inno-
cent till he is proved guiltj-, is more applicable
than this. The Superintendents of asylums for
the insane, as a class, are by no means inferior to
the average of our profession, either in attain-
ments, character or disposition. Their position
exposes them to constant assaults upon their rep-
utation. No degree of humanity or tact will pro-
tect them from charges founded in the delusions
or malice of their patients, and those who are
most faithftil and vigilant in guarding against
abuses and enforcing discipline are most certain
to incur the ill-will of lawless and vicious subor-
dinates. Accusations coming from such sources
may demand investigation, but thej- should be
looked upon with suspicion, and if thej- are
eagerly caught up and assumed to be true b}- the
public, men who value their reputation will be
likely to seek some other employment. Even the
much-abused attendants are entitled to the same
charit}'. In all well-regulated institutions they
are selected with great care among numerous ap-
plicants ; the}' are carefulh- instructed in their
duties, and whatever may be the shortcomings of
some of them, it is safe to say, that as a class,
they are caring for the unfortunates under their
charge with more skill and patience than most of
their critics would exercise in their place.

In the second place, when abuses are discov-
ered, the responsibility should be placed where it
belongs. If an institution of this kind is made a
part of the spoils of partisan politics, if its funds
are used to enrich mercenarj- politicians, and its
offices to reward their heelers, the community

1889.]

EDITORIAL NOTES.

-which allows such a state of things has no occa-
sion to be surprised or shocked if its insane are
•crowded into insufiBcient and unsafe quarters, if
they are hungrj' and naked, if they are neglected
and abused by iucompetent and vicious atten-
dants. The guilt is not confined to those per-
sonall}' concerned in such abuses, it is shared by
those who, actively or passively, have abetted the
system which gave them their opportunities for
mischief. To rest content with their punishment
■while the system remains unchanged would
"be merely setting another set of wolves to watch
the sheep. It may be said in general that at-
tempts to combine a poor-house and an asylum
for the insane under the same management, have
not usually had very satisfactorj- results, at least,
so far as the latter is concerned. The standard
is apt to be set by the accommodations and treat-
ment allotted to paupers, and whether sufficient
for them or not, it is not suited to the needs of
the insane.

Finally, it is, in our opinion, questionable
■whether, in some instances, the well-meant ef-
forts of friends of the insane to improve their con-
dition have not had results which were not fore-
seen nor desired. The abolition of mechanical
restraint, for instance, has been advocated in some
quarters with an enthusiaism which seemed to
make it an end to be obtained at any cost, rather
than a means of securing the comfort and im-
provement of the patients. It might be imagined,
from some of the accounts which have been pub-
lished, that interference with the personal liberty
of the insane was the cause of all their miscon-
duct, and that an asj-lum for their care and treat-
ment would run itself, to the satisfaction of all
concerned, if the patients were only allowed to
do as they pleased, without interference, except
by way of friendly suggestion from physicians
and attendants. Now the fact is, that some of
the hisaiu- are no more amenable to reason than
the sane. Tact, patience and kindness will work
-wonders in many cases, but there are those who
can only be restrained from mischief by physical
force in one form or another, and others with
whom the only alternative is fear. Attendants
are expected to control their patients. Their
reputation, and the comfort and safety of their in-
offensive patients, as well as their own, depend
upon their keeping the disorderly and violent in
subjection. To struggle, for hours at a time, day

after daj', with a powerful man, or to be continu-
ally subjected to assaults from one who under-
stands and presumes upon his impunity, is a
pretty severe strain upon the mildest disposition,
and, though unfortunate and wrong, it is not
strange that human nature does not alwaj's en-
dure the trial. We have reason to think that in
some cases where the use of mechanical restraints
has been forbidden in the quiet and order of the
wards, so gratifj'ing to officers and visitors, has
been due in part, to the clandestine use, by atten-
dants, of still more objectionable means.

The proper care of the insane is a work of
sufficient difficulty to task all the resources of the
best mind. Routine and inflexible rules, whether
self-imposed or dictated from without, will often
stand in the way of the best results. The physi-
cian may be helped by the suggestions or exam-
ple of others, but if he has not sufficient intelli-
gence and humanity to be trusted with the care
of his patients, the probability is that little will
be gained bj- hedging him about with vexatious
restrictions ; if he has, they are more likely to do
harm than good.

It is well that those who have the care of this
most unfortunate and defenseless class should feel
that abuses and neglect cannot pass unknown or
unpunished, but public opinion, in such cases,
should be not only a terror to evil doers, but a
praise to them that do well. Nothing can be, in
the long run, less for the interest of the insane
than indiscriminate condemnation of all who are
engaged in caring for them.

EDITORIAL NOTES.

HOME.

The American Rhinologicai. Association
will hold its Seventh Annual Meeting at Chicago,
Aug. 28, rg and 30. The Committee on the Ex-
aminations of the Inmates of Insane Asylums
will make their report on "The Relations of
Rhinal Inflammations to Mind Aflfections" at this
session.

Leprosy in New Ori,eans. — A despatch to
the daily papers, dated July 21, says : Investiga-
tion of the case of the young man, James Kava-
naugh, in Algiers, who is sufi'ering from tuber-
cular leprosy, discloses the fact that his companion
and associate a few years ago was a man named

132

EDITORIAL NOTES.

[July 27,

Mallegar, who resides in the Third District, near |
the mint. This man was afflicted with the loath- [
some disease and Kavanaugh was constantly in
his company, at times ate with him and drank out
of the same vessel that he did, and it is evident that
he contracted the disease b\- so doing. There are
now under observation several suspicious cases
which the Board of Health will send a corps of
experts to Algiers to inquire into.

The State University of Texas will soon
have a fine building for its Medical Department.
Galveston recentlj* appropriated $25,000 towards
its erection.

Dr. Henry M. Hurd, of Pontiac, Mich., now
Superintendent of the State Lunatic As3-lum at
Pontiac, has been appointed Superintendent of
the Hospital of Johns Hopkins University.

The Treatment of Sunstroke. — Dr. Wm.
F, Waugh contributes to The Dietetic Gazette the
following : In true sunstroke we have succeeded
best at the Medico-Chirurgical Hospital by giving
antipyrin internally or hv hypodermic, in doses
up to 30 grains, and applying ice energeticalh',
externally and in the rectum, until the tempera-
ture descended to the level of safety. The great
majority of cases, however, are really of exhaus-
tion, due to heat and free drinking, with conse-
quent perspiration and loss of salts. Small doses
of brandy, ammonia, wine of coca, selecting a
really eflScient varietj-, and hot coffee are effica-
cious at first ; followed by a hot bath, hot beef-
tea, quinine, or Huxham's tincture. The use of
ice-water gives rise to unquenchable thirst. Free
imbibition of fluids causes loss of appetite. An
excellent beverage for Summer is thin oatmeal
gruel, with salt, but no sugar, taken as hot as can
be swallowed.

Tennessee Medical Examining Board. —
The Times-Register says: Tennessee has now a
Medical Examining Board, and the Governor
with singular good judgment has given to the
State Medical Society the privilege of recom-
mending three members of this Board, he to
nominate the fourth regular practitioner. Elected
in such a manner the Board is likely to be both
competent and just.

foreign.
In Spain the Sociedad Espaiiola de Higiene

has formulated an appeal to the authorities ask-
ing for the establishment of a public system of
disinfection, and the rigorous enforcement of the
measures for that purpose approved of by the
Vienna Congress of Hygiene.

In Great Brit.\in the recent election to fill
the vacancies in the College of Surgeons caused
by the retirement of Sir James Paget, Mr. Hulke
and Mr. Heath, resulted in the return of the two
latter gentlemen, who sought reelection, and Mr.
Howse. At the last meeting of the British Lar-
yngoiogical and Rhinological Association, Dr.
Philip Smyly, of Dublin, was elected President
for the coming year, and the following gentlemen
were elected Honorary Fellows of the Association:
Professor Voltolini, Breslau ; Professor Massei,
Naples ; Dr. Solis-Cohen, Philadelphia ; and Dr.
Fauvel, Paris. Hundreds of applications have
been received for the position of Director-General
of the Naval Medical Reserve. The Proiincial
Medical Journal says : A boy recently died of
hydrophobia near Bradford — at least so it was
said at the Coroner's inquest; but, strange to saj',.
the dog which inflicted the bite also appeared at
the inquir}', sound and health3% from which we
draw the conclusion that the boy did not die of
hydrophobia. The British journals are strongly
advocating the stud}- of shorthand by medical
students.

Prof. Francis Cornelius Donders, the emi-
nent ophthalmologist, died recently at the age
of 71.

An International Courtesy. — The British
Medical Journal pays a well deserved compliment
to Dr. John S. Billings, reciting the valuable
work which he has accomplished and the honors
to which he has attained. It is gratifying to the
American profession that such an able man is
numbered in its ranks, and to know that he is so
well appreciated in other lands.

Professor Billroth completed his sixtieth
year on April 26, but was absent from Vienna at
the time. On his return the students and his
friends prepared a splendid ovation for him. Dr.
Sjsrgerwitch, Minister of Public Instruction of
Servia, presented the Professor with the Grand
Cross of the St. Sava Order, and the \'ienna stu-
dents presented him with a medal which bore on
one side his portrait, with these words: Theodo-
riis Billroth, tctatis sine Ix ; on the other : Medico

1889.]

SOCIETY PROCEEDINGS.

133

artifici, viro optimi pietate co7ijuncfi discipuli et so-
dalcs. Professor Billroth was also the recipient
of several other distinctions on this occasion.

A Philanthropic Prince. — The Duke Charles |
Theodore of the house of Bavaria is well-nigh j
worshiped by the poor peasants about Meran, in i
the Austrian Tyrol, for his goodness of heart and '
his actual services in their behalf. They call him '
" the good Duke- Doctor. " He annually oifers his
gratuitous help to the poor who have need of ej'e
treatment. It is stated that this spring he, with
an assistant surgeon, saw 1,091 cases, many of
them surgical. Cataract operations to the num-
ber of sixty-eight were done, all of them primarily
successful.

This is, indeed, princelj' conduct, and a remark-
able improvement upon the kind of surgery done
by many of his illustrious ancestors, whose work
with cutting implements was chiefly limited to
the field of battle ; they were destructive in their
intents and tendencies, he is reconstructive. And
so he may be considered to mark a new era among
the hereditary rulers of Europe.

to the Section by the essayist. A post-mortem
had been obtained and an excellent specimen,
demonstrating the changes in the supra- renal
capsules, obtained.

SOCIETY PROCEEDINGS.

AMERICA?^ MELUCAL ASSOCIATION.

Fortieth Annual Meeting. Report of
Sections.

(Coyicluded from page 6S.)

Scctioti OH the Practice of Medicine, Materia

Medica a7id Physiology.

Fourth Day, June 28, 1889.

Dr. J. G. Truax, in his paper on Ulcerative
Endocarditis, reported six cases only two of which
were diagnosed before death, thus demonstrating
the difficulty in diagnosis. The writer was in-
clined to believe that the disease was due to mi-
croorganisms, though such had not been dis-
covered .

Dr. Mary E. Baldwin read a paper entitled
Stomach Rest and Cleanliness, in which, with the
reports of cases, was demonstrated the benefit de-
rived from the method of washing out the stom-
ach and the judicious management of diet. Meas-
ures were recommended for similar troubles in
children.

Dr. W. S. Watson read a paper on Addison's
Disease. After a thorough review of the pathol-
ogy and etiology of the affection, a case illustrat-
ing its symptomatology and course was presented

Section on State Medicine.
First Day, June 25, 1889.

Dr. p. H. Millard, of Minnesota, Chairman,
presented the Report of Committee on Uniform
.Medical Legislation in the United States.

Dr. Millard's subject was The Legal Restriction
of Medical Practice in the United States. He finds
this country sadly in need of good medical legis-
lation. North Carolina was the first State to
enact anything like satisfactory medical laws.
He praised the State of Illinois for the work done
in this direction, ascribing great credit to the ef-
forts of the Secretar>- of the State Board of
Health. As the results of hard work in Minne-
sota the relations have been so altered that now
he is able to announce, for the first time, that the
proportion existing between the medical profes-
sion and the general public is as i to 1,300.

The Committee in its report recommended that
such legislation should be secured as would pro-
vide for a careful preliminary examination, a defi-
nitely prescribed course of study, an examination
upon presentation of diplomas, and adequate
power for the revocation of licenses.

In the discussion of the report Dr. N. S. Davis
entered an eloquent plea in support of the pro-
posed measures.

Dr. Millard said that a very carefully pre-
pared law had been framed, and that it was hoped
that the various States would enact similar legis-
lation, so that the regulations for medical practice
might be practically the same throughout the
countrj'.

Dr. Gihon said that the most important con-
sideration was the matter of preliminar}- education.

Dr. Scamjion, of Tennessee, agreed substan-
tially with the views expressed by the others, but
was in favor of having the State Board elected by
the profession.

Dr. Armstrong suggested that Dr. Scammon
misunderstood the matter, as the manner of con-
stituting the Board was not set forth in the reso-
lutions.

Dr. Storer, of Newport, said that the whole
matter had been a live question in Rhode Island
for several years ; that an irregular practitioner
had been cleared of a charge of malpractice on
the ground that a practitioner was only obliged
to exercise a fair degree of skill and that the law
did not require the physician to know very much.
He was in favor of the proposed changes.

On motion the resolutions were adopted and
committed to the general Association with the
request that they be transmitted to the various
States for their consideration.

134

SOCIETY PROCEEDINGS.

[July 27,

Dr. J. B. Hamilton explained the disinfecting
apparatus in use in New York, illustrating his
lemarks by means of a chart.

Third Day, June 27.

Dr. Harvey, of New York, read a paper on
Sanitarv Disposition of the Dead. He said : This
subject is one that has long received the attention
of the Association, but it has made little advance
among the masses. Could a picture of what is
going on below the surface of the earth in our
graveyards be seen in contrast with the life above
it would be disgusting and horrible in the ex-
treme. Dr. Gross said that it took from forty to
sixty years for the dead body to decay. In Paris
frightful epidemics have been traced to their
source in the cemeteries. In Italy experiments
made by inoculation with germs from air polluted
by the emanations from the dead produced typhus
in animals. Gravediggers have been known to
die almost immediately upon entering vaults
where dead bodies were kept. The facts of water
pollution by this means are well known. Crema-
tion is of course extremely obnoxious to some, but
a method of disposing of the dead has been discov-
ered which, while effectual in the reforms desired,
does not offend the sensibilities of the most deli-
cate. This is the method of dessication, whereb>'
bodies laid away in elegant mausoleums can be
exposed to the action of hot, dry air, with the
effect of removing, in the course of three or four
months, all the more volatile elements of the
body. In this way all danger of epidemics from
this source is removed. The method is not open
to the objection made by jurists to cremation,
viz.: that it destroys all evidence of crime.

Discussed by Drs. Formad, of Philadelphia ;
Carrol, of New York ; and Harvey.

Dr. Marcy, Chairman of the Committee on
The Coroner System in the i 'nited States, then
made a brief oral report of the work accomplished.
He said that the Committee had accumulated
material enough for a good-sized volume. The
existing laws, he said, are very objectionable,
both from a medical and legal standpoint ; in
Massachusetts, Rhode Island, and Connecticut,
however, he was glad to report that material im-
provements have already been made.

Dr. G. H. Rohk, of Baltimore read a paper
entitled The Neeessity for Sanitary Supervision of
Schools. Dr. Rohe directed attention to the fact
that nearsightedness increases in proportion to
the grade of the schools, both in regard to fre-
quency and degree of severity, the condition
l)eing much more frequent and serious in the
higher schools. The causes are largely dependent
upon the arrangement of the seats and light.
Large clear type and good paper should be used
in all text-books. The relations as regards pul-
monary consumption and spinal deformity were
also considered, five-sixths of the cases of the

latter disease having been shown to begin during
school life. Nervous and digestive derangements
received attention from the reader, who advocated
the cultivation of more muscle and less brain.
Contagious di.seases have sometimes to be met by
temporary suspension of schools. \'accination
regulations are not well carried out. Heating
and ventilation require adequate supervision. To
secure the proper regulation of these important
considerations an expert officer should be ap-
pointed whose duty it should also be to examine
plans for school buildings; to inspect all buildings
in use from time to time from an hygienic stand-
point, to look after the proper vaccination of the
pupils, to guard against the spread of contagious
diseases, to enforce the adoption of text-books of
suitable type. Such an inspector should be re-
quired to visit every room at proper intervals of
! time, to test the pupils' eyes every j'ear, and to
make reports once a year to the School Board.
For such work an excellent hygienist is needed.
Dr. Rohe in his observations has found that
School Boards are anxious to know just what
their duties in these various directions really
are.

Discussed by Drs. Schenck, of Kansas, and
Lincoln, of Massachusetts.

Resolutions regarding the formation of a com-
mittee to inquire into the advisability of securing
such legislation as Dr. Rohe had suggested were
introduced by Dr. Lincoln.

The discussion was then resumed and entered
into by Drs. Pinkham, of Ma.ssachusetts ; Bell, of
New York ; and Gihon, U. S, N.

The resolutions were then adopted, and Drs.
Lincoln, Rohe, Reed, and Pinkham were consti-
tuted a committee to take the matter in hand.

Dr. Carroll, read a paper on Disposal of
House Refuse. He drew attention to the fact
that the danger from excreta is chiefly after fer-
mentation has taken place, and this danger is in-
creased by the influence of certain diseases. Cess-
pools and privy vaults are extremely dangerous
to health. Disinfection of these by earth or
charcoal is efficient, but impracticable in large
cities. Such refuse may be rendered innocuous
by spreading it on the ground in thin layers with
free exposure to the air. House garbage, how-
ever, is the greatest bane we have to deal with.
This should be burned, and much of it can be
disposed of in the kitchen range.

Dr. Gihon moved a vote of thanks to the
reader of the paper, which was promptly carried.

Dr. Sw.\rtz, of Rhode Island, read a paper on
77/t' Control of Epidemic Diseases. He believes
that chemists, bacteriologi.sts and veterinaries
should be made assistants to the health authori-
ties by which the means of controlling epidemics
would be greatly strengthened. He described
the spread of two epidemics in Rhode Island. In
the first one he made bacteriological and other

1889.;

SOCIETY PROCEEDINGS.

135

examinations in various directions without find-
ing the bacilli of typhoid fever, although the
cases had been reported as of t3'phoid origin, but
a water bacillus was found in the milk used by
the sick, and was thence traced to its origin, in
the water supply of the cattle. The pasturage
was changed with the eifect of checking the epi-
demic. He is of opinion that in this epidemic
the poisoning may have been due to the forma-
tion of a ptomaine. The other epidemic referred
to occurred in Providence, the origin was found
in typhoid stools which had been thrown on the
river bank.

Other papers were read by title.

Second Day, June 26.

[The discussions will be printed with the pa-
pers in the order in which they are published in
The Journal.]

Dr. J. B. LiNDSEv, Chairman of the Section,
delivered an Address on Popular Progress in State
Medicine. (See page 73.)

Dr. Geo. Minges, of Dubuque, read an inter-
esting paper on Bacteriological Examination of
Several Native Mineral I f 'aters in the Bottled State.

The author finds that the bacteriological exam-
ination of drinking-water has become more impor-
tant than the chemical anah-sis. Water from pure
springs is free from bacteria especially if it contains
free carbonic acid. In bottled water there are often
very many. These are derived chiefly from the
corks and from unclean bottles. Sulphuretted
hj-drogen inhibits the development of bacteria to
some extent. Aerated bottled water contains
more bacteria than that which is not aerated.
Bottles should be cleansed by boiling water or
steam.

Dr. Chas. V. Chapin, of Providence, R. I.,
read a paper on The Purification of Drinking-
ll'ater for Cities.

Dr. Chapin discussed this subject in a very
thorough manner, confining his remarks, how-
ever, mainly to the purification of water by filtra-
tion. He believes that domestic filters, with the
exception of the very expensive Pasteur filter, are
worse than useless. Sharp, fine sand is the best
practical agent for use, and fresh sand is less use-
ful than that which has been in use for some time,
because after being in use for some time organic
matter covers the particles of sand, and this serves
to arrest the bacteria. Water has been filtered on
a large scale, and in Berlin, London, and many of
our own cities, water containing n,ooo microbes
per ccm. before filtration has been found to con-
tain only 179 after. The process of filtration on
a large scale has been facilitated by the coagula-
tion produced by the addition of a small amount j
of alum.

Discussed by Drs. Smart, U. S. A.; Mercer, of
Syracuse ; Minges, of Dubuque ; Baker, of Lan- 1
sing; Mercer and Chapin. 1

Dr. N. S. Davis, of Chicago, presented the
Report of Staiiding Committee on Meteorological
Conditions.

As regards the Collective International Investi-
gation of Disease he was obliged to say that the
Committee had scored a failure, but in other lines
of investigation he could say that he had accu-
mulated a mass of valuable statistics. These were
the results of obser\'ations obtained from the Sig-
nal Service, from a chemical daily examination of
the atmospheric air, and from the reports of phy-
sicians as to the exact date of the beginning of
attacks of acute diseases.

On motion the Section resolved to recommend
that the Association continue the Committee, but
that it be excused from the International Collec-
tive plan. It was also resolved to cooperate with
the various State Boards of Health.

Dr. a. L. Bell, of Brooklyn, read a paper on
Stamina.

Dr. Bell stated that it was his object to reduce
the importance of such expressions as susceptibil-
it3% heredity and predisposition. Health is some-
thing more than the mere freedom from disease.
Immunit}' from disease is largely due to "stami-
na." People who live under conditions of life re-
quiring little energy do not live to old age, and
heredit)' is amenable to the same organic forces as
feebleness of constitution in general. Ofl^spring of
poorly nourished parents are scarcelj' less liable
to pulmonar>' consumption than the ofispring of
those affected with that disease.

The election of Section oflBcers was then held.
Dr. J. B. Hamilton, U. S. Marine-Hosp. Service,
was elected Chairman, and Dr. F. S. Bascom, of
Utah, Secretary.

Dr. H. B. Baker, of Michigan, read a valua-
ble paper on The Climatic Causation of Consump-
tion.

In a verj' extensive and elaborate consideration
of this subject Dr. Baker laid down the following
propositions : i . Low moist ground tends ta
consumption, 2. Cold dn,- air has a similar ten-
dency. 3. The bacillus is acknowledged as the
proximate cause of the disease. In a somewhat
elaborate argument, supported \>y a vast array of
facts, the reader undertook to reconcile these ap-
parently irreconcilable ideas. Dr. Baker illustra-
ted his subject by a large number of tables with
which his hearers were furnished. Not the least
interesting of his statements was the one that
whereas 73 per cent, of mankind are inoculated
with tuberculosis, only 13 per cent, die of the
disease.

Discussed by Drs. Flick ; Lyster, of Michigan;
Bell, of Brookl3-n ; N. S. Davis, of Chicago ;
Rives, of New York ; Hibbard, of Indiana ; and
Minges, of Iowa.

Dr. F. S. Bascom, of Utah, read a paper on
the Climatologieal Characteristics of Salt Lake City.

Dr. Bascom presented a verj' attractive picture

136

SOCIETY PROCEEDINGS.

[July 27,

of the advantages offered by his citj-, it having
proved itself to have the requisite qualities of
dryness, equable temperature, moderate altitude,
sunshine, and freedom from high winds and elec-
tric storms.

Dr. Baker criticised the author in that he had
given only the relative and not absolute humiditj-,
and had not supported his claims with tables of
sickness and death.

Section on Ophthalmology.
First Day, June 25.

The meeting was called to order at 3 p.m.. Dr. C.
E. Frothingham, of Ann Arbor, in the Chair.

The Chairman read an excellent address, in
which he emphasized ven,' strongh- the necessity
of discussing freely man}- questions in ophthal-
mology- about which there is an apparent agree-
ment, but which, notwithstanding, are unsettled.
Various of these subjects were mentioned, and
his suggestions were eminently practical.

Dr. Robert Tili.EV, of Chicago, read a paper
on What can ive do to induce the Government to
make the Census of i8go contribute efficiently to a
clear conception of the causes of Blindness. After
stating that Dr. Magnus had in Germany suc-
ceeded in obtaining reliable reports on the causes
of blindness, and having enumerated these
causes. Dr. Tilley strenuously advised that the
same system be adopted in this country, and for
this purpose he presented the printed blanks used
by Dr. Magnus. The main object of the paper
was to have an effort made to ascertain the causes
of blindness and then attack them more intelli-
gently.

Considerable discussion followed this paper, in
which Drs. Connor, Scott, Jackson and Thompson
took part. Finally it was moved and carried that
a committee be appointed by the Chair to request
the General Assembly to authorize the Section on
Ophthalmology, together with the American
Ophthalmological Association, to confer with the
Cen.sus Committee. Drs. X. E. Scott, Robert
Tilley and J. Chisholm were appointed on this
Committee.

Dr. a. E. Prince, of Jacksonville, 111., read a
paper on The Preventioti of Pain and the Improve-
ment of the Stump folloiving Evisceration of the
Eye. Having failed in preventing pain in the
stump in five cases of evisceration. Dr. P. was led
to try carbolic acid, applied to the anterior por-
tion of the stump, with very good results. He
had used the glass ball (artificial vitreous), but
was not satisfied, and has finally adopted the sys-
tem of filling the empty shell with iodoform and
packing it in with cotton, and then inserting
sutures. He is well satisfied with this method.
Dr. Prince also exhibited a book for keeping the
record of patients in such a waj- that they can be
easily found and tabulated.

Dr. Jackson stated that Dr. Williams, of Bos-
ton, was the first to record a case of evisceration.
Dr. Williams was thereupon asked to speak on
the subject. He stated that he preferred eviscera-
tion on account of its safety. That for the pre-
vention of pain he used cold-water applications ;
and that he was pleased with the result.

The third paper was read b}- Dr. W. H.
Williams, of Boston, on Advances in our knozvl-
edge of some Cerebral, Ocular and Intra- Orbital
Lesio7is which facilitate the Diagnosis atid Treat-
ment of Important Diseases.

In this paper a number of very interesting cases
of ocular disturbance produced by brain and kid-
ney disease, which showed how important a part
a careful examination of the eye plays in making
a careful diagnosis of these diseases, for in many
of these cases internal disea.se was not suspected
until the ophthalmoscope revealed its symptoms
in the eye. Dr. W. also reported some very inter-
esting cases of blindness following facial ery-
sipelas.

Discussed by Drs. Chisolm, Knapp, Eeartus
Connor and Noj'es.

Dr. J. L. Thompson, of Indianapolis, then
read a paper entitled Some Cases of Inflammation
and Atrophy of the Optic Nerve, ivith Special Refer-
ence to Etiology and Prognosis. After reporting a
number of interesting cases and commenting on
the difficulty of making a prognosis, and in
tracing the disease to its origin. He read the
following conclusions as the result of his obser\-a-
tion : I. Progressive atrophy with no evidences
of former inflammatioii gives bad progno.sis. If
one is affected the other remaining for several
months unimpaired, prognosis favorable for this
eye. 2. In atrophies following pernicious inter-
mittent fever, improvement sometimes takes place
when least expected. Inflammation of the optic
nerve resulting from violent exercise, disturbances
in menstruation, etc., occurring in plethoric per-
sons admit of very fav^orable prognosis. Inflam-
mations of the optic disc caused by brain tumors
often improve so much that one is liable to doubt
his diagnosis or to modifj- views as to prognosis,
but death is the result, with few exceptions.

This paper was discussed together with that
of Dr. Williams.

It being quite late it was moved and carried
that the reading of papers be postponed until
Wedne.sday at 3 p.ji.

The Committee for Nomiraination of Officers
for the ne.xt meeting was appointed. Drs. X. E.
Scott, A. Iv Prince and J. Chisolm were placed
on this committee.

The meeting then adjourned.

Second D.ay, June 26.

The meeting was called to order at 3 p.m.. Dr.
G. Frothinghaji in the Chair.

Dr E. J. Gardiner read a paper on the Non-

1889.]

SOCIETY PROCEEDINGS.

137

Surgical Treatment of Strabismics Co7ivergens.
After stating its advantages, and making mani-
fest the dangers of hast}- operative interference, he
reported twent3'-five cases in which the onh- treat-
ment used was correction of ametropia and atro-
pine, the orthoptic measures having been omitted
experimental!}-. The correction was over 50 per
cent, of all cases recorded.

Discussed by Drs. H. Knapp, P. D. Keyser, J.
L. Thompson,' R. Tilley, G. Frothingham, S. C.
Ayres, J. Chisolm and Geo. Stevens.

Dr. Leartus Conner then read a paper on
Tobacco Amblyopia, which proved to be ver}- in-
teresting, because a full history was given of two
cases, where the trouble super\-ened in total ab-
stainers, one a gardener, the other a clergyman.
Both were typical cases, and both recovered by
leaving off smoking and using str}-chnia. Dr.
Conner stated that he had not been able to find a
well authenticated case of alcohol amblyopia
where tobacco could be excluded, and believes
that tobacco causes the trouble. He then pro-
pounded a number of questions about which dif-
ferent opinions are entertained by ophthalmolo-
gists, one of them the etiology of central scotoma.

Discussed by Drs. H. Knapp, Myles Standish,
Noyes, P. D. Keyser, J. Chisolm, Blitz, and E.
J. Gardiner.

Dr. S. C. Avres read a very instructive paper
on Tumors of the Optic N^ervc. After reviewing
the literature on the subject he proceeded to give
a history of two ca-ses, with microscopical exam-
ination of the tumors. The first case was a little
boy who presented all the characteristic symp-
toms of intraorbital tumor. It was removed and
proved to be a myxosarcoma, which began in the
connective tissue of the optic nerve sheath. The
lad remains well. The second patient was a young
lady, with a large-sized myxosarcoma of the optic
nen^e sheath. This young lady died six months
after operation from typhoid fever. Dr. Ayres
thinks that the majority of these tumors are of
the myxosarcoraatous variety, that they spring
from the open nerve sheath, and that the progno-
sis is favorable.

Dr. P. Keyser reported two cases of this dis-
ease operated upon many years ago, who are still
alive and well.

Dr. J. A. LiPPiNCOTT operated on a case four
j-ears ago. The lady is doing ver}^ well.

Dr. Thompson stated that he saw Dr. Wil-
liams, of Boston, operate on one, and Dr. Hamil-
ton, of Ohio, upon another, with good results.

Dr. Julian Chisolm then read a paper on Tiie
needless and annoying Restraints after Eve Oper-
ations. He stated that confinement in bed was
unnecessary even in iridectomies and cataract
operations. The dark room he had discarded,
using for his cataract patients a moderately dark-
ened room — a good daylight to make examina-
tions of the operated eye. Antiseptics he thought

unnecessary if thorough cleanliness was enforced.
For the eye bandage he has substituted the isin-
glass entirely, and obtains excellent results by
following the more easy method. He does not
i restrict the diet, allowing the patients to indulge
I in their regular habits. The .securing of the
[ hands after cataract operations he considered en-
tirely unnecessary.

The next paper being on the subject of cataract,
the discussion was deferred until after it was read.
Its title, Glancoma Fitlminans after Operations.
The writer. Dr. P. D. Keyser, reported two
cases in which, after a perfectly smooth and un-
complicated operation for extraction was per-
formed, at the end of six days in one case, on the
third day in the other, sudden and severe pain
was felt, and when the eye was examined, the
characteristic picture of glaucoma fulminans was
discovered. The hsemorrhage in both cases was
copious. In the first case the operation had to
be postponed for a few days, and the result was a
loss of sight ; in the other case the iridectomy
was immediately performed and good vision was
restored. Dr. Keyser was at a loss to explain the
cause. He recommended the opening of the pos-
terior capsule.

Discussed by Drs. Ayres, Tilley, Jackson and
Knapp.

The papers of the following gentlemen were
called but, the writers being absent, were passed:
Drs. Eugene Smith, of Detroit : Le Roy Dibble,
of Kansas City ; J. H. Thompson, of Kansas
City ; Dudley Reynolds, of Louisville, Ky.

On motion the hour of meeting for the next
meeting was made 2:30 p.m.

The meeting then adjourned.

Third Day, June 27.

The meeting was called to order by the Chair-
man, Dr. Geo. Frothingham, at 3 p.m.

The Chairman announced that Dr. S. C: Ayers,
of Cincinnati, had been elected Chairman, and
Dr. E. J. Gardiner, Secretary, of the Section for
the ensuing year and that the next meeting of the
Association would be held at Nashville, Tenn.

Dr. J. E. COLBURN, of Chicago, then reported
Tcvo Cases of Complications Arising During Cata-
ract Operation.

In the first case, after making a perfectly
smooth section of the cornea, and previous to
making the iridectomy, the whole contents of
the eye escaped. A grayish substance was after-
wards discovered in the eye ; on the following
day a large haemorrhage filled the e}-e.

The second patient was a man in good health.
Mature cataract, central perception was ver}- poor,
peripheral perception good. While making in-
cision noticed bead of vitreous, but succeeded in
making iridectomy, and removing the lens with
no further complication. While patient was rest-
ing quietly after operation he suddenly cried out

138

SOCIETY PROCEEDINGS.

[JutY 27,

with pain. Examination revealed a condition
similar to that of the first case. The ej'e was
subsequently enucleated. A calcified ring was
discovered around the optic ner\-e.

Dr. Knapp was then requested to report on his
experience in opening the capsule while making
the corneal section. Dr. K. complied with the
request bj- reading a paper which he had pre-
pared for the Archives of Opiithalmology. He
stated that he had tried to open the capsule while
making the corneal section in sixty-four cases.
In sixty-one he had succeeded. In three he
found difficult}'. The first case in which diffi-
culty was experienced was one of hypermature
cataract. Dipped point of knife into capsule, but
it did not cut and the lens would not come out.
Made peripheral capsulotomy and extracted lens
without difficulty. Healing without reaction,
vision |-{f. No secondary- operation was made.
2. Point entered capsule but could not cut
through, it being verj- tough. Had to draw the
knife back, the iris fell before the knife and was
cut. Iridectomj' was performed, and some vit-
reous escaped. The wound healed kindh-.
Vision ^i\. 3, Ordinary' cataract, anterior cham-
ber very shallow. Point of knife punctured iris,
had to draw the knife back and cut iris. Healing
took place without complication. \'ision good.

The advantages of the operation are that it
simplifies the operation b}' merging two steps
into one, and that one instrument is dispensed
with, thus diminishing the danger of infection.
If the simple operation is performed the knife is
the onl}- instrument that enters the anterior
chamber. The disadvantages are : That even
under the most favorable circumstances the oper-
ation is difficult, by reason of the change in the
direction of the knife. When the anterior cham-
ber is shallow, the pupil narrow, or the cataract
h3'permature, the difficulties are much increased.
Dr. Knapp thinks there is no cogent reason for
the operation.

Then followed a lengthy discussion on many-
details of extraction of cataract and secondary
division of the capsule, followed mostly in ques-
tions addressed to Dr. Knapp, which he answered.
Our space does not permit us to give a full report
of all these remarks. The principle questions were:
Whether Dr. Knapp would perform secondary
operation if the patient could read ? Answer —
Yes ; because we should strive for the verj' best
results obtainable. How soon after the first
operation did he perform the secondary division?
Answer — From three to six weeks, preferred a
little more time to elapse. Sometimes it could
be done after the thirteenth day. Was the oper-
ation performed by ordinary daylight ? Answer
— No ; alwaj's by focal illumination, which is the
only way to thoroughly illuminate the field and
discover the best place for the incision.

A paper on The Ame tropic and their Relation

to Insufficiencies of the Recti muscles, by Dr.
Wright, of Columbus, O., and also one entitled,
Embolus of the Inferior Branch of the Retinal
Artery Visible uith the Ophthalmoscope ; Disap-
pearance of Embolus a?id Recovery of the Greater
Part of the Field Under Massage a7id Nitrate of
Amyl, by Dr. H. Gififord, of Omaha, Neb., were
read by title.

Dr. J. E. CoLBURN requested that his paper on
Insufficiencies of the Recti Muscles, with Report of
Cases, be read bj- title, because it was on the same
subject as that of Dr. Stevens, of New York, and
that he would report one of his cases in the dis-
cussion of Dr. Steven's paper. Dr. Colburn's
request was granted.

Dr. G. T, Stevens, of New York, then read
a paper entitled, Respecting the Determination of
the Deviations in Strabismus and their Treatment.

Several cases were reported illustrating the im-
portant part which the vertical deviations play in
the production of strabismus, and also showing
the importance of detecting these deviations. He
then concluded b}' calling attention to the follow-
ing principles here briefly stated and abridged :

Results of examination for strabismus should
be expressed in angles and not in linear meas-
urements. To this end diplopia must be recog-
nized and the double images carefully located. In
cases of moderate strabismus this can be accom-
plished, with patient and intelligent effort. Ex-
treme cases should be converted into moderate
cases for better observations. The relative posi-
tion of the double images is sometimes contrary
to well-known laws, and unless the surgeon is on
his guard, may be misleading. These exceptional
positions of the images should lead us to the con-
clusion that the case is probablj- one of hyper-
tropia. The unequal tension of the two pair of
superior and inferior recti is often responsible for
an apparent converging or diverging strabismus.
The standard operation for strabismus bj' reason
of its disabling effect upon the severed muscle, is
an obstacle to a perfect result.

Graduated tenotomies, in which no tendon is
disabled from performing the full required rota-
tion of the eye, combined with tendon resection
of the opposing muscle, operations if need be to
be made oij several muscles should supercede the
severing of the tendon completely.

Dr. J. E. CoLBURN reported the case of a
brawny Irishman who had an apparent divergent
strabismus due to hyperphoria. He operated
and the divergent entirely disappeared.

Discus.sed by Drs. Jackson, Savage, Tillej',
Connor, and Gardiner.

Dr. a. Bi.itz, of Indianapolis, Ind., read a
carefully prepared paper reporting A Typical Case
of Ocular Irritation Caused by Chronic Rhinitis
Relieved by Treatment of the A^asal 7'rouble. In
the discussion which followed, several gentlemen
spoke, reporting interesting cases of this character.

1889.]

FOREIGN CORRESPONDENCE.

139

The work of the Section having been finished.
Dr. Frothixgh.\m thanked the gentlemen who
had so efficiently helped to make the meeting
successful, both by the careful preparation of
papers and by participation in the instructive dis-
cussions which in even,- case followed the reading
of the papers.

On motion, a vote of thanks was tendered to
the President and Secretary of the Section, and
to the reporter of The Journal.

A vote of thanks was tendered to the Commit-
tee of Arrangements for their kind attentions in
procuring such excellent rooms for the meetings
of the Section, and the thanks of the Section of
Ophthalmology was tendered to the Casino Club
for allowing the use of their beautiful rooms for
this purpose.

The meeting then adjourned.

FOREIGN CORRESPONDENCE.

LETTER FROM PARIS.

(FROM OUR REGULAR CORRESP0XDE>fT.)

M. M. Germain See and Laborde on the Utility
of the Exclusive Administration of Alkaloids ex-
tracted from Plants — Dr. Bouilly defends the Use
of Pessaries — Dr. Mosse on the Re-plantation of
Bones removed by the Trephine — An anonymous
writer in "The Scalpel" on the Hccmostatic .Action
of Cocaine — Dr. Doyon on the Action of Bromide
of Potassium.

With reference to the debate that lately took
place at the Academy of Medicine, M. M. Ger-
main See and Laborde maintained the utilit}- of
the exclusive administration of alkaloids extract- !
ed from plants. The immediate principle, thej-
say, is always one, identical in itself, invariable
in its proper constitution, as in its fundamental, j
physiological and medicamentosis action, the i
total matter which contains it is complex, variable \
in its composition as it is in its effects. Apropos '
■of this subject, a writer in the Gazette Hebdoma-
dairc remarks that while it may be admitted that
the preparations taken from plants maj- contain
divers alkaloids, it is precisely because the matter
extracted from a plant is variable in its composi-
tion that its effects differ from the action exercised
by a single alkaloid. As successive!}' stated b}-
M. M. C. Paul, Trasbot and Gariel, chemical
analysis has not isolated, and never will isolate
all the active principles which a plant contains.
The latter contains not only crystallizable sub-
stances, but also soluble substances, and if it be-
comes possible to isolate all, it will still be diffi-
cult to combine and associate them to produce
the therapeutic effect obtained in employing the
plant itself. It may therefore be concluded that
digitalis is an excellent medicament and which

produces effects verj- different from those which
are produced h\ digitaline, that the extract or
the tincture of aconite should be preferred to
aconitine, that, in children it would be ver}- dan-
gerous to substitute emetine for ipecacuanha, in
a word, the medical practitioner should know
how to formulate, that is to say, in combining
and associating the divers medicaments of which
a long experience has demonstrated the efficacy.
In illustration of the inconveniences of alkaloids,
I maj' here cite the researches of Dr. Alfonso
Montefusco, published in the Giomale di Clinica.
in which the author states that scillitine has no
diuretic property. It determines a diminution in
the force and in the frequency of cardiac contrac-
tions as well as a lowering of the sanguineous
pressure. Injections of this substance diminish
the frequency and the force of the respiration. It
has no action whatever on sensibilitj- and on
motility.

At the Societede Chirurgie Dr. Bouilly defends
the use of pessaries and tried to prove that they
are useful and that they are not dangerous. He
would not, of course, defend the employment of
those enormous pessaries that were formerly in
use, but he would willingly adopt instruments,
whether malleable or not, which, are made to
measure, and which adapt themselves to the parts
to which they are applied, such for instance the
pessaries of Hodge and of Smith. Dr. Bouilly
thinks that the)' are clearlj- useful in simple,
mobile, retro-deviations, and that it would be
dangerous not to maintain the uterus in position.
Between doing nothing on the one hand, or
practicing Alexander's operation on the other,
which does not often produce satisfactor}' results,
there is a treatment to institute, and that is that
of the application of a pessary. Dr. Bouilly had
already collected 84 cases of retro-deviation in
which he employed this instrument and which
always proved satiefactory. But to apph' the
pessarj' reduction must first be effected, either by
the genu-pectoral or knee-and-chest position, or
by the method of Schultze. In these conditions
an instrument of good dimensions reestablishes
the cul-de-sac of Douglas, the portion of intestine
that was displaced will resume its normal posi-
tion, and in directing the attention of the patient
to the necessity of not allowing the bladder to get
full, of avoiding shocks, pregnancy may take
place, or the maintenance of the uterus in proper
position may be obtained in eight or nine months
of treatment. The danger is ;/// when the pessary
is well applied, and accidents may occur only in
cases where the instrument is too large, ill-chosen
and badlj' applied to a womb imperfectly reduced.
Only once did M. Bouilly see an ulceration in the
posterior cul-de-sac, and it was healed up in a few
days. It is, of course, understood that the pos-
terior adhesions are a contraindication. M. Pozzi
supports the opinion of M. Bouilly. M. Terrier

140

FOREIGN CORRESPONDENCE.

[JutY 27,

thinks that this question might be discussed for
a long time, it is to experience that the demon-
stration of the fact must be left. As far as he is
concerned, without having applied as many pes-
saries as M. Bouill}', he thinks that this instru-
ment is without any action, unless it acts by
auto-suggestion analogous to a case he had re-
ported at a previous meeting.

Dr. Mosse, of Montpellier, has published a note
on the re-plantation, practiced with success, of
fragments of bones removed by the trephine.
These operations had been performed on rabbits,
dogs and monkeys. The experiments consisted :
I. In re-plantations, on the same animal, of a
rundle of the skull removed by trephining. 2. In
the transplantation on an animal, of the same
species, of a rundle of bone removed from the
first subject. 3. In the transplantation on an
animal of a different species. In all these experi- '
ments the crown of the trephine was applied to
the bone, the periosteum of which was scraped
and turned over with the skin, without any pre-
caution being taken to preserve the periosteum
itself After having replaced the bony rundle
in position, the soft parts were simply reunited
above the rundle by points of suture. After a
certain time the animals were sacrificed, and it
was found that in the greater part the osseous
rundles were soldered to the neighboring tissue.
These experiments had been practiced on man by
Ewen, Barrel and Horsle}'. The results obtained
by these experimenters would authorize one to
think that a rundle trephined is susceptible of
being grafted in the place it occupied before its
removal.

An anonymous writer in the Scalpel on the
haemostatic action of cocaine, remarked that, for
the last three years he had recourse to the subcu-
taneous injections of the hydrochlorate of cocaine
to produce local anaesthesia, that after these in-
jections there was no haemorrhage, or at least the
flow of blood was less than when he did not em-
plo3' cocaine. From this fact the idea struck him
that it would be a useful means against excessive
haemorrhages, which are sometimes difficult and
long to arrest. With the view of correcting the
flow of blood, the author tried the direct appli-
cation to the bleeding surface, of pads of charpie
imbibed in the following solution : Hydrochlo-
rate of cocaine, i gram, alcohol, 5 drops, laurel-
cherry water, 5 grams. He sometimes applied '
the powder of cocaine to the wound, at others he
employed a subcutaneous injection of the same
substance, in the neighborhood of the seat of
hemorrhage. The first mode of application suc-
ceeded in rapidly arresting a severe attack of
epistaxis. Suppositories containing from 15 to
20 centigrams of cocaine have always succeed-
ed in arresting persistent oozing of blood. Com-
menting on this note, Dr. Fano, in \\\& Journal
d' Octtlistiquc, observed that this latter dose of co-

caine is not without danger. It is well knowa
with what facility and rapidity is accomplished
the function of absorption in the rectum.

Dr. Doyon, writing on the accumulation of the
bromide of potassium in certain organs, states
that this salt preferabl}^ accumulates in the cen-
tral nervous system, which is not surprising, as
it exercises its physiological action particularly
on the nervous centres. It is found also in large
proportions in the liver. a. b.

LETTER FROM SAO PAULO, BRAZIL,.

(from an occasional correspondent.)

Yellow Fever — Unprecedented Severity of Epi-
demic of i88g — Can true Yellow Fever pass the-
Coast Range and become Epidemic in the Uplands
of the Interior.^ — Influence of bad Sanitary Condi-
tions— Does Frcire' s Inoculation of the Attenuated
Microbe Protect f — Sudden Deaths — Beriberi.

It is quite certain that since the epidemic which.
devastated Memphis in 1878, nothing has hap-
pened in the history of j-ellow fever so severe as
that which has decimated Santos and Camfinas
this year.

The epidemic in Rio de Janeiro presents few new
features, and the frequency with which the city is
visited by yellow fever, its commercial impor-
tance and rapid and frequent communication be-
tween it and the States, place the matter within
easj' reach of your readers. Not so with Santos
and Camfinas.

Santos is, after Rio, the most important of the
coffee ports. A city of about 20,000 souls, situ-
ated just within the tropics, it is almost entirely
surrounded by water ; in fact, at high tide it is
completely surrounded by the sea. The business
part of the city is but little above the tides and
is cut off from the sea breeze by Mt. Serrate, a
high point within the city limits. Some years
ago drains were constructed under the streets to
carry off the rain-water, but there is no system of
sewers. During the last few years permission has
been granted to householders to connect their
privies and house serv'ice with these loosel}- built
mains. No precautions whatever have been taken
in the way of tide flaps on the lateral pipes, so-
that the incoming tide, which flushes the drains
of the lower part of the city, carries back the ac-
cumulated filth, forcing poisonous gases back \\\\x>
the tide drains. The soil has become thoroughly
impregnated with faecal matter, as the bricks at
the bottom of the drains are laid without mortar.
The city is supplied with drinking-water from the
neighboring mountains, of excellent quality, but
in quantity inadequate to the demands of the city.
The present season has been noted for the almost
total ab,sence of rains, the heat has been intense
and continued, for weeks and weeks, often reach-
ing 36°C. in the shade and 54° in the sun. Under

iSSg.]

FOREIGN CORRESPONDENCE.

141

these conditions it is not strange that yellow fever
should make its appearance, particularly as the
streets and tenements of the city have been full
of the poorest class of Italian immigrants for
months.

On the 14th of Januarj- a man who had not
been out of the city was seized with yellow fever
and died. From this case and date the disease
spread over the city. Several cases about this
time were landed from foreign steamers, and were
taken to the hospital and died, but it is true that
the first case zcas not imported atid had not been in
contact -cvitli foreign shipping. Early in February
the inhabitants began to abandon the city, so that
during the height of the epidemic not more than
10,000 or 12,000 remained. The deaths in the
city, so far as can be ascertained, from January
14 to date, have been 1,238. This does not in-
clude those who died outside of the city who had
been exposed before leaving.

It is difficult to estimate the proportion of
deaths to the number attacked. At one time at
least one-third of the whole population was pros-
trated with some kind of fever. As nearly as I
could judge by visiting the hospitals and accom-
panying some of the most prominent physicians
in their private practice during the height of the
epidemic, about 40 per cent, of all the cases were
different types of malarial fever.

The most striking feature of the epidemic both
in Santos and Rio was the great frequency of sud-
den deaths, falling down in the street, becoming
unconscious and dying in from two to eight hours.
The native doctors call these cases of ^' acccsso
pcrnicioso " — pernicious attacks.

In the confusion and panic incident to an epi-
demic like the present one it is almost impossible
to get at the real facts. The exact character of
these cases " fuhninanlcs" has not been deter-
mined ; whatever it may be it is clear that it is
not sunstroke, as these cases are strictly confined
to the places where yellow fever is epidemic.

In the early days of the epidemic it was diffi-
cult to organize tlie medical or sanitary service.
Temporary hospitals were opened, but, with the
overworked doctors and entire absence of nurses,
they were little more than convenient places to
die in. In the public hospitals the death- rate was
something fearful, probably 80 or 90 per cent.

So far as treatment was concerned it was most-
ly palliative. The physicians are divided into
three classes : those who gave quinine in all cases,
those who discriminated carefully between yellow
and malarial fever and who never gave quinine in
the former, and those who treated symptoms only.
The treatment employed in the Garcia Ho,spital,
at Havana, was tried with fair success by Drs.
Miranda de Azevedo and Henchel. The influence
of order and perfect organization under good con-
ditions was strongly accentuated in the Portuguese
Hospital ; which, by the way, is a model hospital

under the very best of direction. Here Dr. Fur-
tado lost only about 10 per cent, of the yellow
fever cases. This physician does not use quinine
in any stage, but after the preliminary treatment
relies on alkalies and salicylate of soda, followed
by perchloride of iron and iodine.

The disease at Santos and Rio has nothing par-
ticularly new about it, presenting about the same
features as are found in the sweeping epidemics
of our own country. But the outbreak at Cam-
finas is altogether new.

CAMPINAS.

This city is situated on the first plateau of Bra-
zil, 2,250 feet above sea level and 160 kilometres
from the coast in a straight line. It is somewhat
lower than the range of mountains that separate
it from the coast. The city is in a sort of basin
surrounded on three sides by low hills. The pop-
ulation is estimated at 20,000. The houses are
built without any attention to requirements of
health, and in the poorer quarters crowded with
Italian emigrants, six, seven and eight families
often occupying the same house. There is no at-
tempt at drainage, each house having its own
privy vault, often only a shallow excavation in
the back yard in close neighborhood to the well.
The cemetery is situated on the brow of the hill
just above the town, and in the soft, porous earth
it is fair to suppose that the wells get the full ben-
efit of it. The heat in Camfinas is quite as in-
tense as in Santos, the absence of rain more sen-
sible because of the absence of the ocean or any
other body of water. Under the old theory that
yellow fever is a coast disease Camfinas would be
safe from its ravages — but in spite of all theories
it is true that it has this year been swept by the
most destructive epidemic of yellow fever of which
we have any account during the last half century.

On the 9th of February a German woman ar-
rived in Camfinas from Santos with yellow fever
and died in a Swiss bakery boarding-house.
Within fifteen daj'S the persons who slept on the
mattrass upon which the woman had died were
taken sick and died also. The family nearly all
died, and many of the customers of the bake-shop.
About the same date a child was taken ill with
what was supposed to be a bad type of bilious
fever, in a house in which ten months before two
persons had died of yellow fever contracted in
Rio. The child died, and a competent physician
pronounced it a case of genuine yellow fever. It
is true, at all events, that other members of the
familj' were taken down and died. From these
two points the disease spread in widening circles
until new foci were established in difi"erent parts
of the city, spreading in time to every corner of
the place. Violent discussions arose among the
physicians as to the real character of the dis-
ease — some classified it as typhus, others as
the black plague, others as the ictero-haemor-

142

FOREIGN CORRESPONDENCE.

[July 27,

rhagic fever of the East. In the early days of
the epidemic the clinical features of the disease
were quite different from those of the fever raging
in Santos. The temperature curves more abrupt,
complete jaundice supervening on the second day,
the thermometric record showing distinct inter-
missions, frequent cases of new invasion after en-
tering upon a free convalescence, apthous sores
in the mouth, rapid pulse, violent delirium, etc.
— still showing many of the characters of yellow
fever : the suddenness of the onset, the lumbar
pains, the flushed face, injected eyes, and redness
of upper thorax, tendency to hsemorrhage. Here
and there, however, a clear and almost typical
case of yellow fever w-as found. \'ery soon the
large majority of the cases became unmistakably
yellow fever. Pari passu with the development
of the epidemic the ordinary malarial fevers began
to assume a grave character, so that I would ven-
ture to say that 30 per cent, of the cases pro-
nounced yellow fever were grave cases of remit-
tent fever. I saw two such cases myself, both of
which recovered, but one of which was attacked
by genuine yellow fever afterwards. It was no-
ticed that however severe an attack of either type
of fever was, it conferred no immunity from the
other.

The flourishing city was almost entirely aban-
doned ; business was suspended and the inhabi-
tant, including many of the physicians, fled for
their lives, until not more than 3,000 remained,
and neither medical advice, medicine, nor food
could be had in the city. People who were re-
covering from the fever actually died of starva-
tion. It seemed like one of the cities described
in the times of plague in the middle ages. vSoon,
how-ever, Sao Paulo went to the rescue. The
provincial and the general government sent relief
committees with supplies of food, medicines and
nurses, and a systematic course of disinfection
was instituted under Dr. Araujo Goes, who had
been entrusted with the same work b\- the gene-
ral government in Santos, aided by a corps of
volunteer medical students from Rio. The epi-
demic reached its aiige in April. During this
month there were 893 deaths out of a population
of not more than 3,000. The death-rate among
the poorer classes was something frightful. I
saw in one of the small tenements seven persons
sick on three beds, in a room without a window,
all Italians recently arrived.

BELEM DO DESC.\LV.\DO.

At this point, 350 kilometres from the coast,
and 2,200 feet above the sea level, has up to date I
lost seventeen citizens from yellow fever, start-
ing from a case which came from Camfinas.
The.se cases are pronounced genuine yellow fever \
by physicians who are well acquainted with the
disease : characterized by black vomit, jaundice, i
anuria and death. This city has the same un- j

sanitary privies and wells in close contiguity and
has been visited b}- the same heat and drouth.
Its mean temperature in ordinary j-ears being 20°
centigrade. It has a mean during March and
April of 30.5° centigrade.

RIO CLARO.

This cit}' is 240 kilometres from the coast, and
614 metres above sea level. It has a population
of 7,000, and is barely free from malarial fever,
and has no system of sewers, but relies upon pri-
vate sanitation : as usual, wells and privies are
near neighbors. Yellow fever was brought in by
the refugees from Camfinas and spread to the in-
habitants. There have been twenty-three fatal
cases among people who have not been out of
town.

LIMEIRA.

Two hundred kilometres from the coast, 542
metres above sea levels, having last year a mean
of 20.06° during March and April. This year
an average temperature of 30° (centigrade) dur-
ing the same period without rain. Fever was im-
ported from Camfinas and spread to the inhabi-
tants. Sanitarj- arrangements wretched as usual.

Now, while no one thinks that bad water,
filthy privies, or bad drains, create or spread yellow
fever, as numerous .striking cases might be cited
to prove that the disease was in the air, and car-
ried by the air or by some solid substance, such as
clothing, etc., still the conditions created bj^ these
bad sanitary elements contribute in some way to its
getting a foothold, as under the same climatic in-
fluences the same conditions of heat and absence of
moisture at the same altitude the disease has not
obtained a foothold whenever and wherever the
sanitarj' conditions were good.

This cit}' of Sao Paulo, being only 40 miles
from Santos, and receiving nearly half of its pop-
ulation as refugees, many of them arriving with
yellow fever and dying here, having besides
12,000 Italian emmigrants. recently arrived in
Santos, and brought here after exposure to yellow-
fever, and many of these with the disease already
developed, crowded into close quarters, has not
had a single case of yellow fever that was not
brought here from Rio or Santos.

Why this immunity ? You must pass through
Sao Paulo to get to Camfinas. Why should this
disease pass Sao Paulo with a population of
50,000, and make its headquarters in Camfinas
and the cities beyond ? It is becau.se these cities
are clean, well drained and well supplied with
pure water, and, in the case of Siio Paulo, well
paved with clean granite.

There are numerous other points in the neigh-
borhood of Rio that have been attacked by yel-'
low fever, but while above the mountains they
are in direct communication with an infected sea
port by a water course. Such infections are not
rare in the historj' of yellow fever epidemics,

1889.]

NECROLOGY.

143

but Camfinas, Limeira, Rio Claro, and Belem do
Descalvado are out of the j'ellow fever range and
form a new chapter in the history of the disease.

Dr. Domingos Freire came to Camfinas person-
ally to superintend the inoculation of the people
with his attenuated virus of yellow fever. Being
obliged to return to Rio by the duties of his posi-
tion, he left Dr. Angelo Simoes in charge of the
service. Up to the 7th inst., according to letter
published, he had inoculated 630 persons, of
ivhom only three had been attacked, and then in a
mild form. The names and residences of these
persons are recorded in the city offices, and are
open for inspection and study.

lu Santos, Dr. Barrata, a colleague and fellow
professor of Dr. Freire, inoculated several hun-
dred, chiefly among the foreign element, before
the worst of the epidemic, and I am informed by
reliable physicians, residents in Santos, that only
a ver)' insignificant number of those inoculated
by Dr. Freire' s method had yellow fever. These
are significant facts in centres where, to escape
an attack of the disease is the rare exception,
and to have it, the rule.

Whatever may be said of the merits of Dr.
Freire's attenuations from a scientific standpoint,
these facts have a commercial significance not to
be ignored. Whether he has found the microbe
of yellow fever or not, or whether the fluid he
injects contains the attenuated microbe or not, if
it prevents yellow fever, or even if a large per-
centage of those inoculated e.scape in times of
such sweeping epidemics as that of 1889, it de-
serves to be carefully investigated. Dr. Freire
courts investigation. He, at least, has what is
not always to be found among scientists, the cour-
age of his convictions.

He seeks out the disease during dangerous
epidemics, and in the face of his most determined
opponent (Dr. AraujoGoes, who was sent by the
government to Santos and Camfinas) makes the
test fearlessly.

It is to be regretted that the gentleman who
was sent out here by our government to investi-
gete Dr. Freire and his method, could not have
selected this season of the year for his studies,
when yellow fever can always be found, and Dr.
Freire is always at home.

So far as we can see in the scientific journals
of the world that reach this distant point. Dr.
Freire is on the top with his germ.

A disease which is rapidly coming into promi-
nence now that the yellow fever excitement is
subsiding, is beriberi, which, if it keeps on at the
present rate, will before the year closes have a
larger death roll than yellow fever. It is now
almost epidemic in the prisons of the large coast
cities, and also among the seamen of the marine.

S. Paulo, May 28, 1889.

NECROLOGY.

Henry F. Craiii, M.D.

Henrj' F. Crain, M.D., a native of Walpole,
N. H., was born September 22, 1810, the eldest
son of Dr. Eleazer and Sarah Crain. At the age
of 5 years his parents left Walpole and settled in
the flourishing village of Springfield, Vermont,
where he passed the greater part of his life. His
father, a noted physician, pursued the study and
practice of medicine and surgery during the re-
mainder of his life, his death occurring in his 60th
year.

H. F. Crain, after being well advanced in the
common schools, completed the study of letters
in the Springfield and Chester academies. Hav-
ing decided to make the study of medicine and
surger}- his life work, he, under the able tutelage of
his father and Dr. Amos Twitchell, of Keene, N.
H., entered Dartmouth Medital College, attended
the usual course of lectures, and was prosector to
the professor of anatomy. He graduated, and
commenced practice with his father in 1837. In
1838 he went to central Pennsylvania, where he
practiced four years.

Having paid especial attention to gynecology,
and believing that some mechanical design would
be beneficial in the treatment of many cases of
female complaints, he, in company with his
father, invented the then famous spino-abdominal
supporter, and for seven years manufactured and
sold them to physicians and druggists ; traveling
in the eastern, middle and many of the western
and southern states.

In 1 849 he returned to Springfield, resumed the
practice of medicine, and continued in active
practice till 1882, when he removed to Rutland,
Venuont, where in company with his son. Dr. M.
R. Crain, bj' his ripe age, long experience, pro-
fessional bearing, ready speech and affability of
manners, he soon gained the confidence of a large
and influential class of patrons, among whom he
was appreciated to an extent seldom gained in
so short a time.

He rarely neglected the wants of the sick, and
was ever ready to alleviate the sufferings of his
patients. Carefully investigating and diagnosing
disease, he was prompt in the use of remedial
agents.

He died March 16, 18S8, after a protracted
sickness, of eczema, complicated with disease of
the heart. At the time of his death he was a
member of the American Medical Association,
Vermont State Medical Society, Rutland County
Medical and Surgical Society, Rutland Medical
Club and Connecticut River Medical Society.

In the death of Dr. H. F. Crain, the profession
sustains a loss not easil}' repaired, the loss of one,
who, during his long professional life, held
strictly to the high dignity of the profession as
taught and practiced in our regular schools and

144

MISCELLANY.

[July 27, 1889.

colleges, never wavering from the true principle
of medical ethics, discarding quacker}', whether
within or out of the profession. He was a criti-
cal ob.ser\'er of men and measures, of strong con-
victions, studious in keeping pace with the im-
provements in remedies or mechanical inventions
for the better treatment of disease, testing every
new element, giving rational reasons for approval
or rejection. He had in his library' books for
reference from the most approved authors, foreign
as well as American, of which he evinced a
thorough knowledge, duly appreciating the great
responsibility resting upon the profession which he
so long aiid faithfully honored. s. h. g.

MISCELLANY.

New York State Medical Association. — The
seventh special meeting of the Fifth District Branch of
the New York State Medical Association will be held in
Port Jervis, Orange Co., N.Y., on Tuesday, Aug. 27, 18S9.
For those who are willing to spare the time after the
meeting, a beautiful and interesting carriage drive of
seven miles along the Delaware river to Milford, Penna.,
is promised. All are urged to make an effort to attend
this meeting as the following Committee of ,\rrange-
ments are making every preparation to insure an inter-
esting meeting, both scientifically and sociallv :

Drs. J. H. Hunt, of Orange Co., Chairman; W. B.
Eager, of Orange Co.; M. C. Connor, of Orange Co.; T.
W. Bennett, of Sullivan Co. ; AV. H. DeKay, of Sullivan
Co.; J. A. Munson, of Sullivan Co.

W. T. LUSK, M.D., President.

E. H. Squibb, M.D., Secretary-,

P. O. Box 94, Brooklyn," N. Y.

Health in Michigan, June, 1S89. — For the month
of June, 1889, compared with the preceding month, the
reports mdicate that pneumonia, tonsilitis and influenza,
decreased in prevalence.

Compared with the preceding month, the temperature
in the month of June, 1889, was higher, the absolute and
relative humidity and the day and night ozone were
more.

Compared .with the average for the month of June in
the three years, 1886-88, inflammation of kidneys was
more prevalent, and cholera morbus.measles, and inflam-
mation of bowels were less prevalent in June, 18S9.

For the month of June, 1889, compared with the
average of corresponding months in the three years 1886-
'88, the temperature was lower, the absolute humiditv
was about the same, the relative humidity was more, and
the day and night ozone much more.

Including reports by regular obser\-ers and others, diph-
theria was reported present in Michigan in the month of
June, i88g, at 23 places, scarlet fever at 37 places, t}--
phoid fever at 16 places, and measles at 19 places.

Reports from all sources show diphtheria reported at
I place more, scarlet fever at 1 1 places less, typhoid fever
at 6 places more, measles at 4 places less, than in the
preceding month.

New York ; Dr. Irving C. Rosse, Washington ; Dr. Robt.
Newman, New York ; Dr. G. W. McCaskey, Fort Wayne,
Ind. ; Dr. John N. Hess, New Marion, Ind., Drs. Pease &
Jones, Concordia, Miss.; Dr. S. T. Armstrong, U. S. M.
H. S. , Washington ; Dr. Thos. W. Kav, Scranton, Pa.;
Dr. R. Harvev Reed, Mansfield, O ; 'Dr. A. B. Hirsh,
Philadelphia; 'Dr. D. Colvin Hyde, Clyde, N. Y.; Dr. E.
M. Marbourg, Hudson, Wis.; Dr. Maris Gibson, Wilkes-
barre, Pa.; Dr. M. .A.bel. Providence, R. I.; Dr. L. P. Bush,
Wilmiugton,Del.; Dr.C. E.Winslow,.^lberciuerque,N. M.;
Dr. A. Nash, Joliet, 111.; Dr. S. C. Plummer, Jr., Beaver
Creek, Minn.; Dr. Thos. Elliot, Worth. Texas ; Fairchild,
Bros. & Foster, New York ; Dr. E. A. Christian, Pontiac,
Mich.; Dr. O. T. Masson, So. Evanston, 111. ; Dr. R. S.
Knode, Omaha, Neb.; Dr. P. O. Hooper.Little Rock, Ark.;
Dr. S. N. Sims, St. Joseph, Mo.; Dr. A. B. Newkirk, Falls
City, Neb.; Parke, Davis & Co., Detroit, Mich.; Dr. H. O.
Knoll, New York ; Dr. E. Fletcher Ingals, Chicago ; Dr.
D. W. Prentiss. Washington ; Dr. William H. Morrison,
Holmesburg, Pa.; Dr. G. C. H. Meier, New York ; Dr.
C. S. Wood, New York ; Dr. C. F. JIcGahan, Chatta-
nooga, Tenn.; Dr. S.J.Jones, Chicago ; Dr. James Orne
Whitney, Pawtucket, R. I.; Dr. R.J. Dunglison, Philadel-
phia; Dr. Howard Morgan, Westerly, R. I.; Dr. H. Y.
Sweringeu, Fort Wavne, Ind.; Dr. J. B. Pellet, Hamburg,
N. J.; Dr. J. F. Snider, Monroe Center, 111.; Lorin F. De-
land, Boston ; Health Restorative Co., New York ; Dr.
J. M. Bessev, Denver, Col. ; Dr. E. R. Squibb. Brooklvn,
N. Y.; Rev' Wm. R. Scott, Sterling, Kan.; Dr. Charles
F. Southwood, Monroe, Mich.

LETTERS RECEIVED.

S.A.Brewster, Creston, la.; Battle & Co., St. Louis,
Mo.; Dr. S. Thompson, Toledo, la.; Dr. R. M. Wvcoff,
Brooklyn, N. Y.; Dr. G. H. Grant, Hanover, Ind.'; Dr.
R. C. Kedzie, Agricultural College, Mich.; Dr. James H.
Buckner, Cincinnati, O.; Dr. Henry O. Marcy, Boston,
Mass.; Dr. L. G. North, Tecumseh, Mich.; Dr. J. B. Ham-
ilton, U. S. M. H. S., Washington; Dr. Thos. H. Manley,

Official Li it of Changes in the Stations and Duties of
Officers Serving in the Medical Department, U. S.
Army, from fitly /j, iSSg, to fitly ig, iSSg.

Capt. Louis Brechemin, Asst. Surgeon U. S. \., ordered
to Illinois National Guards, near Springfield, 111., dur-
ing remaining portion of encampment. Par. I, S. O.
159, A. G. O., July 12, 1889.

Lieut. R. R. Ball, Asst. Surgeon U. S. Army, is granted
leave of absence for fifteen days. Par. 3, S. O. 87,
Dept of the Missouri, July 9, 18S9.

By direction of the Secretary of War. the extension of
leave of absence on surgeon's certificate of disability
granted Capt. H. G. Bunton, .\sst. Surgeon, in S. O.
22, January 26, 1S89, from this office, is further extend-
ed two months on account of sickness. Par. 1, S. O.
162, A. G. O., July 16, 18S9.

F. J. Ives, Asst. Surgeon U. S. .\rmy. now at Ft. Lyon,
Cal., will proceed to camp near Oklahoma City, I. T.,
and report to the commanding officer for duty, reliev-
ing Capt. W. C. Gorgas, .■\sst. Surgeon, who, when so
relieved, is authorized to avail himself of the leave of
absence granted him in par. 2, S. O. 84. c. s., Dept. of
the Missouri. Par. i, S. O. 87, Dept. of the Missouri,
July 9, 18S9.

Official List of Changes of Stations and Duties of Medi-
'cal Officers of the U. S. Marine-Hospital Service, for
the Five Weeks Ending fitly is. iSSg.

Surgeon C. S. D. Fessenden, to proceed to Cairo, 111., on
special duty. July S, 1S89.

Surgeon W. H. Long, granted leave of absence for twen-
ty-eight days, June 18, 1SS9.

Surgeon H. W. Austin, to proceed to Cairo, 111., on spe-
cial duty. July 8, 1889.

Surgeon Fairfax Irwin, granted leave of absence for ten
days. July 6, 1889.

P. A. Surgeon F. W. Mead, granted leave of absence for
thirtv days. June 24. 18S9.

Asst. Surgeon G. M. Magnuler, relieved from duty at
Baltimore, Md.; to report to the Supervising Surgeon-
General for duty as acting Chief Clerk and attending
surgeon. July 10, 1S89.

.^sst. Surgeon H. T. Goodwin, granted leave of absence
for thirtv davs. July S, 18S9.

THE

J ournal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.
PUBLISHED WEEKLY.

Vol. XIII.

CHICAGO, AUGUST 3, 1889.

No. 5.

ADDRESSES.

ADDRESS OF WELCOME.

Read at the Fortieth Annual Meeting of the American Medical
Association. Xezcport, R. I.. June, iSSg.

BY HENRY E. TURNER, M.D.,

OF NEWPORT, R. I.

Mr. President and Gentlemen of the American

Medical Association :

The honor of presenting to you, gentlemen, an
Address of Welcome on this highly interesting
occasion, on the part of the local faculty of New-
port, is one which I duly appreciate, as a flatter-
ing mark of confidence on the part of m}' associ-
ates, and as an agreeable form of introduction to
yourselves, to whom I am very largely unknown,
having never, though often delegated by the
Rhode Island Medical Societ}', had the satisfac-
tion of attending a Session of the National As-
sociation, because, generally, of the great dis-
tances of the meetings from my place of residence.

Newport, as a resort for health or pleasure, is
more or less familiar to you all, but its pre-
tensions as a centre of wealth, and taste and cul-
ture, in days long past, and especially of medical
interest, are not as familiar to your minds, as to
those of the residents of this ancient and formerlj'
metropolitan borough ; a few remarks of an his-
torical character, have therefore seemed to me ap-
propriate to the occasion.

During the greater part of the eighteenth cen-
tury, Newport was the theatre of a very ex-
tensive and lucrative foreign trade, which came
to a conclusion at the Revolution bj- reason of its
occupation by British forces for a long period, and
the consequent interruption to trade, and removal
of a large proportion of its population, and the
absolute loss and waste of much of its capital,
and the diversion of a large part of the balance to
other fields of industrj' ; so that at the conclusion
of the war it presented a scene of desolation, di-
lapidated wharves and store-houses, neglected
buildings, streets and dwellings and general de-
cay, and an idle and poverty-stricken population
in place of one characterized as formerly by all
the marks of thrift and industry, and only feeble
remnants of the elegance and style formerly ex-
hibited, and in which, in the heyday of its pros-
perity, it had been preeminent.

One result of the wealth and hospitality, and
high cultivation of the better classes of Newport
society, was the inducement presented b}' con-
stant familiar association with European capitals,
to men of culture and refinement, to take up a
temporary or permanent residence in Newport,
whose natural attractions were then as now,
highly appreciated ; and we find, accordingly, a
galax}' of names of medical men of European
birth and education, who became identified with
Newport in its palmiest days as practitioners of
medicine, who left on the minds of their contem-
poraries and of several succeeding generations
the impression of ven,- high accomplishments and
verj- profound wisdom, and the 3-ounger natives
who had the benefit of their instructions and ex-
ample, sustained the character which they had
established.

Among the former the names are prominent of
Vigneron, Brett, Fletcher, Mofifatt, Haliburton,
and Oliphant. Among the latter, Senter, Mason
and others.

Dr. Morbert Felicien Wigneron, or as it was
latterly written and pronounced Vigneron, was
bom and baptised June 2, 1660, in the Parish of
La Ventie, Diocese of Arras, Province of Artois,
France. He is presumed to have been in New-
port earh' in the eighteenth centurj-, having mar-
ried Susanna Pierce in 1704. He died in New-
port, at a very advanced age, having practiced
with a very high degree of reputation, and was
succeeded bj' two sons and one grandson in his
practice and in popular esteem, insomuch that
within fifty years of this time tradition had pre-
ser^'ed his fame, and the old French doctor was
I often referred to by old people as one of the lum-
inaries not entirely forgotten.

His son, Charles Antoine Vigneron, after thirty-
five j'ears' practice in Newport, in which he fully
maintained the reputation of his father, died of
small-pox in New York, in 1772.

His other son, Stephen, sailed as surgeon of
a privateer in the old French war, after conspicu-
ous service at Cape Breton, and the capture of
I Louisburg, and was never heard of after.
1 The grandson, Stephen also, was a surgeon in
; the Continental Army, and died of typhus on
board the Jersey, prison ship, in New Y'ork.

Dr. John Brett, a graduate of medicine at

146

ADDRESS OF WELCOME.

[August 3,

Leyden, where he enjoyed the advantage of the
instruction of the celebrated Boerhaave, came to
Newport about 1743 and lived here for many
3^ears. He enjoyed the reputation of a highly ac-
complished physician, and a man of great scholas-
tic and literarj- attainments.

Dr. William Fletcher came to Newport during
the Revolutionary war as surgeon in the British
nav3', but was transferred to the armj- and retired
on half pay, when he entered on the practice of
medicine in Newport, in 1785, and died here
March 9, 1788, having, as his epitaph relates,
" lived like a gentleman and died like a philoso-
pher." Dr. Fletcher was born in Lancashire,
England, in 1742, and was, therefore, at his death
46 years of age.

Dr. John Haliburton came to Newport about
1760, probably, and married January 4, 1767,
Susannna, daughter of Jahleel Brenton, Esq., of
Newport, sister of Admiral Jahleel Brenton, of
the British Navy. This connection gave him
high social position, and identified him with the
wealthiest and most influential famil}- in the Col-
ony, and his career was a most successful and
brilliant one until at an earl}' period of the Revo-
lution, he came under suspicion of loj'alist prac-
tices and became a refugee, and passed the rest
of his life in Nova Scotia, dying there in 1807,
set. 69 years. He was the father of Sir Brenton
Haliburton, an eminent jurist, and for many
years Chief Justice of Nova Scotia.

Dr. William Hunter, said to have been a kins-
man of the distinguished brothers, William and
John Hunter, oT Edinburgh, was a native of
Scotland, and a graduate of Edinburgh Uni-
versity-, then considered the centre of medical
light. He was born in 1731, and died at New-
port, January 31, 1777, from fever incurred in
hospital service, He has been reputed to have
been a refugee after Culloden, but if the dates are
correct, he was too j-oung to have acquired a
medical education in 1746, when the rebellion
collapsed, and too young to have incurred the
penalty of rebellion, but the tradition has been a
very tenacious one. He is supposed to have
come to Newport about 1750. He soon acquired
a prominent position as a practitioner in Newport,
and in 1758 was elected physician and Surgeon-
General of the Rhode Island troops, and ser\-ed
in the unfortunate expedition to Canada under
General Abercrombie, and the subsec^uent more
successful one under General Amherst, when the
fall of Montreal clo.sed the war, and Dr. Hunter
returned to his practice in Newport, which was
very successful.

In 1756, Dr. Hunter delivered in the State
House in Newport, the first course of anatomical
lectures ever given in America. September 13,
1 76 1, he was married to Deborah Malbone,
daughter of Godfrey, Esq., of Newport, by which
he established an alliance with one of the most

influential and wealthy families in the Colonj^
and until his death he was a prosperous and suc-
cessful man.

Dr. Hunter was active and very positive in his
adherence to the cause of the Crown in all the
troubles preceding the Revolution, and was con-
sequently' verj' obnoxious to the other party, but
he died while the British forces were in posses-
sion at Newport, and in the full persuasion of the
final triumph of the roj'al cause. He was out-
spoken in his denunciation of those he was
pleased to style ' ' the domned Rubbels. ' '

Dr. Thomas Mofifatt, a Scotch refugee, after
Culloden, came to Newport, and practiced medi-
cine with much reputation until 1765, when he
became obnoxious to the people from his activity
in the enforcement of the Stamp Act, and was
driven away, but returned to Newport when it
was in the possession of the British, and left on
their evacuation, never returning. He was a
man of high reputation. Dr. Senter was a student
in his office.

Among the highly distinguished medical men
who made Newport their residence in the last
: quarter of the eighteenth century, Dr. David
' Olyphant should not be overlooked. He was
born in Scotland, at Pitheaoles, near Perth, and
was a younger brother of Lord Olyphant and was
I heir to his title, which he never claimed having
become thoroughh' Americanized. He was in
the Jacobite Rebellion of 1745, and escaped and
'. came to Charleston, South Carolina, where he
practiced for many j'ears with great succe.ss and
distinction. At the commencement of the Revo-
lution he offered his services to Congress, and
was appointed Director-General of the Southern
■ Hospitals. He removed to Newport in 17S5, and
married his third wife. Miss Ann Vernon, here in
{ 1786. He died in Newport in 1804, set. 85 years.
Dr. Olyphant was an esteemed member of the
Societ}' of the Cincinnati of Rhode Island, and
emphasized his devotion to American sentiments
b}- naming his son David Washington Cincinnatus
Olyphant.

Among those who were in the settlement at
Portsmouth, (upon the island of Rhode Island),
in its first year, 1638, were Dr. John Clark and
Dr. Robert Jeoffreys.

By Act of the General Court of date September
17, 1644, at Newport,

" It is ordered that Jlr. Robert Jeoffreys shall be au-
thorized to exercise the function of Chiruri;erie."

Mr. Jeoffreys was active and prominent in the
aff'airs of the settlement, but his claim as a med-
ical practitioner is not otherwise alluded to, and
as John Clarke was a signer of the original com-
pact, and one of the first arrivals, and was a very
much more important member of the body, and
is not mentioned in the public record in his med-
ical relation, the inference is that Mr. Clarke had
the authorit}' of a European University, while

1889.]

ADDRESS OF WELCOME.

147

Mr. JeofFre)'S depended on this act of the Legis-
lature for his license to practice, and there is
almost conclusive evidence, recently obtained by
Dr. Storer through exhaustive inquiries made for
him by Dr. Wm. O. Priestle}-, of Kings College,
London, that Mr. Clark, who spent many years
afterward in successful practice in London, was a
graduate of the University of Leyden, then the
most famous school of medicine in the world.
He is entered upon the registry of that University
in 1635 as "Johannes Clarcq, Anglus."

Singularly enough in March, 1664, the year in
which the Charter of King Charles II went into
force, the General Assembly passed the following
Act, viz.:

"Whereas : The Court have taken notice of the great
blessing of God, on the good endevers of Captayne John
Cranston, of Newport, both in Phissick and Chirurger\',
to the great comfort of such as have had occation to im-
prove his skill and practice, etc. The Court doe, there-
fore, unanimously enacte and declare, that the said Cap-
tayne John Cranston is lycenced and commissioned to
administer Phissick and practice Chirurgery throughout
this whole Collony, and is, by this Court, styled and re-
corded. Doctor of Phissick and Chirurgery, by the au-
thority of this, the General Assembly of this Collony."

This, it is safe to say, was the first degree of
M.D. ever granted and promulgated on this Con-
tinent, and we have no means of knowing what
qtialifications Mr. Cranston possessed or by what
means the General Assembly ascertained them.

Dr. Cranston was born in Scotland in 1625 or
1626, and appears first on the Rhode Island
Record in 1644, aet. about xg years, and died in
Newport, March 11, 1680. He was very con-
spicuous and influential in all the affairs of the
Colony, and was Governor at his death. His son
Samuel was also Governor from 1698 to 1727, 29
years, also dying in the office.

Dr. John Clarke, who was one of the first set-
tlers and a signer of the Compact, was undotibt-
edly the most conspicuous and important of the
Rhode Island founders. He was born in 1609
and died April 20, 1676, being at the time of ex-
odus from Massachtisetts 30 years of age.

Evidently Dr. Clarke was a potential factor,
and an esssential element in all the events which
resulted in establishing and maturing the little
Commonwealth which eventually comprised the
settlements of Aquidneck, Providence, and War-
wick, with the gradual annexation or re-annexa-
tion of Kings Province, now Washington County,
always claimed by Rhode Island, but contested
by Massachusetts and Connecticut, and finally of
the Eastern towns in 1747, which had been at-
tached to the jurisdiction of Plymouth Colony,
which itself had been merged in Massachusetts
since 1690. In all these transactions Dr. Clarke
had been an effective agent, as he was in procur-
ing the charter of 1663, which charter, under
which the Colony, and State of Rhode Island and
Providence Plantations was administered until

1843, confirmed by the royal authority of Charles
II, the right of liberty of conscience to all living
under it, in the most formal manner, even as it
had been previously established by law under the
former charter. Thus did the State of Rhode
Island become the first political organization
among men, having as its basis of organic law
this vital principle of individual freedom.

Besides being thus important in the Colonial
affairs. Dr. Clarke held high professional rank as
a physician. He also was the founder and first
pastor of the first Baptist Church in Newport,
and it is a mooted point whether this did not
antedate that in Providence, in which case it
would be the first Baptist Church established in
America. Dr. Clark was the faithful and dili-
gent, and learned pastor of this Church until his
death. His estate was bequeathed to three as-
signs for public purposes, as a perpetual trust.

Drs. Thomas and John Rodman, came to New-
port in 1680; they were sons of Dr. John Rodman,
of Christ Church Parish, Island of Barbadoes.
Dr. John, after some years practice in Newport,
went to Block Island, and after remaining there
for several years, he settled on Long Island,
where he has a numerous progeny. Dr. Thomas
remained in Newport and died here, January 17,
1727, aet. 80 years and 16 days.

Two of Dr. Thomas Rodman's sons were phy-
sicians. Thomas lived and practiced in South
Kingstown, R, I., where he has numerous de-
scendants. Clarke remained at Newport where
he died in 1752, aet. 53 years.

Two sous of Dr. Clarke Rodman were phy-
sicians, Walter and Thomas.

Dr. Walter Rodman died at Jamestown, in
1753, aet. 34 years, having practiced at Newport
for fourteen years.

Dr. Thomas Rodman was born in 1726, was
Freeman of the Colony in 1745. In 1759 he was
elected surgeon of the Rhode Island Regiment in
the service of the Crown, and in 1760 was re-
elected. He was in the campaigns against the
French and Indians on the Canada frontier dur-
ing those two years, from which time his record
is not known. So that from 1680 to 1760, not
quite a century, the citizens of Newport were in-
debted to the Rodman family for continuous med-
ical ser\'ice. They were all esteemed members of
the Friends' Society.

Among the sons of the soil who worthily suc-
ceeded the luminaries heretofore mentioned
towards the close of the eighteenth century,
were Drs. Senter and Mason.

Dr. Isaac Senter was born in Londonderry, New
Hampshire, in 1753. Nothing is known of his
boyhood. In early youth he became a student in
the office of Dr. Thomas Moffatt, before spoken
of as a Scotch refugee. Dr. Senter joined the
Rhode Island forces, before Boston, at the begin-
ning of the Revolution, and soon became surgeon

148

ADDRESS OF WELCOME.

[August 3,

of a Rhode Island Regiment of the Continental
line, and was in Arnold's department of Mont-
gomer\-'s unfortunate expedition to Quebec. In
1779 he left the sen'ice and returned to a practice
which he had left in Cranston, R. I. Here he re-
mained until 1780 when he came to Newport, and
was the leading practitioner here until 1799, when
he died at the earlj' age of 44 years, having
achieved a more brilliant fame, particularly as a
surgeon, than has fallen to the lot of any other
man in this community.

Dr. Benjamin Mason, a native of Newport,
after studying with Dr. Senter, settled in New-
port, and practiced with great success until his
death in 1801, aet. 40 years. Dr. Ursher Parsons
described him as at the head of his profession in
Newport.

The faculty has been represented in the present
century, in a manner not unworthj^ the example
given in the-two preceeding ones, by a most re-
spectable bod}" of men, one generation of whom
passed away between 1830 and 1840, viz.; Dr.
William Turner, Dr. Edmund Waring, Dr. David
King, and Dr. Enoch Hazard, all of whom com-
menced practice with the centurj', to be suc-
ceeded by Dr. James \'. Turner, Dr. Theophilus
C. Dunn, who was an earlj^ Vice-President of the
American Medical Association, Dr. Daniel Wat-
son, and Dr. David King, Jr., Dr. Samuel W.
Butler, and others, including some of those still in
active life, who need not be mentioned in detail.
There should be named Dr. Charles Cotton, who
came to Newport about 1814, and formed a link
bfetweeu the first and second class, dying in 1870
at the ripe old age of 8 1 years, an age verj' much
beyond anj- of his professional contemporaries.

Having said this much of the profession, I trust
a few remarks, not especially pertaining to it,
raay be excused.

One of the most interesting episodes in New-
port history was the arrival here of the dis-
tinguished Dr. George Berkely, the author of
the " Minute Philosopher," in 1728. He had
left Europe with the design of establishing at
Bermuda a college for the education of the Ameri-
can Indians. Having abandoned this plan as
impracticable, he made his abode for several years
at Newport, where his influence was soon felt in
the inauguration of a decided advance in literary
culture, which eventuated in the founding of a
literarj^ association which afterward became the
Redwood Library Association, an institution
which at an early period held a high rank among
the American localities of literar\' pretensions,
and which gave to Newport the advantage of a
library' of a high tone at an earlier time than any
other American town, not the seat of a Collegiate
Institution, The original books in this collec-
tion were of the highest character.

Among the beautiful spots which adorn this
Island, none is more beautiful than Butts' Hill,

at Portsmouth, and none appeals as strongly to
the interest of all Americans, it having been the
central point (Point d'Appui) of the battle of
Rhode Island, fought on the 29th of August,
1778, and pronounced by Lafayette "the best
fought action of the War." The site at present
is marked by the remains, remarkably well pre-
served, of a strong fort erected b\- the British,
but at the time of the action in possession of the
Americans, and from which the most vigorous
assaults of the British and Germans were success-
fully repulsed bj' the Americans, leaving them
still in possession at the close of the daj'. But
during the night the Americans made a most suc-
cessful retreat across the bay, as was said, with-
out the loss of a man or a pound of ammunition
or stores. The expected British fleet arriving
next morning surrounded the Island, and but for
their timely retreat not a man of the American
army would have escaped.

From the fort a most superb landscape is pre-
sented comprising the East and West Narragan-
sett Ba3' and Mount Hope Baj-, and exhibiting
very distinctlj^ all the lines of approach and retreat.

The failure of the siege of Newport and the
capture of General Piggott's army of 7,000 men,
which had seemed almost assured, and was de-
feated only or chiefly through adverse weather,
was one of the bitterest disappointments en-
countered by Washington during the entire war,
and bore \'er3- hea\-ily on the scattered and im-
poverished population of the State, and especi-
ally on the Islanders who were generally refugees
dependent on the hospitality of the already over-
burdened denizens of the mainland, and when,
after the British evacuation, thej' returned to
their homes, universal and indiscriminate desola-
tion had usurped the place of their thrifty and
comfortable farm steads, and houses, bams,
fences and orchards, and everything capable of
being used as fuel had been consumed to supply
the garrison and residents. No accessible portion
of the mainland being in possession of the British,
and the British troops and German contingent
are said to have suffered excessivelj- from want of
fuel, the winters during their occupation having
been exceptionally severe.

From DeWar\-ille's travels in America," 1788,
page 80 :

" I went from Providence to Newport in a packet boat
This jonrnev might be made by land, but I preferred the
water. We arrived in seven hours and a half, and dur-
ing two hours we had contrary wind. This distance is
thirty miles. We never lost sight of land, but it offers
nothing picturesque or curious. A few houses, some
trees, and a sandy soil are all that appear to the eye.

" The Port of Newport is considered as one of the best
in the liiited States. The bottom is good, the harbor
capable of receiving the largest ships and seems destined
by Nature to be of great consequence. This place was
one of the scenes of the last war, the successive arrival
of the American, English and French armies left liere a
considerable quantity of money.

1889]

ADDRESS OF WELCOME.

149

"Since the peace everything is changed. The solitude
is only interrupted by groups of idle men standing, with
folded arms, at the corners of the streets, houses falling
to ruin ; miserable shops, which present nothing but a
few coarse stuffs, or baskets of apples, and other articles
of little value ; grass growing in the public square, in
front of the court of justice ; rags stuffed in the windows,
or hung upon hideous women ; everything announces
misery, the triumph of ill faith and the influence of bad
government. You will have a perfect idea of it by call-
ing to mind the impression once made upon us on enter-
ing the City of Liege.

"Recollect the crowd of mendicants besieging us at
every step, to implore charity ; that irregular mass of
Gothic houses falling to ruin, windows without glass,
roofs of half uncovered ; recall to mind the figures of
men scarcely bearing the print of humanity, children in
tatters, and houses hung with rags, in short, represent to
yourself the asylum of famine, the rascality and the im-
pudence that general misery inspires, and you will recol-
lect Liege, and have an image of Newport."

The over-weening pride and aifection, which a
native Rhode Islander cherishes towards his natal
soil and the time-honored traditions and institu-
tions of the Commonwealth of his fathers, must
to denizens of other States comprising many
times its area and supporting many times its pop-
ulation, seem almost absurd, but patriotism is a
sentiment which bears no relation to the magni-
ttide of areas, or to the numerical features of
populations. The Scot of the days of Bruce and
Wallace yielded no tittle in his devotion to Scot-
tish independence and in national pride to the
adherents of the great monarchies of France,
England, Spain, and the German Empire, and
despite the overwhelming superiority of England
in population, territory, and resources, defied for
generations with dogged tenacity, all the power
of her arms and all the guileful influence of her
most astute politicians in the unstinted and un-
scrupulous use of her almost unlimited wealth.
Corrupt as were many of the leading Scots, the
great popular heart always beat responsive to the
love of country and to the honor of the name of
Scot. And the final union of Scotland and Eng-
land was not the result of conquest on the one
part and of submission on the other, but of equal
and harmonious adjustment of all differences.

The circumstances surrounding the first settle-
ment of Rhode Island and the earlier portion of
its career, were such as to give a peculiar bias to
the minds of the settlers, and to cultivate the
tenacity of purpose and the stern energj- which
especially characterized the early Rhode Islanders,
even when compared with the Puritan and other
elements which were in no wise deficient in the
same characteristics so necessary in struggling
again.st the disadvantages of a rough and un-
thankful soil, a rigorous climate, and a savage
and relentless population. Besides all these, the
Rhode Islanders encountered from the beginning,
and at every subsequent period the antagonism of
the adjacent Colonies.

All three of the Settlements, Providence, Aquid-
neck and Warwick, were made by parties who

were refugees from Massachusetts, either ex-
pelled that jurisdiction or in fear of expulsion for
the entertainment of opinions deemed heretical
there, and particularly they held the opinion,
which the}' directly promulgated and always ad-
hered to, that in matters of belief every man is,
and of right ought to be, his own judge. This
doctrine, now accepted by all civilized commun-
ities, was then comparatively novel, and was long
familiarly known as the Rhode Island doctrine or
idea, and although not entirely new, had never so
far cr3'stalized into active power as to be enacted
into authoritative form until adopted as their
fundamental law by the General Assembly of
Rhode Island, although understood by the set-
tlers in their first informal agreement of settlement.

Ever>' Rhode Islander, therefore, is peculiarly
sensitive in relation to the sacredness of individ-
ual liberty, and no doubt this sentiment, in its
excessive development, has often prevented the
enactment of laws which may have been bene-
ficial, but still we look upon it as calculated to
have a beneficent influence, and the fact of its
existence, which could hardly have failed to re-
sult from the relations referred to, will explain
the excessive local feeling which belongs, of right,
to a Rhode Islander.

The long delay of Rhode Island to accept the
Constitution of the United States grew, in a great
measure, out of this distinctive sentiment, and al-
though unwise at that crisis argues no disparage-
ment to Rhode Island patriotism, which has
always made prompt and active response to all
subsequent appeals as it had adhered to the strug-
gle for independence under the stress of particu-
larly severe and trying circumstances. I refer to
the occupation, for a long period, of its principal
town and seaport, and the suppression of its
commerce, which had been its principal resource.

With the same warmth and singleness of heart,
with which she has hitherto always responded to
the call of duty, and with a full conception of the
honor conferred on her, by your selection of her
as your place of meeting on the present occasion,
Rhode Island now opens its arms to welcome you,
gentlemen of the American Medical Association,
to all the enjoyments and conveniences which can
be secured to you by willing hearts and active
hands, and hoping that the most gratifying re-
sults may be derived from your deliberations,
offers to you a warm greeting.

Mme. Dejoine Klumpke, an American lady
married to a Frenchman, carried off" her degree of
doctoress at the Faculty of Medicine, Paris, last
Saturday, with high honors. The lady has dis-
tanced all her competitors in the medical field.
She was a pupil of the late Professor \'ulpian.
She has also written several standard works on
ner\'ous pathologj- and won valuable prizes.

I50

FRACTURES OF NECK OF FEMUR.

[August 3,

ORIGINAL ARTICLES.

THE TREATMENT OF FRACTURES OF
THE NECK OF THE FEMUR BY IM-
MEDIATE REDUCTION AND
PERMANENT FIXATION.
BY N. SENN, M.D., Ph.D.,

OF MILWAUKEE, WIS.
ATTENDING SUKGEON MILWAUKEE HOSPITAL ; PROFESSOR PRIN-
CIPLES OF SURGERY AND SURGICAL PATHOLOGY, RUSH
MEDICAL COLLEGE, CHICAGO, ILL,

The treatment of a fracture of the neck of the
femur is always a source of anxietj' to the sur-
geon. In many instances the diagnosis is at-
tended by unusual difficulties and not infre-
quently a fracture of this kind is overlooked,
even after what appears to have been a thorough
examination, while at other times, for want of a
correct diagnosis, patients have been submitted
to a long and debilitating treatment when no
fracture existed. Patients suffering from this
injury are with few exceptions advanced in years
and liable to succumb to complications incident
to prolonged confinement in bed. The marantic
changes in the tissues of the aged and in persons
rendered prematurely old by hereditary- or ac-
quired causes are known to be antagonistic to a
rapid repair of such an injun,% while at the same
time the anatomical conditions at the seat of
fracture are such as are well calculated to retard,
if not to prevent, the production of callus. With
few exceptions our surgical text books and spe-
cial work on fractures continue to advance the
same ideas that have been prevalent for centuries
concerning the process of repair in fractures of
the neck of the femur, and assert that bony union
is only possible if the line of fracture is com-
pletely, or at least, partially outside of the limits
of the capsular ligament. Teachers and authors
are so positive in their assertions that if the frac-
ture is entirely intra-capsular a pseudo-arthrosis
is inevitable, that many cases of partly extra-
capsular fractures have been treated on the ex-
pectant plan the same as intra-capsular fracture,
and only too often with the same unsatisfactory-
result. The time has come when it is no longer
admissible to make such a distinction in the lec-
ture room, the text books or at the bedside. Ex-
perience and experimental research have demon-
strated that the proximal fragment, in case the
line of fracture is entirely intra-capsular, does not
only retain its vitality, but if placed in accurate
contact with the opposite fragment, either by im-
paction or by mechanical fixation it takes an
active part in the production of callus.

In a paper read at the meeting of the Ameri-
can Surgical Association, in 1883, ("Fractures of
the Neck of the Femur, with Special Reference
to Bony Union after Intra-capsular Fracture,"
Transactions of the American Surgical Associa-

tion, vol. i), I gave an account of fiftj'-four cases
collected from different sources of bonj- union
after intra-capsular fracture and in most of them
the proofs in support of the assertion were so con-
vincing that even skeptics on this subject would
find it difficult to give to them a different inter-
pretation. In the same paper I recorded the results
of my own experimental work undertaken for the
special object of demonstrating, if possible, that
bony union after intra-capsular fracture is so
seldom obtained, not so much on account of the
anatomical peculiarities of the parts involved in
the fracture as the inefficient treatment which is
usuallj- resorted to in its treatment. In the ani-
mals subjected to experiment the fracture was
produced by making multiple punctures with a
small drill through the neck of the femur entire-
h- within the limits of the capsular ligament and
fracturing the balance of the bone by forcibl)- ro-
tating the femur inwards. Twenty-three frac-
tures in so many different animals thus produced
were treated on the expectant plan, or by
simple fixation with a plaster-of-Paris dressing.
The animals were killed from four weeks to three
months after fracturing the bone, and the seat of
fracture was carefully examined in ever}' in-
stance, but in none of them was I able to find
any evidences of bony union. The best result
obtained by this method of treatment was pseudo-
arthrosis by the interposition of a short ligament
between the fractured ends. Discouraged by the
many failures I finally resolved to secure accurate
coaptation of the fragments by drilling a hole
from the trochanter major through the entire
length of the neck and well into the head and
fastening the fragments together with an aseptic
iron, bone or ivory nail. Eight such experiments
were made on cats. In two suppuration followed
the operation. In the rest bony union or union
by an exceedingl}- short ligament without any
displacement of the fragments was obtained. I
will quote only two of the experiments for the
purpose of illustrating the method of procedure
and of showing the condition and appearance of
the bone after permanent union by callus.

Experiment 2j. — Adult Maltese cat ; subcuta-
neous fracture of left femoral neck : fixation of
fragments by means of bone nail made from com-
pacta of tibia of an ox. Animal killed fourteen
weeks after operation. Neck of femur only
slightly shortened ; capsular ligament nearly
normal ; ligamentum teres intact ; vertical sec-
tion shows a slight cun-e in the upper portion of
the neck ; the head being slightly depressed.
Perfect and complete bony union, the spongiosa
being restored nearly to its normal condition. No
traces of bone nail or perforation.

Experiment J3. — Young cat ; subcutaneous
fracture of neck of right femur, direct fixation of
fragments with bone nail. Animal killed four
months after operation. During life function of

1889.]

FRACTURES OF NECK OF FEMUR.

151

the joint was perfect ; vertical section through
the head; neck and upper portion of shaft, shows
that the line of fracture must have been entirely
within the capsule, as the capsular ligament and
bone outside of it presented a perfectly normal
contour and appearance. Accurate measurements
show only a very slight shortening of the neck ;
the osseous tissue composing the interior of the
neck more dense than in the opposite bone.
Spongiosa restored to nearly its natural perfection.
No traces of track of perforation or bone nail.

In no case did I feel crepitation after the frac-
ture more distinctly than in this instance, and the
sudden giving way of the bone the moment it
was fractured was well marked, and was heard
by all of the assistants, and as the post-mortem
examination shows a perfect restoration of the
continuity of the bone, I am firmly convinced
that this specimen represents a typical and per-
fect recovery of union by bone after intra-capsular
fracture of the neck of the femur. The results
obtained by immediate transfixion of the frag-
ments stand in direct contrast to those treated by
external fixation. Bonj' union, or union by short
ligament, was the rule, non-union the exception.
In the treatment of all fractures the two cardinal
indications are : Firstly, to bring the fractured
surfaces into accurate coaptation as soon as pos-
sible after the accident, and, secondly, to maintain
uninterrupted approximation bj^ permanent im-
mobilization. In these respects the treatment of
fractures is governed by the same rules as the
treatment of wounds of the soft parts. In the
repair of all injuries the severed tissues should
be brought as nearly as possible in the same rel-
ative position they occupied in their normal con-
dition and to retain them in such position by
temporary mechanical measures until the comple-
tion of the reparative process. By following this
rule the normal regenerative resources inherent
in the tissues are taxed only to a minimum ex-
tent and definitive healing is obtained in the
shortest possible space of time. As union be-
tween the divided or severed parts can only take
place by the interposition of new material, the
product of a regenerative process in the tissues at
and in the immedate vicinity of seat of trauma,
and as this process presupposes the existence of a
connecting bridge of new blood vessels, it is evident
that the length of time required to secure union
will be greatly modified by the width of the inter-
vening space. It is somewhat strange that the
customary treatment of fractures of the neck of
the femur which has governed the practice of
surgeons from time immemorial, still commands
the confidence of the profession. For centuries
these fractures have been treated by some kind
of extension and imperfect immobilization. The
favorite treatment of to-day consists of extension
by means of the weight and puUej- as devised by
Gordon Buck, and fixation of the limb by a long

splint or two sand bags. The extension is ap-
plied for the purpose of counteracting muscular
contraction, the cause of the shortening of the
limb. If we consider the number and strength
of the muscles which are inserted in the lower
fragment, and which are the direct cause of the
shortening, we can imagine the force requisite to
overcome the longitudinal displacement. At best
permanent extension by weight and puUy cor-
rects the shortening only gradually and always
imperfectly and never secures immediate reduc-
tion, the first and most important indication in
the treatment of any fracture. As the upper
fragment is short, sometimes not reaching beyond
the niveau of the cotyloid cavity, is deeply lo-
cated and not parallel to the long axis of the
lower fragment, but nearly at a right angle to it,
all means of fixation short of complete immobili-
zation of the pelvis and the lower fragment upon
it must fail in securing uninterrupted coaptation
and perfect immobilization. The result obtained
by the customary- treatment have been such that
no better proof need be advanced to demonstrate
its inadequacy. The long confinement in bed
which it necessitates has often proved a direct
cause of death. Bony union of fractures within
the capsule has only occurred in cases where im-
paction had taken place and where this means of
fixation was allowed to remain undisturbed until
union was completed, in all other cases a pseudo-
arthrosis proved to be the unavoidable result. In
fractures outside of the capsule healing with
shortening of an inch has always been considered
an excellent result, and more frequently the short-
ening was in the neighborhood of two inches. The
treatment \>y weight and puUy extension and
splint fixations requires constant watchfulness on
the part of the surgeon and those who are in
direct charge of the patient. Extension con-
tinued for two or more months not infrequently
is followed by serious, if not permanent, damage
to the structures of the knee joint.

It is my purpose on this occasion to call your
attention to the advantages to be derived from
the treatment of fractures of the neck of the fe-
mur by immediate reduction and permanent fixa-
tion as compared with the treatment by the usual
methods. The treatment I shall describe is equally
well adapted for intra- and extra-capsular, impact-
ed and non-impacted fractures. As it is no longer
necessary, from a practical standpoint, to make a
distinction between an intra- and extra-capsular
fracture, I will only allude to a few diagnostic
signs which indicate the existence of a fracture
through the neck of the femur which should be
sought for, and carefully considered before a pos-
itive diagnosis is made.

SYMPTOMS AND DI.\GNOSIS OF FRACTURE OF
THE NECK OF THE FEMUR.

Displacement after fracture through the fern-

152

FRACTURES OF NECK OF FEMUR.

[August 3,

oral neck is due either to the fracturing force,
muscular contraction or simple gravitation. In
incomplete and impacted fractures it is caused en-
tirely by the fracturing force. A number of in-
complete fractures have been reported by Konig,

an indication of the extent to which impaction
has taken place. In very exceptional cases, if,
as has happened in a few instances, the fractur-
ing force is applied against the posterior border
of the trochanter major, the anterior wall of the

King, Jackson, and Billroth. These fractures are neck is fractured first and impaction takes place
produced by crushing, not overbending. If the ' at this point, an occurrence which is always indi-
force is transmitted through the long axis of the 1 cated by the limb being rotated in an inward di-
femur the lower portion of the neck gives way rection. In impacted fractures the upper margin
and Adam's arch penetrates the cancellated tis- of the trochanter major will alwaj's be found
sue of the neck to a certain distance, thus short- above the level of Roser-Nelaton's line, the
ening the lower border of the femoral neck, a con- outer surface of the trochanter is less prominent
dition which would give rise to slight adduction, than on the opposite side and its posterior border
but no shortening of the limb, and the upper \ is displaced backwards in the most common form
border of the trochanter major will be found in of impaction with outward rotation of the limb,
normal position in reference to Roser-Nelaton's , In complete fractures without impaction the dis-
line. If incomplete fracture take place at the j placements are due to active and passive causes,
expense of the posterior portion of the neck the ; The shortening results from muscular contraction
limb will retain its normal length, but the pos- and increases with the restoration of muscular
terior margin of the trochanter major would be action, while the rotation outwards of the limb
displaced slightl}- in a posterior direction and is due to the tendency of the limb to fall in this
would be somewhat less prominent than on the direction when in a condition of complete repose,
opposite side. If in an exceptional case the frac- 1 Method of Examination. — Injuries about the
turing force should be transmitted through the I hip-joint of sufficient intensity to fracture the

trochanter major in an opposite direction and
would crush a portion of the bone on the ante-
rior surface of the neck, the slight deformity pro-
duced would be the same, only that the trochan-
ter would be found rotated in an opposite direc-
tion

femoral neck in persons advanced in years should
always be examined with the utmost care for
evidences of fracture. Whenever possible a posi-
tive diagnosis should be made at the first exami-
nation. In some cases the symptoms are so

In all incomplete fractures then, no short- characteristic that a correct diagnosis can be made
ening exists and the upper margin of the tro- ; almost on first sight, while in other instances all
chanter major corresponds to the Roser-Nelaton diagnostic resourses must be exhausted before a
line. In complete but impacted fractures the correct idea of the nature of the injur}' can be
displacement is caused entirely b}' the fracturing I obtained. To make a thorough examination all
force and is commensurate with the amount of j clothing as far as the chest must be removed and
bone tissue crushed at the seat of fracture. As the the patient placed upon an even, smooth, un-
fracture in these cases is complete, more or less ' 3-ielding surface, either upon a table or the floor,
shortening is always present. A fall upon the ; Inspection will reveal the presence or absence of
foot or knee, as a rule, will fracture the neck at j a bruise over the trochanter major. If present
its narrowest portion, and, if the fracture is com- 1 the location of the superficial contusion will indi-
plete, no impaction will take place, unless it fol- j cate the direction of the fracturing force. Suggil-
lows as a secondarj' occurrence from transmission 1 lations about the hip are suggestive of a deep-

of force through the trochanter major. In such
cases the impacting force acts at a right angle to
the fracturing force. Experiments and clinical
obser\-ations have shown that the majority of

seated injury, and not infrequently they make
their appearance over the groin and along the
inner side of the thigh in a few days after a
fracture of the neck of the femur. If the limb is

fractures of the femoral neck are produced by i strongly rotated outwards, and by its position
force applied in the direction of the axis of the , dislocation of the hip-joint can be excluded, it is
neck by falls upon the trochanter major. It is ! more than probable that the femoral neck is frac-

also well established that in most instances the
neck gives way at its trochanteric portion, and
that the posterior wall is crushed or fractured first,
impaction of the posterior wall is therefore the rule.
Besides shortening, an impacted fracture of the
neck is always attended by slight rotation of the
limb in the direction of the impaction. For in-
stance, if the force is applied laterally through
the trochanter, and, as is n.sually the case, from
before backwards the posterior wall fractures first
and impaction takes place here, the degree of ro-
tation of the limb in an outward direction will be

tured. In all cases of fracture of the neck, there
is an appreciable fulness in the fold of the groin
corresponding to the seat of the fracture. This
swelling is caused by the hinge-like projection of
the anterior portion of the neck, efifusions of
blood or inflammaton,- products, and, lastly, by
the overriding or impaction of the fragments.
When impaction has taken place at the base of
neck, the trochanteric portion of the femur is en-
larged from implantation of the upper fragment.
More swelling is present in extra than intra-cap-
sular fractures, as in the former there is more

1889.]

FRACTURES OF NECK OF FEMUR.

153

haemorrhage and the bone injurj- is more exten-
sive. Another witness which can be elicited bj-
inspection in cases of fracture through the femo-
ral neck, is a slight depression between the great
trochanter and the crest of the ilium, a change in
contour caused bj' relaxation of the fascia lata, as
was first pointed out by Dr. Allis, This sign is
most marked when the patient is placed in the
erect position. The symptoms which have been
elicited by inspection and gentle palpitation must
be verified by careful measurements. The inform-
ation furnished by measurements carefully made
can be relied upon in arriving at positive con-
clusions concerning the nature of the injurj*. It
is not only superfluous but positively harmful to
search for positive symptoms of fracture, crepitus,
preternatural mobility of fragments, and new
point of motion, in these cases ; all manipulations
during the examination of a supposed fracture in
this locality should be made with the utmost care :
and gentleness. The search for crepitus and ;
other positive symptoms of fracture has been the
cause of incalculable harm. In many instances
careless handling of the limb has resulted in dis-
junction of impacted fractures, or in tearing of
periosteal or ligamentous bands, thus removing
the conditions upon which rested the possibility
of obtaining os.seous union bj- the interposition of
a short ligamentous band. In every case care is
to be taken not to disturb the parts at the seat of
injury for the purpose of making a diagnosis ; it
can never become necessary to administer an an-
aesthetic for the purpose of making a so-called
thorough c.xatnination. Our diagnosis should de-
pend on the presence or absence of the three most
important symptoms — position of the trochanter
major, shortening and eversion. A line drawn
from the tuberosity of the ischium to the anterior
superior spinous process of the ilium is called the
Roser-Nelaton line, and with the trochanter
major in its normal position and relations marks
its upper edge. If the measurements show short-
ening, and the femoral neck is fractured, the
upper border of the trochanter major will be
found displaced beyond the Roser-Xelaton line to
the extent of the actual shortening. It has re-
cently been shown by Wight, Hamilton, Gurson,
and others that inequality in the length of the
lower limbs is a rather common occurrence, conse-
quently in order to eliminate sources of error, it
becomes necessan,- to ascertain the presence of
asymmetry', should such exist, in applying meas-
urements in the diagnosis of a fracture of the
neck of the femur. For the purpose of avoiding
errors, which might accrue from asj-mmetry of
the lower extremities, Wight directs that the fol-
lowing measurements should be taken : (i.) In-
side measurements from the superior anterior
spines of the ilium to the lower ends of the inter-
nal malleoli. (2.) Outside measurements from
the superior anterior spines of the ilium to the

lower ends of the external malleoli. (3.) Meas-
urements from the tops of the great trochanters
to the lower ends of the external malleoli. (4.)
Measurements from the bases of the tibiae to the
lower ends of the internal malleoli. (5,) Meas-
urements from the superior anterior spines of the
ilium to a line drawn transversely in front be-
tween the top of the great trochanters. These
measurements give the length of the femur and
tibia on each side as well as the entire length of
both limbs, and if asymmetrj' of any of the
bones exists this fact is easily determined. If
actual shortening is found the existence of a frac-
ture of the femur below the hip-joint is excluded
by ascertaining the exact relation of the great
trochanter to the Roser-TSTelaton line, if the tro-
chanter is found displaced upwards to the extent
of the shortening and other symptoms point to
fracture, the diagnosis of a fracture through the
femoral neck may be considered as established.
In verj' fleshy persons the landmarks which serve
as points from which the measurements are made
are not well-defined and not easily located, and it
is on this account advisable to fix the location of
each as accurately as possible and indicate it on
the surface by a pencil mark before any of the
measurements are made. The best instrument
for making the measurements is a steel tape-line,
with feet and inches marked on one side, and
centimetres and millimetres on the other. Ever-
sion is readily detected by inspection. In im-
pacted fractures it may be very slight and a sud-
den or gradual increase of these displacements,
days, week, or months after the accident, signifies
that disengagement of the fragments has taken
place, an accident probably caused b}' inflamma-
torj' osteoporosis and imperfect immobilization. If
the surgeon has demonstrated by his examination
that a fracture exists, the presence of impaction
can be readily ascertained by genth- rotating the
limb upon its axis and by making slight traction ;
if these manipulations affect the head of the bone,
impaction has occurred, and ever>' care should
be exercised to presen'e the mutual fixation of
the fragments. Unimpacted fractures of the
neck of the femur seldom give rise to anj' diffi-
culty in diagnosis. The symptoms attending them
are so well marked that a correct conclusion can
be reached without causing needless suffering or
inflicting additional injuries in searching for any
of the positive signs.

Treatment. — The treatment I shall advocate in
fractures through any portion of the femoral neck
consists in the fulfillment of two principal indica-
tions : (i.) Immediate reduction. (2.) Perma-
nent fixation. The first part of the treatment,
the adjustment of the fragments, is of course only
necessary in non-impacted fractures. In im-
pacted fractures no attempt should be made to
correct any of the displacements, as the inter-
locking of the fragments secures the most favor-

154

FRACTURES OF NECK OF FEMUR.

[August 3,

able conditions for bony union to take place. It
is not too much to assert that if the impaction in
such cases can be maintained until the reparative
process is completed, union by callus would be
the rule, and non-union the exception. In all
intra-capsular fractures, union is effected exclu-
sively by the production of an intermediate cal-
lus, from the broken surfaces ; nature's splint,
the external or provisional callus, for well-known
anatomical reasons, is always wanting, hence the
mechanical support which is requisite to main-
tain uninterrupted coaptation has a more impor-
tant and prolonged application than in the treat-
ment of fractures in other localities. The time
required for bony union to take place in fractures
of the femoral neck is an unusually long one.
Gurlt fixes the time at from 56 to 207 days, and
the average duration at 84 days. Dupuj'tren es-
timates the time from 100 to 120 days, and states
that it has been customary at the Hotel-Dieu to
keep these patients in bed for 80 to 100 days.
There can be no doubt that manj- cases, which
promised well from the beginning, terminated un-
favorably from failure on the part of the surgeon
to secure efiicient means of fixation or by aband-
oning the treatment too early. An impaction
may become disengaged after a few weeks spon-
taneously or by a slight movement of the patient
if the fragments are not immovably fixed by some
efficient external mechanical support. To guard
against such an occurrence, the retentive meas-
ures should not be removed for at least 80 to
100 days. In impacted fractures the fragments
have been placed in the best possible condition
for bony consolidation, and the object of treat-
ment consists simply in preser^-ing the mutual
penetration for a sufficiently long time to obtain
restoration of the continuity of the bone. Per-
manent fixation of an impacted fracture in the
position in which it has been placed by the acci-
dent is necessary for the following reasons :

1. It prevents disengagement of the frag-
ments.

2. It obviates secondary shortening and ever-
sion during the stage of interstitial absorption
which attends inflammatory' osteoporosis.

3. By keeping the injured parts at rest, it
serves as a prophylactic measure against the ac-
cession of arthritis and para-arthritis.

4. It enables the patient to leave the bed any
time after the dressing has been applied, and thus
guards against decubitus, hj-postatic pneumonia,
and other affections incident to prolonged con-
finement in bed.

The advantages arising from immediate reduc-
tion and permanent fixation in fractures of the
neck of the femur are the following :

(a.) The untorn portions of the joint struc-
tures are replaced at once into their normal rela-
tions ; a procedure which cannot fail to influence
favorably the circulation in vessels which may
have escaped injury.

(b.) The sharp and irregular margins of the
broken surfaces act as irritants to the surround-
ing soft tissues ; immediate reduction, by placing
the fractured surfaces at once into mutual coapta-
tion, acts as a preventive agent against the su-
pervention of undue inflammation in and around
the hip-joint.

(c.) With coaptation the process of repair is
initiated at once, the blood and exudation ma-
terial between the fragments act as a temporary
cement substance, and at the same time ser\'e a
useful purpose in re-establishing the interrupted
circulation.

(d). Perfect reduction and permanent fixation
prevent muscular spasm and diminish pain.

M\- experimental work convinced me so strongly
of the not only possibility, but the probability, of
obtaining bony union in cases of intra-capsular
fractures, provided the fractured surfaces are kept
in uninterrupted contact for a sufficiently long
time, that I was led to suggest what justly ap-
peared at the time as heroic measures in securing
this end. It appeared to me impossible in cases
where no impaction had taken place to insure
sufficient innnobilization of the fragments with-
out some direct means of fixation. I suggested
at that time the advisability of immobilizing the
lower fragment by means of a sharp steel pin,
regulated by a set screw passing through the cen-
tre of a curved steel bar, incorporated in the plas-
ter-of-Paris splint over the fenestrum, in such a
way that the sharp point of the pin would perforate
the soft parts over the centre of the great
trochanter, and by penetrating a small distance
into the bone, could make the necessary- lateral
pressure and secure perfect immobility of both
fragments. As still a more direct means of fixa-
tion of both fragments, I advocated that in some
cases it would be justifiable to secure transfixtion
of both fragments by an ivory or bone nail which
was to be driven through a perforation made with
a drill, from the outer surface of the great tro-
chanter through the centre of the neck and well
into the head of the bone. The result of my ex-
periments convinced me that this means of fixa-
tion answered an admirable purpose in placing
the fragments in a position where union by callus
could take place. The specimens illustrating
this treatment demonstrated that such nails, if
a.septic, and in aseptic tissues, are completely re-
moved by absorption during the time required for
bony union to take place. These suggestions
were dictated by an honest conviction that any
less direct measures would fail in accomplishing
the desired result. It is only natural that this
plan of treatment was objected to as being utterly
inapplicable in most ca.ses, and too heroic in all.
Clinical experience has since satisfied me that
these direct measures are unnecessary, and that
the same object can be obtained by well regulated
lateral pressure in the direction of the axis of the

1889.]

FRACTURES OF NECK OF FEMUR.

155

femoral neck combined with perfect fixation of
the lower fragment upon the pelvis. The influ-
ence exercised by impaction in determining the
ultimate result in fractures within the capsule of
the hip-joint, has been repeatedly alluded to.
Many fractures of the femoral neck are kept from
becoming displaced for a variable period of time,
by interlocking of the denticulated broken sur-
faces, a condition which has been termed by
Bigelow ' ' rabbeting. ' ' Believing that the surgeon
should imitate the reparative resources of nature
wherever it is possible to do so, it occurred to me
that artificial rabbeting could be produced in all
cases by uninterrupted lateral pressure. It is not
difficult to conceive that if the fractured surfaces
are placed as accuratelj' as possible in apposition,
lateral pressure would effect perfect approxima-
tion and a mutual interlocking of the fragments.
Lateral pressure thus applied is one of the most
efhcient means in preventing secondary, lateral
and longitudinal displacements. Pressure, to be
efiective, must be applied in the direction of the
broken neck, that is, directlj^ over the trochanter
major, and in such a manner as not to interfere
with the superficial circulation. Pressure with
belts and strips of adhesive plaster encircling the
whole pelvis, can exert but little, if any, influ-
ence on the fractured bone, at the same time it
impedes the superficial circulation. In the more
recent cases of fracture of the neck of the femur
that have come under my observ^ation, I have pur-
sued the following plan of treatment.

The patient is dressed in well-fitting knit
drawers and a thin pair of stockings. For
strengthening the plaster- of- Paris dressing over
the joints, and at other points where greater
strength is required oaken shavings are placed
between the layers of plaster, these small thin
splints greatly increase the durability of the dress-
ing without adding much to its weight. The
bony prominences are protected with cotton be-
fore the plaster-of- Paris dressing is applied. The
drawers and stockings furnish a more complete
and better protection to the skin than roller
bandages. Usually about twenty-four plaster-of-
Paris bandages are required for a dressing. The
fractured limb is first encased in the dressing as
far as the middle of the thigh, when the patient
is lifted out of bed b}- two strong persons, the
physician supporting the limb so as to prevent dis-
engagement of the fragments if the fracture is im-
pacted, and to guard against additional iujuries
in non-impacted fractures. The patient is placed
in the erect position, standing with his sound leg
upon a stool or box about two feet in height : in
this position he is supported by a person on each ;
side until the dressing has been applied and the
plaster has set, A third person takes care of
the fractured limb which is gently supported and
immovably held in impacted fractures until per-
manent fixation has been secured by the dressing.

In non-impacted fractures the weight of the frac-
tured limb makes auto-extension which is often
quite suflScient to restore the normal length of
the limb ; if this is not the case, the person who
has charge of the limb makes traction until all
shortening has been overcome, as far as possible,
at the same time holding the limb in a position so
that the great toe is on a straight line with the
inner margin of the patella and the anterior
superior spinous process of the ilium. In apply-
ing the plaster-of-Paris bandages over the seat of
fracture, a fenestrum, corresponding in size to the
dimensions of the compress with which the lateral
pressure is to be made, is left open over the great
trochanter. To secure perfect immobilitj' at the
seat of fracture, it is not only necessary to include
in the dressing the fractured limb and the entire
pelvis, but it is absolutely necessar>- to include
the opposite limb as far as the knee, and to ex-
tend the dressing as far as the cartilage of the
eighth rib. The splint, which is represented by
figure I, is incorporated in the plaster-of-Paris

dressing, and must be carefully applied so that
the compress composed of a well-cushioned pad,
with a stiff unyielding back rests directly upon
the trochanter major, and the pressure which is
made by a set screw is directed in the axis of the
femoral neck. The set screw is projected by a
key which is used in regulating the pressure.
Lateral pressure is not applied until the plaster
has completely set. If the patient is well sup-
ported and the fractured limb is held immovably
in proper position, but little pain is experienced
during the application of the dressing. Syncope
should be guarded against by the administration
of stimulants. As soon as the plaster has suffi-
cientl}^ hardened to retain the limb in proper po-
sition, the patient should be laid upon a smooth^
even mattress, without pillows under the head,
and in non-impacted fractures the foot is held in
a straight position, and extension is kept up until
lateral pressure can be applied. The lateral
pressure prevents all possibility of di,sei:gageraent
of the fragments in impacted fractures, and in
non-impacted fragments it creates a condition
resembling impaction by securing accurate appo-
sition and mutual interlocking of the uneven
fractured surfaces. No matter how snugly a
plaster-of-Paris dressing is applied, as the result,
of shrinkage in a few days it becomes loose, and

156

FRACTURES OF NECK OF FEMUR.

[August 3,

without some means of making lateral pressure
it would become necessary' to change it from time
to time in order to render it efficient. But by in-
corporating a splint, as shown in figure i, in the
plaster dressing (figure 2) this is obviated, and
the lateral pressure is regulated from day to da3-
b}' moving the set screw, the proximal end of
which rests in an oval depression in the center of
the pad. From time to time the pad is removed
and the skin washed with diluted alcohol for the
purpose of guarding against decubitus.

After- Treatim-Jit. — If the application of the
dressing, as just described, is a tedious, laborious
and difficult task, it will prove a rich compensa-
tion for physician and patient during the after-
treatment. I have never found it necessarj- to
apply more than one dressing. If the fracture is
properly reduced and the limb fixed in normal
position in the dressing, then the only thing that
requires watchful attention is the regulation of
the lateral pressure. The patient can move him-
.self in bed and can lie on the back, face, and on
either side, and can be taken out of bed and, if
the weather is favorable, outdoors daily if desir-
able, without pain or risk of displacement of the
fragments. If necessary, a patient in such a dress-
ing could be transported great distances without

any immediate or remote risks. The impunity by
which the patient can change his position, the
benefits to be derived from outdoor fresh air, are
advantages which cannot be obtained by any
other treatment, and to them must be attributed
an important influence in the prevention of a num-
ber of the fatal complications which have so often
figured as causes of death in patients suffering
from fracture of the femoral neck. If the dress-
ing has been well applied, and more especially if
the precaution has been followed to protect the
bony prominences with a layer of salicylated cot-
ton, there is little or no danger of the formation
of excoriations. At the expiration of eight}- to
one hundred days, the time required for bony
union to take place, the dressing is removed, but
the patient should be cautioned not to step on the
limb until the end of the fourth or sixth month,
when union will be sufficientlj- firm to sustain the
weight of the bod}-. As soon as the dressing is
removed passive motion should be made, and the
nutrition and function of the limb promoted bj-
massage and, if considerable muscular atrophj^ is
present, the use of the faradic current.

During the last six years the following cases of
fracture of the neck of the femur have come under
my observation, and were treated bj^ immediate
reduction and permanent fixation as detailed in
this paper. A number of the cases occurred in
the practice of other physicians, and I was onh-
called in to apply the dressing. I desire in this
place to express to them my sense of obligation
for their permission to use the material in the
preparation of this paper,

C.\SES OF FRACTURE OF THE NECK OF THE FEMUR

TRE.ATED BY IMMEDIATE REDUCTION .AND

PERM.\NENT FIXATION.

Case I. — Female, Get. 68, in fair general health,
slipped on the sidewalk and fell upon the right
hip. The examination made a few hours after the
accident revealed a contusion over the trochanter
major, some swelling about the region of the hip-
joint, limb everted, shortening of i '4 inch. The
displacement of the great trochanter above Roser-
Xelaton's line corresponded with the extent of the
shortening. No impaction. Crepitus elicited by
the slightest movement of the limb. Anatomical
diagnosis : Fracture of the neck of the femur
partially within and partially without the capsular
ligament. In this case reduction was made by
placing the patient upon a pelvic rest and making
extension. The limb could be brought down to
within '4 inch of its nonnal length, and in this
position, with the foot in proper line, it was fixed
in the plaster-of- Paris dressing, and as soon as the
plaster had become firm lateral pressure by means
of the pad and set-screw was applied. The pa-
tient suffered but little pain at any time, and
could roll herself in bed from one side to the other
I with ease. The dressing was removed after three

1889.]

FRACTURES OF NECK OF FEMUR.

157

months, when it was ascertained that bony union
had been obtained with } i inch of shortening and
the limb in good position. Passive motion and
massage were now made daily and the patient was
allowed to walk on crutches. Four months after
the accident she was able to walk with the aid of
a cane, and three months later she required no
further mechanical support. At the end of a year
recover}' was complete and she could walk nearly
as well as before the accident.

Case 2. — Male, aet. 65 years. Patient is some-
what anaemic and presents evidences of senile
marasmus. Fell from a ladder a distance of about
6 feet directly upon his left side. No external
contusion, and swelling over anterior aspect of
hip-joint slight. A number of careful measure-
ments revealed -'4 of an inch of shortening. Foot
moderately everted. No impaction. Gentle trac-
tion upon the limb and slight rotation produces
crepitus. After fractured limb was encased in
plaster as far as the knee patient was made to
stand with the sound limb upon a stool and was
supported on each side b}- an assistant, while a
third person made traction until the shortening
was nearly corrected, and with the foot in proper
position the fixation dressing was applied. Lat-
eral pressure was applied the next day and was
kept up carefuU}' for eighty-five days, when the
dressing was removed. A careful examination
showed that bony union had taken place, and
that the shortening did not exceed ■ 3 of an inch.
The patient used crutches for six weeks, later a
cane for a few months longer, and at the end of a
year he walked well without anj- support and with
only a slight limp.

In this case the symptoms after the accident
pointed to a fracture of the neck of the femur in-
volving more of the bone within than without the
capsular ligament. Only a slight amount of cal-
lus could be found behind the posterior margin of
the great trochanter.

Case J. — Female, 58 years old. Senile maras-
mus well marked. Patient stumbled and then
fell on right side. A few hours after accident the
right foot was found everted and the limb short-
ened 23 of an inch. No impaction. Right groin
considerably swollen. Trochanter major displaced
backwards and upwards. Probable seat of frac-
ture partly within and partly without the capsule.
Reduction was effected by auto-extension and trac-
tion upon the limb. After the limb was immobi-
lized in the dressing the foot was in normal po-
sition and apparently little or no shortening.
Fixation and lateral pressure were continued for
three months. On removal of the dressing the
union was found firm with 'j inch of shortening.
Patient used crutches for three mouths. Stiffness
in the hip-joint was only overcome by regular ac-
tive and passive exercise and massage continued
for a long time. At the end of eight months the
patient was able to take care of her household.

and the function of the limb was nearly restored.
Measurements made at this time showed that the
shortening had not increased.

Case /. — Male, 50 years old, prematurely old,
the result of intemperate habits. Patient slipp>ed
and fell on the doorsteps, fracturing the left fem-
oral neck. Considerable swelling at the seat of
fracture. Foot strongly everted, shortening 1%
inches. No impaction. Trochanter major less
prominent than on the opposite side and displaced
upwards above Roser-Nelaton's line 1J4 inches.
No impaction. On making extension and gently
rotating the limb crepitus can be distinctlj- felt.
Reduction and immobilization in the usual man-
ner. The second day the patient had an attack

I of delirium tremens. During the maniacal ex-

j citement he tossed himself in everv- direction and
the nurses were kept busy in preventing him from
demolishing the dressing. It was during this at-
tack that the fixation dre.ssing and the lateral
pressure gave evidence of their efficiencj- in main-
taining uninterrupted coaptation under the most

I unfavorable circumstances. Under the use of nar-
cotics the patient became rational and quiet on
the third day. The dressing had to be repaired
in several places. Subsequently the progress of
the case was favorable. The dressing was removed
after ninety da3"S, when the fracture was found
firmly united with nearly an inch of shortening ;
considerable callus in front of and behind the
trochanter. The patient was soon able to walk
around on crutches, but I have been unable to
obtain any reliable information as to his condition
since.

Case J. — A female, weighing nearlj' 200 lbs.,
was thrown out of a buggy and fell upon her left
side. After she recovered from the immediate
effects of shock she found that she could not use
her left leg. Two ph3'sicians who examined the
patient soon after the injur>' suspected a disloca-
tion of the hip, but made no attempts at. reduc-
tion. When I examined her the next day I found
marked eversion of the foot, and a number of
measurements made showed 'i inch of shorten-
ing. The great trochanter had been displaced
beyond Roser-Nelaton's line to the same extent,
and appeared to be less prominent than on the
opposite side. No swelling in the groin or poste-
rior aspect of the hip-joint. On gently rotating
the limb the great trochanter described a smaller
circle than on the opposite side, and the move-
ments affected the head of the femur. Slight

I traction had no effect in diminishing the shorten-
ing. The diagnosis of intracapsular impacted
fracture was based upon these symptoms, and

! every precaution was exercised not to cause dis-
junction of the fragments during the examination

j and the application of the dressing. As I was
anxious to maintain the impaction during the

I required time for bony union to take place, the

I patient was treated in the same manner as in the

158

FRACTURES OF NECK OF FEMUR.

[August 3,

preceding cases, only that no attempts were made
to overcome the shortening or to correct the
other displacements. Lateral pressure was ap-
plied in a line with the axis of the outer portion
of the femoral neck for the purpose of maintain-
ing the impaction during the stage of inflamma-
tory osteoporosis. The dressing was not disturbed
for three months, when it was removed and the
limb was found in the same position as when it
was applied. The shortening had not increa.sed.
The patient Was cautioned not to use the limb for
another three months and to depend in walking
entirely on crutches. For a long time the move-
ments in the hip-joint were impaired, undoubtedly
the result of a traumatic plastic inflammation of
the structures of the joint. Passive motion and
massage succeeded in restoring the normal func-
tions of the joint. At no time could any callus
be felt, which must be considered as another proof
that the fracture was intracapsular. At the end
of a year the patient walked nearlj' as well as
before the accident.

Case 6. — A man, 65 years of age, slipped on an
icy sidewalk and fell in such a manner that the
right femoral neck was fractured. A few hours
after the accident a considerable swelling had
formed in the groin. Contusion over the great
trochanter ; eversion so marked that the outer
margin of the foot rested on the mattress. Short-
ening i)j inch. No impaction. Crepitus on
slightest motion of limb. Diagnosis non-im-
pacted extracapsular fracture of the neck of the
femur. Reduction was accomplished by auto-
extension and traction on the limb. Fixation by
means of plaster-of-Paris dressing and lateral
pressure. Patient was relieved of pain as soon
as the dressing had been applied and remained in
good health during the entire treatment, which
was continued for seventy-five daj-s, when the
dressing was removed. Bony union with -):| of
an inch of shortening. A large mass of callus
on each side of the great trochanter could be dis-
tinctty felt. Crutches were used for four months.
At the end of a year walked without any support
and with only a slight limp.

Case 7. — A strong, healthy blacksmith was
thrown from a buggy which was upset by an un-
ruly horse. He fell in such a manner that his
full weight came upon the right hip. Immedi-
ately after the fall he found that he was unable
to use the right leg. He was conveyed in a car-
riage to his home some three miles distant, and
examination two hours later revealed the follow-
ing : superficial abrasion of skin over the great
trochanter; marked eversion of foot. Shortening
I y-i inches ; tip of trochanter some distance above
Roser-Nelaton's line; right femur 17'+, and left
femur i-jyi inches in length. Crepitus on exten-
sion and rotation of the limb inwards. New
point of motion at seat of fracture verj' evident.
Pain is referred to point immediately behind the

great trochanter. Considerable swelling in the
groin and behind the great trochanter. The in-
jury was diagnosticated as an extracapsular non-
impacted fracture. Reduction by auto-extension
was made on the third day and the fracture im-
mobilized by plaster-of-Paris dressing in which
the splint was incorporated for making lateral
pressure. Patient sufiered but little pain after
the dressing was applied. The dressing was not
removed for twelve weeks, when a large mass of
callus was found behind and in front of the great
trochanter, which for quite a long time seemed to
impair the movements of the joint. With the
disappearance of the callus the functional result
improved. The fracture healed by bony consoli-
dation with an inch of shortening. In six months
he dispensed entirely with the use of crutches,
and with a high sole on right boot to make up
for the shortening of the limb he walks with only
a verj- slight limp. In twelve months he was
able to attend to his business, even to horse-shoe-
ing, and has since, aside from the slight lameness,
sufiered no inconvenience from the accident.

Case 8. — An invalid lady, 61 years old, while
descending three low steps caught the left heel in
the skirt of her dress and fell, striking on the left
hip. Examination soon after revealed the follow-
ing status pmsens: Dark blue discoloration of
skin over the outer and posterior aspect of the
great trochanter and from 2 to 3 inches below the
hip-joint indicates the point where the fracturing
force was applied. Slight eversion of foot. No
swelling in groin or posterior aspect of hip-joint.
Tip of great trochanter '-> inch above Roser-Ne-
laton's line. On making measurements from an-
terior superior spine of the ilium to the internal
malleolus no shortening could be detected, but
the apparent discrepancy between the result ob-
tained by these measurements and the Roser-Ne-
laton's test-line was subsequently explained by
the other measurements, which showed asymme-
try of the femora, the femur on the injured side
being 'j inch longer than its fellow on the oppo-
site side. Left trochanter rotates on a shorter
radius of a circle than the right. Pain in the hip
increased by pressure over the great trochanter.
Patient is able to elevate the limb about 2 feet
from the bed, but all such efi"orts aggravate the
pain. The symptoms in this case, as well as the
manner in which the injury occurred, pointed di-
rectly to an impacted intracapsular fracture of the
neck of the femur. In order to .secure the bene-
fits of long continued impaction during the pro-
cess of repair immobilization of the fracture was
secured bj- a plaster-of-Paris dressing and splint
for lateral pressure. The general condition of the
patient was not impaired by this kind of treat-
ment of the fracture, and when the dressing was
removed eight weeks after its application the limb
was found in the same position as after the acci-
dent. The patient was directed to rely on crutch-

1889.

THE STUDY OF PNEUMONIC FEVER.

159

es for a number of weeks and then to use the limb
cautiously. At the end of five months she could
walk without a cane and with an almost imper-
ceptible limp.

The treatment I have described I recommend
for adoption in all cases where there is a reason-
able hope that by it a bony union of the fracture
will be obtained. It is superfluous to remark that ;
it is not applicable in all cases of fracture of the '
femoral neck, and is positively contraindicated in
cases of extreme obesity and debility, and in pa-
tients suffering from concomitant diseases which
in themselves wonld lead to a fatal termination.

CONCLUSIONS.

1 . From a scientific, prognostic and practical
standpoint it is not necessary to make a distinc-
tion between intra- and extra-capsular fractures of
the neck of the femur. '

2. An impacted fracture of the neck of the fe-
mur will unite by bony union, provided the im-
paction is not disturbed and is maintained by
appropriate treatment for a sufficient length of
time for the fragments to become united by callus.

3. Impacted fractures of the neck of the femur
should be treated by a fixation dressing consisting
of a plaster-of-Paris case, including the fractured
limb, the pelvis and the opposite limb as far as
the knee, in which a splint should be incorporated
by which lateral pressure can be secured in the
direction of the axis of the broken femoral neck.

4. Unimpacted fractures of the neck of the
femur, both intra- and extra-capsular, should be
treated by immediate reduction and permanent
fixation, so as to place the fragments in the same
favorable condition during the process of repair
as in impacted fractures.

5. Reduction is effected most readily- by auto-
extension and traction upon the fractured limb
with the patient in the erect position, resting his
weight upon the sound limb. 1

6. The fixation dressing should not be removed
and the lateral pressure should not be discontin- i
tted for from ten to twelve weeks, the shortest
space of time required for bonj' union to take
place.

7. Patients who have sustained a fracture of
the neck of the femur should not be allowed to
use the fractured limb earlier than four to six
months after the accident, for fear of establishing
a pseudo-arthrosis at the seat of fracture.

8. The functional result is greatly improved by
passive motion, massage, and the use of the far-
adic current.

EuCALYPTOL IN HEADACHE. — Dr. M. J. Lewis
states, in the Medical News, that eucalyptol, in
doses of 5 grs., six times daily, is useful in head-
aches, particularly those of a congestive char-
acter.

AN INTRODUCTION TO THE STUDY OF

PNEUMONIC FEVER.

BY EDWARD F. WELLS, M.D.

EIGHTH PAPER.

CAUSATION: PREDISPOSING INFLUENCES.

(Concluded from page S3 ■)

Cold' has long been recognized as one of the
most energetic of the predisposing causes of pneu-
monic fever, although the proposition has been
denied by some.= I have myself no doubt regard-
ing the predisposing influence of exposure to cold
and wet in the causation of the disease, and it is
to this I attribute the preponderance of persons at-
tacked whose habits and occupations l^ad to such
exposure.

It was the impression of Laennec' that cold, as
a cause of pneumonic fever, was much less active
when it temporarily followed excessive heat.

Thus "the Russian who rolls himself in the
snow after coming out of the hot bath, or the
baker who goes from his heated oven, almost
naked, into an atmosphere below zero, is not lia-
ble to attacks of this disease."

I may add that I have seen iron and lead smelt-
ers, working in a superheated atmosphere, plunge,
when heated and perspiring, into cold water, and
they claim to be not more liable than others to
attacks of this malady.

Exposure to cold is especially apt to be followed
bj' pneumonic fever if the subject is depressed by

■ Williams. Laticel, N. V., 1862, Vol. ii, p. 3; Rindfleisch, Path.
Histol., Philadelphia, 1S72. p. 423; Patton, Jour. Am. Med. Ass'n.
Oct. 16. 1886. p. J25 ; Hourmann et Dechambre, .\rch. Gfiii. de MM..
T. xii, p. 29 ; Cruvielhier, Anat. Pathol.; Fox, op. cit., p. 158 ; Pinel;
Nosol. Phil.. T. ii, p. 163; Heidenhain, Virchow's Archiv., Bd. Ixx ,
Howard, N. C. Med. Jour.. Feb. and Oct., 1859, and Jan. and Mar.,
i860; Batemau, Dis. London, 1S19, p. 234; Schiitzenberger, Gaz.
MM. de Strassb., 1856, No. 2; Rigler, Wieiier med. Wochenschr..
1S58. S. S34: DeBordes, Nederl. Weekbl. voor Geneesk., 1855, Nr. 22;
Warfwinge. .Am. Jour. Med. Sci., Jan., 1883. p. 261 ; Juergensen,
Ziemssen's Handb., Bd. V, S. 14; Niemeyer, Spec. Path. u. Therap.;
Thompson. Epidem. Catarrh, p. 109; Storer, Sanitarian, April 19,
1S83; Green, Quain's Die. Med., p. 874; Reuhle, Berliner, k. Woch-
enschr., 1884, S. 22S; Flourens, Jour, de MM. Prat.-, August, 1829;
Ziemssen, op. cit., S. 159 ; Hertz, Ziemssen's Handb., Bd. v, S. 360 ;
Huss, op. cit., S. 6S ; I.ebert, Klinik. d. Brustk., Tiib., 1874, Bd. i, S.
698; Frank, op cit.; Campet, Mai. des Pays Chauds, p. 210; Cho-
mel. loc. cit., S. 322 ; Corney, Lancet, 1884. Vol. i, p. 810; Remy,
Arch. G^n. de MM., Mar., 18S3 ; CoUes, U. S, Naval Rpts., 18S1, p.
415 ; Bouillaud, Die. de MM., T. xiii. p. 359: Davis, Rpt. Mich. Bd.
Health. 1880, p. 450 ; Rogers, U. S. Naval Rpts., 1S81, p. 471 ; Hilde-
brand, Med. Prac, Vol. iii, p. 194; Grisblle. op. cit., p. 147; Laen-
nec op. cit., p. 22^; Swett, op. cit., p. So; Hermann, Lungenentz.,
S. 4; Andral. op. "^cit., p. 284; Rilliet et. Barthez. Mil. des Enfants,
T. i. p. 11=;; Pinel et Richeteau, Die. de MM.. T. xliii, p. 396; La-
Roche, op. cit.. p. 347; Monro, Path. Anat., Vol. ii, p. 247; Wood,
Prac. Med., Vol. ii, p. 42; Brunton. Brit. Med. Jour.. 1875. Vol. i, p.
204; Bristowe, Lancet, 18S4, Vol. i, p. 382 , Peter, Bull, de I'Acad. de
MM.. 18S3; Stedman. Boston Med. and Surg. Jour., Oct. 9, iSSi, p.
507- Tess'ier, Bull, de I'Acad. de MM.. 1S83 ; Bossbach u. .Aschen-
brandt. Med. Chir. Rundschau, Wien. 1882,5.51; S4e, Bull.de l'.\cad.
de MM.. 1.883; BoUes, Boston Med. and Surg. Jour.. Nov. 20, 1879,
p. 736; London Lancet, 1881. Vol. ii, p. 148; Lawson, Edinb. Med.
and Surg. Jour., Vol. Ixii, p. 50 ; Snow, Boston Med. and Surg. Jour.,
Feb. 24, 1S76. p. 225; Bondet, Bull, de I'Acad. de MM., 1883; Des-
partes. Mai. de St. Domingo. T. i, p. 32 ; Mattocks. Boston Med. and
Surg, Jour., May 24, 1876. p. S27 ; Baker, N. Y. Med. Rec, Sept. 10,
1887, p. 315; Drake. Fevers. Phila., 1854, p. 799 : Flint. Prac. Med.,
1868, p. 182; Watson, Prac. Phys., 1845, p. 73; Hirsch. op. cit., S.
32; Heiss. Inaug. Diss., Miinchen, 1857. p. 20; Jaccoud, La France
MM., 18S7.

! Sanders. .Am. Jour. Med. Sci., July, 18S2, p. 91 ; Cohn. Traite
des Mai. Epidem., Paris. 1879, p. 440; Laveran, Mai. des Arme6s,
Paris, 1875. p. 49; Baiimler, Berliner klinische Wochenschr., 18.84,
S. 288 ; Purjesz. Wiener med. Wochenschr., 1884, S. 43 ; S&, L'Union
MM., Nov. 29, 1884.

3 Op. cit., p. 225 ; see also Watson, op. cit., p. 71.

i6r-

THE STUDY OF PNEUMONIC FEVER.

[August 3,

hardships, want, despair, hunger debility, intox-
ication, etc. There are verj- few physicians who
have not met with the disease in patients who had
been exposed to cold after a debauch.

My experience has furnished a number of in-
stances in which unusual exposure to cold and
wet has been followed by an attack of pneumonic
fever.

Many years ago, whilst as yet an undergradu-
ate, I spent a few days in a small village in which
was progressing a religious revival under the aus-
pices of ministers who deemed baptism by immer-
sion a necessan.' prerequisite for admission into
the church. The weather was ven,' cold and ice of
several inches' thickness covered all the streams,
nevertheless many embraced religion and were
baptized, holes having been cut in the ice for that
purpose. After the ceremony the hapless victims
stood about, in their dripping and freezing gar-
ments, for a considerable time previous to their
departure for their homes, which lay, in some in-
stances, at quite a long distance. Being a stran-
ger in the community, and having preserved no
notes, I am unable to state either the number of
persons immersed or the proportion subsequentlj'
attacked with pneumonic fever ; suffice it to say
that the number of those who sickened was so
great as to be a matter of common mention in the
community and to lead to the adjournment of the
meetings until the weather should have become
warmer.

In the summer of 1S80 a farmer was exposed,
whilst overheated and perspiring, to a shower of
cold rain and hail. He felt chilly at once, became
drowsy, and a few hours later had a profound chill
followed by pneumonic fever.

Another man lay for several hours upon the
wet and cold ground and was promptly attacked
by the same disease.

Instances similar to these might be multiplied
from my own records and from the published ob-
servations of others.''

Hertz' considers the drinking of cold fluids at
a time when the body is very warm a fruitful
source of pulmonarj' congestions and inflamma-
tions, and I have met with several cases which
seem to uphold this view.' Cold baths, under
like circumstances, are accompanied b)- similar
dangers.'

A rheumatic patient, with high temperature,
was treated by immersion in a cold bath. Pneu-
monic fever developed at once.'

A girl was given three cold baths on the twen-
ty-first day of an attack of typhoid fever. Fatal
pneumonic fever developed during the night."

A manufacturer, aged 40, ill with typhoid fever,

* Ziemssen, op. cit., S. 159 ; and many others.
5 Op. cit.. S. 360.

* Sec Andral's — op. cit.. p. 169 — forty-second case.

7 Peter, BuU. de lAcad. de M^d., 18S3 ; S^c, Ibid ; Brislowe's
Lancet, 1884, Vol. i, p. 382; Bondet, op. cit.

** Carter, London Lancet. N. V.. iW*i. Vol. ii, p, 148.

'y Stednian, Boston Med. and Surg. Jour., Oct. 9, 1879, p. 507.

was given a cold wet pack of two hours' duration,
and was immediately attacked by pneumonic
fever. '"

The loss to the armj' of Alexander the Great,
after their plunge into the river Oxus while the
men were thirsty, fatigued and perspiring after a
march of fortj'-six miles across the scorching
sands of the desert, was greater than from any of
its battles."

Although every writer'^ upon pneumonic fever
is sure to mention cold as one of the predisposing
(or active) causes of the disease, 5'et few have es-
saj'ed to explain its action. The first effect of re-
frigeration upon the respiratory mucous membrane
is to greatly contract the blood-vessels — rendering
the surface pale and causing a .sensation as if the
lungs were torn asunder. This contraction is
onlj- temporarj-, the vessels graduall}^ regaining
their normal dimensions, and finally becoming
greatly dilated, the color of the mucosa passing
through all the shades of red, from pink to pur-
ple. The normal bronchial secretion is greatly
diminished or suppressed with the contraction of
the capillaries, but as these dilate it is restored
and finally becomes excessive." How much of
this effect is due to refrigerating shock and how
much to the abstraction of moisture from, and the
deposition of chloride of sodium upon, the walls
of the air-cells and minute bronchi is not definitelj^
known. We know that the air of a zero temper-
ature is very drj' as it enters the lungs, containing
only j4 grain of aqueous vapor to the cubic foot,
whilst the expired air from the lungs, at a temper-
ature of 98° F., is nearly or quite saturated with
moisture and contains about iS'j grains of vapor
of water — iS of which have been abstracted from
the mucous surfaces with which it has come in
contact." This moisture is nece.ssarily taken from
the blood, and as it leaves the circulation holds in
solution certain salts, especially sodium chloride,
which are non-volatile and are left behind to irri-
tate the mucous surfaces'" or afford a pabulum for
the growth of infective germs.

In regard to the influence of fogs and cold damp
air in the production of the maladj-, it has been
suggested that the lungs may be greatly chilled
bj- the abstraction of the heat necessarj- to convert
into vapor the minute particles of water contained
in such an atmosphere.

There is a verj- close connection between night
air and pneumonic fever, as is shown by the num-
bers of cases following exposure to its influences,
and the vast majority of instances in which the
attack commences during the hours of the night.
The preference which this disease shows toward
attacking its victims at night has led .some obser-
vers to attribute to ozone, which is then present

■0 BoUts, Boston Med. and Surg, Jour., Nov. Jo, 1879, p. 736.

*i Quintius Curtius ; Diodorus.

■=Brunton. Brit. Med. Jour., Feb. 13, 1R75.

>i Rossbach u. Asclieubrandt, Med. Chir. Rundsch., 18S2, S. 51.

'* Baker, N. V. Med. Rec. Sept. 10, lS.^7, p. 3l,s.

'5 This is not accepted by Scibert, Berlin, k. Wochenschr., 1887.

1889.]

THE STUDY OF PNEUMONIC FEVER.

161

in its maximum proportion, a causative relation
to it.'»

EXCITING CAUSE.

Formerly, in a large proportion of cases,'' the
attack could not be referred to any obvious cause,
and from this circumstance pneumonic fever is
often said to be of spontaneous origin.'* That
this conclusion is erroneous requires no argument.
That there can be no effect without an adequate
cause is an axiom of universal applicability, and
it is no more reasonable to adopt the de noiv ori-
gin of diseases, than to acknowledge the same
doctrine of the origin of life or of matter. The
term, unless used in a very restricted sense, should
be expunged from medical writings. Not onh'
must a given and unique effect proceed from an
adequate cause, but such cause must be specific
in its nature.

In the case of pneumonic fever we have a series
of phenomena which, within certain limits, are
unvar\'ing, and which necessarih- require for their
production a single cause ; of varying potencj*.
infectious'' certainly and possibly contagious,''
but always unchangeable in its nature. This
specific Diatcries morbi may be actively destruc
tive, or it may be an agent acting by its mere
presence— catalysis — and much research has been
expended in the endeavor to discover and isolate
it. To-day it is generally acknowledged that the
poison" must be a microscopic vegetable parasite.
The acceptance of this proposition does not nec-
essarily require the demonstration of the infec-
tious material, for in this instance, as in so many
others in nature, its existence is manifested and
proven bj' its effects, both objective and subjective.

From the fact that pneumonic fever is ubiqui-
tous we may infer that its essential cause is ever
present"' in the atmosphere we breathe, and nec-
essarily in the lungs, but that its onslaughts are
successfully repelled, until a time when, through
a variety of circumstances, the system can no

■6 Baker, Proc. Mich. Bd. Health, Oct. i, 18S6.

'7 Flint, Prac. Med, 1S6S, p. 1S2 : Fox, Reynolds' Svst. Med.,
Phila,, 1880, Vol. ii. p. 157 ; Green, Quain's Die. Med., p. 874 ; Swett.
Dis. Chest, p. 79: Ziemssen, Pleuritis u. Pneumonic, 1.S62 ; Double-
day, N. Y. Med. Rec, March 28, 1SS5, p. 343.

^^ Flint, op. cit.

'9 Bermann, Jour, Am, Med, .^ss'n, Aug. 14, 1886. p. :8s ; Flint,
N. Y. Med. Rec, July 14, 1877 ; Hirsch, Handb. d. Hist. ii. Geog.
Path,, Eriangen, 1S64. Bd, ii, S. 26 : Moore, X. Y'. Med. Rec, Sept.
10, 1887, p. 314: S^e, .\m. Jour. Med. Sci., Jan,, iSSs.p. 261 ; Virchow,
Berliner k. Wochenschr,, 1SS8, S, 113 ; Kiihn, Arch. f. k. Med., 1SS7:
Gieke, N. Y, Med. Rec. Sept. 10. i!^7 : Heidenhain. Yirchow's Ar-
chiv., Bd. Ixx. 1877 ; Virchow. Berliner k. Wochenschr., Feb. 6, 188S.
S. 113 ; and many others,

=« Blythe, London Lancet, 1S75 ; Coulthard, Cincinnati Lancet
and Clinic, April 14, 1883, p. 353: Cullen. Prac Physic, Phila.. 1792.
Vol. i, p. 182: Daly, Lancet, 18S1. Vol, ii, p. 824; Krebs, .\rch, f.
Expm. Path.. Bd. 'iv. S. 420; Brvson. Lancet. X. Y.. 1864. Vol. i. p.
198; Fischer, N, Y. Med. Rec.; July 28, iSSS. p. 93; Netter, .4rch,
Gen. de Med.. Juillet, 1S8S : Morgagni. Dc Cans, et Sed, Morb.. Ep.
xxi. art. 26 : Walton, U. S. Naval Rpts., 1879, p. 67 ; London Lancet,
1877, Vol, ii, p. 324; 1878, Vol. ii. p. 266; 18S1, Vol, ii, p. 824; 16S2,
Vol. i. p. 139; Rosse, Cruise of the Corwin, Wash,, 1883, p, 16; St,
Louis Med. and Surg. Jour., Dec, 1S7S, p. 350: Marriner, I.ancet,
1882, Vol, ii, p. 237 ; Neal. Med. Digest, Sec. 667, 3 ; Kiihne. Berliner
k, Wochenschr., 1.S88, 8,337; Sturges, Pneumonia, p. 6 ; Wvman,
Boston Med. and Surg. Jour., Dec 15. 1S81, p. 569; Bielinski Medv-
cyna. 18S2; et. al.

:> I here use the word " poison " in its broadest sense.

^ In greater or less quantity, in various stages of development
and of variable potentiality.

longer cope with the enemy and capitulates — a
victim. This ready susceptibility of the system
ma}- follow some marked change in the subject
or his surroundings, e.g., becoming chilled from
facing an east wind, or the conditions may not
attract attention.

With the entrance into the system of this ex-
citing cause there usually arises in some portion
of the lungs, and possibly in some other organs,'^
an irritation which attracts an increased blood
supply to the part and causes the exudation into
the alveoli and connective tissue of certain con-
stituents of the blood. The entrance of these
germs into the system is not always and of neces-
sity followed by an attack of the disease. It has
been shown that when certain microorganisms
enter the systemic circulation they are immedi-
diately surrounded and destroyed-' and the debris •
is quickly extruded from the economy by the ex-
cretory- organs It is probable that this destruc-
tive digestion is favored by certain conditions of
both the leucocytes and disease germs. ■°

\'arious living vegetable formations are found
in the exudation which fills the alveoli, in the
secretions from the bronchial mucous membrane,
in the substance of the inflamed tissues and in
other parts of the body. That these organisms,
although microscopic in size, have a verj' definite
and intimate relationship to the pneumonic pro-
cess is certain, and by a majority of pathologists''
they are recognized as the causa vera of the dis-
ease, whilst others consider them only the scaven-
gers of the malady, and yet another small con-
tingent'" think their presence accidental and in
no wise essential.

= 3 Koch. Imp. Bd. Health Rpt., 1S81 : Eberth, Arch, f k. Med.,
Bd. xxviii ; Smith, N, Y. Med. Rec, May 14, 1SS7, p. 543; Levden.
Deutsche nied, Woch., April 4, 1883: Frjenkel, Ibid, Nov, 13, "1886;
Pollock, Lancet. N. Y.. 1883, Vol. ii. p. loi ; Juergensen. Berliner
k, Wochenschr., 1S84, S. 270; Pushkareff, Ejenedelnais Klin. Gaz.,
April 21, 1SS5.

-J By a process of digestion.

"5 For further information see Metschnikoff. Virchow's Arch,,
18S4, Bd, xcvi, S, 177. and Bd. xcvii. S, 502 : Morris, N, Y, Med. Rec,
June 4, 1SS7, p. 629,

^ Marriner, Lancet, 18S2, Vol, ii, p, 237 ; Geike. Trans, Int, Med.
Cong., Wash,, 1887 ; Friinkel, Berliner k, Wochenschr., 1S84, S. 271;
Bonci, Lancet. 1S87, Vol. ii. p. sii ; Moore. N. Y. Med. Rec. Sept. 10,
1887. p. 314: Leyden. Deutsche med. Wochenschr.. April 4. 1883;
Smith. N. Y. Med. Rec, May 14, 1SS7. p. 543 ; Jones. Jour. Am. Med
Ass'n. July 31. 1886. p. 114: Koch. op. cit.rPollock. Lancet. N. Y.,

1883, Vol. ii. p. 101 : Didima, N. Y. Med. Rec. Sept. 10. 1887, p. 294;
Friedlander, Fortschritte der Med.; S^e. L"l'nion Med.. Nov. 29.
1884; Lester. Trans. Int. Med. Cong.. Wash.. 18S7; Pushkareff. op.
cit.; Shakespeare. Jour. .\m. Med. Assn. .\pr. 50. 1SS7. p. 47S ; Sen-
ger. Arch. \. Exp. Path.. 18S6, S. 519; Juergensen. Berliner klin.
Wochenschr.. 1SS4. S. 270; Smith. Brit. Med. Jour.. July 1.8S3 ; Gar-
land. Pleurisy and Pneumonia 1S88; Spiner and Strieker. ^Tuber-
culosis, etc. Wien. 1S83 ; Klebs. .\rch. i. Exp. Path.. Bd. iv. S. 420 ;
Kiihn, Arch, f k. Med.. 18S7 ; GriflRn and Cambria. Giornal Int. d.
Scien. Med., iv. 5-6; Talamon, Bull, de la Soc. de r.\nat.. Nov. 30,
1883 ; Nauwerck. quoted bv Juergensen, op. cit.; Netter. .\rch. G^n.
MM., Juillet, iS,8S; Koch.' Centfalbl. f Chir.. 1S87; Formad, Jour,
Am, Med. Ass'n, Apr, 26. 18S4. p. 454 ; Frobenius. Berlin, K, Wochen-
schr,, 18S4, S, 16; Whittaker. Jour. Am. Med. Ass'n. May 15, 18S6, p,
538 : Brenda, Berliner k, Wochenschr,. 1884. S, 221 ; Jacob, Lancet,

1884, Vol, i, p. 758: Scott, N, Y, Med, Rec, Sept, 10, 1S87. p, 294;
Bermann. Jour. Am. Med. Ass'n. Aug. 14, 1886, p. 1S5 ; Afanasieff,
Lancet. 1887, Vol. ii. p. 1131 ; Garr^. N. Y. Med. Rec. Dec. 17. 1887,
p. 764 ; Perret. Lyon M^d., 1887 ; Weichselbaum. Edinb. Med. Jour.,
1887; Welch. Tour. Am. Med. .^ss'n. 1S8S; Semmola. Trans. Int.
Med. Cong. Wash.. 1S87 ; Thaon. Rev. des Mai. de I'Enf. Feb., 1886 ;
Lebashoff. Lancet. 1886, Vol. i ; Aufrccht. Deutsche Med. Zeit., Jan.
8. 1885 ; Prudden. N. Y. Med. Rec, Mar. 7. 1S65. p. 273 ; Emmerich,
Sanitary- News, Nov, 12, 1S87 ; et, al,

-7 King, Jour, Am. Med. Ass'n, Aug. 14, 1S86, p, 1S5 ; Claxton^
Phila. Med. Times, June 17, 1882; Steinberg, Am, Jour, Med. Scr,^

l62

THE STUDY OF PNEUMONIC FEVER.

[August 3,

Of these various organisms the one simultane-
ously discovered bj' Talamon and Friedlander,
and known by the name of the pneumococcus,
has attracted the most attention. It is an ellipti-
cal micrococcus, in length three times its thick-
ness, found singly, in chains, spread out in a film
or grouped in masses. It is surrounded by a cap-
sule which does not stain-' readilj% and which dis-
appears during cultivation, but reappears again
when inoculated in an animal. It grows readily
on gelatine at ordinarj- temperatures without
liquefying the gelatine. When the inoculations
in the gelatine have been made by a needle and
to a considerable depth the resulting growth as-
sumes a nail-shape, with an elevated and spread-
ing head.

Originally Friedlander claimed that the pecu-
liar mucinous capsule was the distinctive portion
of the organism, but this has been denied by oth-
ers, who contend that the encapsulated appearance
witnessed by Friedlander was due to his method
of preparation. Talamon made no mention of it
in his original paper, and Friedlander himself,
before his death, acknowledged that the capsule
was not an important part.

Repeated cultivation changes its form so that it
resembles -a bacillus. Its vitality is destroyed bj*
a temperature of 136.4° F.=' It will not grow in
a medium impregnated with the bacillus fluores-
cens putridus or its products, but the reverse does
not hold good.''

Thej- are most abundant in the exudation mat-
ter filling the alveoli and in the bronchial secre-
cretions, but may also be found in the interstitial
tissue, lymphatics, pleura, brain, kidneys and
other organs. ■■'

Other microorganisms ma}-, because of their
near resemblance, be mistaken for the pneumococ-
cus. This is true of the micrococcus of erysipe-
las,'"' the bacillus of whooping-cough,'^ the micro-
coccus of cerebrospinal meningitis,'' and one of
the micrococci usually found in the buccal cavitj-.

July, 1S85, p. 106; SalWoli. Arch le Scienze Med.. 1SS4, Vol. viii, p.
127; Purjesz. Wiener med. Wocheiischr., i.';S4. S. 43.

^ Staining fluid : .\kohoI. 50 : distilled water. 100 : acetic
acid, 10; sol. gentian violet, q.s. Immerse the specimen for 24
hours. Bleach in solution of acetic acid — o. i per cent. — for one or
two minutes. Dehydrate with alcohol and clear up with oil of
cloves.

For further information consult Hueppe. Die Formen der Bak-
terien, Wiesbaden, 1886: DeBarry, Bacteria. N. v., 1SS7 ; Crook-
shank. Bacteriologv. N. Y., 1887; Satterthwaite. Bacteriolog\-, De-
troit. 1S87; Frankel. Bakterienk., Berlin. 1SS7.

^ The degree of heat required to kill the germs of some other
diseases is as follows :

Cholera bacillus of Koch 125.6° F.

Anthrax bacillus 129.2 "

Streptococcus erysipelas 129.2 "

Typlioid bacillus 132. S "

Streptococcus pyogenes aureus .... 136.4 "

Micrococcus Pasteurii 140.0 "

Tubercle bacillus 212.0 "

3oCarr6. N. V. Med. Rec . Dec. 17, 1887, p. 764,
3' Klein. Microorganisms and Disease, London, 1884; Salvioli,
Natura infettiva allu pulnionite croupale, 1SS4.

3-^I,eyden. Deutsche mcd. Wochenschr.. April 4. 1883.
33 Afariasiefl". lancet, 1S87. Vol. ii. p. it^i.
3* Smith, N V. Med. Rec. .Mav 14. 1887^5. 543.
'S Pa.steur, Compt Rend Acad, de Sci., iSSl. T. xcii, p. 159 ;
Klein, Microorganisms and Disease. London, 1SS5: Claxton, op.
cit.; Frankel. Berliner klin. Wochenschr., (SS4. S. 271 : Sterntjerg.
Am. Jour. Med. Sci.. July. 1885. p. 106; Salvioli, op. cit.

The micrococcus of Friedlander" and Talamon"'
through a number of different kinds of animals?
has been isolated by repeated cultivations and vari-
ous animals, such as dogs, mice, rabbits, etc., have
been inoculated with the pure cultures, with the
result of inducing a pneumonic inflammation
which is regarded as being that of veritable pneu-
monic fever/' and identical with that caused by
inoculating pneumonic sputum and exudation
matter. Whether these toxic eflects are due to
the direct action of the microorganisms or to the
noxious and decomposed elements — ptomaines —
which they produce is, as yet, not certainly
known. ^'

Other microorganisms are found in the inflam-
ed tissues of pneumonic fever, and some of
these have been presumed to be the cause by their
discoveries. Thus so long ago as 1877 Klebs'"
described a microbe — the monas pulmonale —
which he considered the essential element in the
causation of the disease, and his observations
were later confirmed by Eberth*' and Koch.'"

Frankel" and Talamon" describe a microbe
which is lanceolate, with a capsule which disap-
pears b}' cultivation, and which requires for its
development a temperature somewhat above that
of ordinary rooms. It is not certain that the
microbes described by Friedlander, Frankel and
Talamon are distinct organisms.

Microorganisms peculiar to other diseases may
be found, incidentally, in cases of pneumonic
fever. ''

These facts vers- naturally lead up to the ques-
tion of the contagiousness of pneumonic fever.
That there is a contagious element in the causa-
tion of this disease has been afiirmed for a long
time, although the fact has not been demonstrated.

If the occurrence of multiple cases amongst
people who commingle together can be accepted
as proof positive of contagion, it would be easy
and quite convenient to answer this question in
the affirmative. Under such circumstances, how-
ever, it has not yet been proven that the patients
have not been exposed to a common cause, as
owing to the universal presence of the disease, is
most probable. To be sure there are numerous
instances on record where, after assiduous attend-
ance upon pneumonic patients, the nurse has
been attacked by the same disease.

Blythe'' reports two such examples : "A farmer
at Bow, North Devon, was affected with acute

3' Op. cit.

3? Op. cit.

38 Whittakcr, Jour. Am. Med. .•Vssn. May 15. 1SS6, p. 53S ; et. al.

^) For further infonuation consult Semmola. Jour. .\m. Mcd.
Ass'n, Oct. 3. 1S87 ; Burdon-Sanderson, Brit. Med. Jour.. July 14.
1877 ; London Lancet, 1SS7, Vol. ii. p. 927 ; Sternberg, Phila. Mcd.
Times, Vol. .\ii, p. 386; Shakespeare, Jour. Am. Med. Ass'n, April
30, 1S87, p. 478.

'» Arch f. Expmt. Path., 18J7.

" Arch, f k Med.. Bd. xxvlii.

*=Op.cit ':Op cit. « Op. cit.

*5 See Smith. Brit. Med. Jour., July. I!».S3 ; Spina and Strieker.
Tuberculose. Wien, 1883 ; ShaVespeare, Jour. .\ra. Med. Ass'n. .\pr.
30, 1887. P.47S.

4" London Lancet, 1875.

1889.]

MEDICAL PROGRESS.

163

pneumonia, and was nursed during his illness by
his niece. His niece became affected bj' the same
disease and carried it to her husband. In another
case, an old man, affected with pneumonia, re-
posed on an affectionate relative's breast during a
great part of his fatal illness. The relative was
verj' shorth' affected by the same ailment."

Wj'man'" relates the historj' of a woman who
died from pneumonic fever contracted whilst nurs-
ing her 9-year-old son who was ill with the same
disease.

Daly*- cites the case of a man who nursed his
wife during a fatal attack of pneumonic fever,
and himself succumbed to the same malady a
week later.

Coulthard" reports the case of a large fleshy
woman of 73 j-ears, who died from pneumonia
fever after four days' illness. Two days after her
death her husband, of the same age, was also
taken with the same disease and also died in four
days. In both the right side was affected.

To these I might add several cases coming
under m^- immediate observation, but will give
only one: A gentleman, set. 69, whom I had
previously treated three times for pneumonic fever,
died in his fourth attack. His wife, a large fleshy
woman, aet, 79, who nursed him, also took the
disease and died. They expired within forty
minutes of each other — he on the ninth, and she
on the fifth daj- of illness. The husband seemed
in a fair waj- of recovering until he was informed
that his wife would probably die, after which his
courage and desire for life forsook him and he
died forty minutes before her.'"

In discussing this subject the limit to the mean-
ing to be attached to the term contagion should
be clearh' understood. For a plausible explana-
tion of the cases above detailed, we must ac-
knowledge that the}' did not arise from accidental
or common causes, but that there were present
influences which acted upon the pneumonic
poison in such a manner as to render it especially
abundant or virulent, or that some local influences
caused the patients to be pecularly susceptible to
the morbid agent, or a combination of both.
Now if we employ the term contagion in its
broad and original sense these cases would all be
contagious, but if we limit our meaning of the
word, as is now usual, to infection by a materies
morbi which has been first passed through and
elaborated in the system of some other patient
laboring under the same malady, the conclusion

that pneumonic fever is a contagious disease is
open to so much doubt that we must await
further and more conclusive evidence before it
can be accepted.

MEDICAL PROGRESS.

■»7 Boston. Med. and Surg. Jour.. Dec. 15, 1881, p. 569.

45 Op. cit., p. 824.

49 Cincinnati Lancet and Clinic, April 14, 1S83, p. 353.

5^ For further information consult Gairdner, London Lancet,
1887, Vol. ii, p. 247: Smith. N. V. Med. Rec. Feb. 21. 1885, p. 208;
Neal, London Med. Rec. Jan. 15, i5S2, p. 14; Martin, Trans. Acad.
Med,, ireland. Vol. iv, 1S86: Chomel. Pneumonic, 1841 ; S^e, Cin.
Lancet and Clinic. Oct. 28, 1882. p. 421 : Kiihn, Arch. f. klin. Med.,
Bd, xxi. Heft 4 ; Rosse. Cruise of the Corwiu, Washington, 1883;
Sturges. Nat. Hist, of Pneumonia, London. 1876: Ozanam. Hist.
M^. des Mai. Epidem,, Paris, 1817, T. iv, p. 76 ; Hecker, Epidemics
of the Middle Ages, London, 1844. p. 20 ; Brvson, London Lancet,'
N. v., 1864, Vol. I, p. 198 ; CuUen. Prac. Phys.', Phila., 1792, Vol. i, p.
182 ; Juergensen, Ziemssen's Handb., Bd. v, S, 56,

On the Influence of Aniline and of the
toluidines on the respiratory capacity of
THE Blood, and on the Temperature. — In an
article in C. R. Soc. de Biologic, ^zn. 5, 1889, p. 10,
E. Wertheimer and E. Meyer publish the re-
sults of experiments which show that chloride of
aniline and of toluidine injected into the veins of a
dog (30 centigr. per kilo, animal) cause within a
few minutes an abundant transformation of haem-
oglobin into methaemoglobin (proven spectroscop-
ically). Also in vitro methaemoglobin originates
very rapidh- in the blood after introducing aniline
or toluidine. These substances produce in the dog
a moderate decrease of carbonic acid in the blood
and considerable decrease of oxj'gen. The latter
is for aniline (7.3 instead of 23.1 vol. per cent.),
and for metatoluidine (6.8 instead of 20.4 per
cent, o), much more considerable than for para-
toluidine (13.5 instead of 23.1 per cent, o), or for
orthotoluidine (15. i instead of 24.2 per cent. o).
Also the decrease of temperature effected is much
greater for the two former substances (from 39°
down to 32° and 30° within from five to six hours)
than for para- and orthotoluidine (from 39° down
to 37° or 36°).

The authors mention also the experiments of
Jaffe and Hilger (Zeitsch. f. Physiol. Cliemie,
1888), which showed a strong temperature lower-
ing effect in metacetotoluidine, whilst para- and
orthoacetotoluidine do not influence the tempera-
ture.— -Centralblatl fill- Physiologic, Yio. 3, 1889.

On the Treatment of Hydrocele. — A. E.
Hind, F.R.C.S,, in the La>icct s&ys : The treat-
ment of hydrocele of the testis by injection of
solution of perchloride of mercurj' was discussed,
I believe, in the medical journals some j'ears ago,
but has not yet received the attention it deserves.
In my hands it has always given complete satis-
faction, but mj- cases have only been a limited
number. I use a solution three times the strength
of liquor hydrag. perchlor., and first draw off the
hj-drocele fluid and then wash out the cavit5'
with the perchloride solution and draw off any
remaining fluid. The last case on which I oper-
ated was an old double hj-drocele with thick
walls. The result was quite satisfactorj-. The
injection does not cause pain, and is not followed
by inflammation. In these respects it is superior
to iodine. Its action depends on its power of
forming an insoluble albuminate of mercury, by
which the walls of the cav'it}' are glued together.

164

MEDICAL PROGRESS.

[August

As far as 1113' experience goes, there is no danger
of mercurial poisoning. The albuminate is
fairly insoluble, and a large amount of mercury
is not required. I have tried this treatment with
success in a case of infantile hydrocele, after tap-
ping had failed. Iodine causes pain when used,
and often much pain afterwards by setting up
more inflammation than is required to cure.
Iodine also is not always efficacious, and ma}' be
followed by abscess. I believe perchloride is
sure in its action, and its use does not necessitate
rest in bed afterwards. I should like to know if
the experience of others who may have used it
coincides with mine. Have any ill results been
known to follow ? Has it ever been known to
fail ? What is the weakest solution that is effec-
tual ?

Ox THE Treatment of Variola and of Va-
rioloid WITH Cocaine. — Dr. Ory reports in the
Rev. gen. declin. et de Thtr., No. 9, that in a case
of severe confluent variola improvement ensued
and the eruption began to disappear iramediatelj'
after the patient had taken more than ten pills of:
0.002 gr. of cocaine each in one night. After a ^
few days 10 drops of a 5 per cent, solution of co- 1
caine muriate was given four times a day, and the
patient was well inside of ten days. In another
case a cure of varioloid was efiected under the
cocaine treatment in five days after the appearance
of the pustules. A third case of acute haemor-
rhagic varioloid got well without scars under the
cocaine treatment within five days. Also in two
children (8 drops of a i per cent, solution each
four times a day 1 a cure of varioloid ensued under
the same therapy in five and six days. As the
blisters dried up immediately after the use of co-
caine in all cases it could not be determined with
certaintj' whether, in one case or another, the
disease was not variola. Cocaine neutralizing
the variola virus in the infected organism so rap-
idly', Orj' is of the opinion that it is capable also
of preventing its development in the health}' or-
ganism, and advises its use as a preventive for
those surrounding variola patients. — Wiener Med-
icinische Wochenschrift, No. 22, 1889.

The Diagnosis of Pancreatic Disease. —
From a careful examination of a case which was
under Gerhardt's care at the Berlin Charite von
Ackeren endeavors to assign a certain diagno.stic
importance to the presence of undecomposed
carbo-hydrates in the urine of cases suffering from
disease of the pancreas. The patient was a man
49 years of age, admitted suffering from vomiting,
constipation and emaciation. To the right of the
umbilicus there was palpable a painful irregular
tumor which moved to the right when the stom-
ach was full. The emaciation progressed, although
the size of the tumor scarcely increased ; cedema
of the legs and ultimately ascites and hydrothorax

set in, and he died five months after admission.
At the necropsj- there was found in the p^-loric
region an ulcerated carcinoma with secondary
growths in the retro-peritoneal glands. Two
such nodes were present in the pancreas — one in
the tail and a larger one in the head of the gland.
Two or three weeks before death the urine, which
had hitherto been normal, increased in quantity,
notwithstanding the oedema, and the specific
gravitj' went up to 1028 and 1030. Fehling's
solution showed reduction only some time after
heating, while the nitrate of bismuth solution
turned black after some minutes' boiling. Polar-
ized light was rotated to the right, and the fer-
mentation test gave a positive result. The appli-
cation of other tests showed these reactions as
due to the presence of maltose and a closely allied
carbohydrate. Indican was present in abundance,
and there was no biliary pigment. The motions,
although repeatedlj' examined, never showed any
fat, but, on the other hand, there were numerous
striped muscular fibres. As these symptoms were
added to those of cancer of the stomach only two
or three weeks before death, they probably coincid-
ed with the occurrence of secondarj' growths in the
pancreas: The presence of striped muscular
fibres in the fseces was of great importance, as
the}' have been found in nearly all those cases,
although here, as shown by the constipation
which existed, they could not be looked upon as
due to a rapid passage through the intestine.
Both this symptom and the absence of indican
from the urine have been attributed to the failure
of tn'psin. In a case recorded by Gerhardt, where
the enlarged head of the pancreas had led to in-
testinal obstruction, indican was absent, and that
observer sought to invest it with some diasnostic
significance ; but it may be explained by albu-
minous matter not entering the intestine, as it
has been shown that indican disappears entirely
by the third day in cases of inanition. In this
case it was present in abundance. With regard
to the presence of fat in the fceces, F. Miiller has
shown that when this occurs the case is always
complicated by other conditions, especially jaun-
dice. Here no bilian,- pigment appeared in the
urine, nor was there any fat in the motions. Ac-
cording to V. Mering, the pancreas possesses the
most powerful diastatic ferment ; and it is proba-
ble that it is the pancreatic secretion alone which
converts the maltose, derived from the carbohy-
drates of the food, into grape sugar. As carbo-
hydrates do not appear in the motions, the only
symptom pointing to disturbance of this pro-
cess is the excretion of sugar in the urine, and
in this connection it is interesting to recall the
fact, long ago observed by Frerichs, that in dia-
betes mellitus the pancreas is frequently found
much atrophied. {Berlin, klin. Wochenschrift,
No. 14, 1S89.) — The Praetitioner, ]un&, 1889.

1889.] EDITORIAL. 165

I
, , r 1 4 -^"^ 1/ 1' 1 . • • cal Society and to American gynecology and

Journal of the American Medical Association dentistry.

PUBLISHED WEEKLY. .^^.^ Americans are certainly verj- much inter-

suBscR.PT.oN PRICE. INCLUDING POSTAGE. ^g^^^ -^^ ^^^ British Gvnecological Society, for it

Per Annum. IN Advance $5.00 - '^

Single COPIES 10 cents. has ever shown since its foundation an amount of

subscription may begin at any time. The safest mode of retnit- g^tgrprise that is really QUitC American ! An OUt-
tance is by bank check or postal money order, drawn to the order ^ - ^ ^

of The JorRNAL. When neither is accessible, remittances may be grOWth of the Obstetrical Society of LondoH, it
made at the risk of the publishers, by forwarding in Registered ^^^ j^ beginning in l8Ss, sinCe when the acces-
letters. j 00^'

Address sions to its membership haye been extremely rapid,

Journal of the American Medical Association, I .^^j^jjg ^j^g character of its work has been the very

No. 6S Wabash .\ve., i t^ 1 ^>.i •!.->■• , ^

Chicago, Illinois, best. By the Obstetrical Society It was regarded,

AU members of the Association should send their Annual Dues ^t firSt, aS simply a little rabble of fanaticS blindly
to the TVioiMrfr, Richard J. Dunglison, M.D., Lock Box 1274, Phila . , '. , , „, . ,„,

deiphia. Pa. running after their leader, Tait. Three years ago

I 7 I II an American in London was informed, by one of

London Office, 57 and 59 Ludgate Hill.
. . the most prominent obstetricians of England, that

SATURDAY, AUGUST 3, 1889. he could not possibly promote his interests either in

=^====^^^^^=^=^==^= England or in America by joining such a society as

AMERICAN GYNECOLOGY. this one. To-day the British Gynecological Society

T/ie Provincial Medical Jouryial of England, in ^ has a large number of members in this country
an editorial relating to the British Gynecological who take a yery cordial interest in the work being
Society, paj'S a verj- high and well deser\-ed com- done by the Society, many of whose home mem-
pliment to the Society in question, and incident- bers, such as Tait, Bantock and Barnes, are well
allj' to American gynecology and dentistry. "We ; known by us not only from their published works,
write with regret," says the editor, "that the 1 but from yisits made us. We are little concerned
Americans are ahead of us in dentistrj* and in in the rivalrj' between Sir Spencer Wells and Mr.
gynecolog}-. The reason is that gj'necolog\- was Tait. Even if it be true that Tait's eminence
separated from obstetrics, and its studj- put on a made easj- the establishment of a new society in
proper basis. Excellent handbooks, as those of 1 which Americans at once took a great interest, we
Thompson, Munde, Goodell, have been published find no evidence of weak idolatry in the members,
and are to be found in every practitioner's library The Obstetrical Society decries its rival " because
in the States. The Americans took up the study | its members remove too many ovaries." After
with all the energy of a young people, and we are I all, each one will have to decide such matters for
simply following in their wake, and attempting to himself.

interest general practitioners in a branch of prac- We admire Wells and we admire Tait, and we
tice which is the most important one to them, do not believe that the former is the Obstetrical
There is alwaj's a little difficult}- in launching out Society', or the latter the Gynecological Society,
a new society. Even in the practice of medicine | Each has had a rich experience which we who
there are jealousies, but the British Gynecological are interested in operative g\-necology will do well
Society had even less difficulty than was antici- to carefully study. Meanwhile we find that the
pated. It evidently met a want ; hence its hun- British Gynecological Society is doing more to
dredsof members; hence the success of its meetings make its work known abroad than is any other
and its transactions. Opposition and competition ^ special society in England.

are excellent things ; the}- stimulate to action ; |

and the best thing for the British Gynecological 1

Society would be personal antagonism, as we feel j HEALTH BOARDS AND PHTHISIS,

sure it would stir up those who are interested in j The circular recentlj' issued by the Health De-
it to make it a still greater success." partment of the City of New York, in relation to

The Provincial Medical Journal evidently has the prevention of tubercular consumption, is un-
considerable fighting blood in its veins ; but if doubtedl}- founded upon the most advanced lab-
inclined to be aggressive it is certainly just and orator}- investigations of the life history of the
candid, both in regard to the British Gynecologi- bacillus which is supposed, in the present state of

1 66

WITH RIGHT INTENT.

[August 3,

our knowledge, to constitute the " contagium
vivum " of this disease: but it is hardly char-
acterized by a sufficient degree of practical ap-
plicability to warrant the hope of an immediate
abolition of infection. Granting the postulate
that the ' ' living germs ' ' in the sputa of con-
sumptives, expectorated "on the street, floors,
carpets, handkerchiefs, etc.," may, after drj-ing,
"float in the air as dust," and admitting the
germicidal efficacj', even in a highlj- albuminous
medium, of mercuric chloride, it is still difficult
to understand how the prophylactic directions of
the circular are to be generally carried out. In
the population of New York there are probably
more than twenty thousand consumptive people
daily frequenting public places, and expectorat-
ing their "enormous numbers" of bacilli on the
sidewalks, in cars and other conveyances, in lec-
ture rooms, theatres, hotels, and even churches.
The parks naturally possess a peculiar attraction
for them, and an excursion-boat commonly bears
more than its statistically normal share of them.
The circular wisely ordains that such persons
should not be permitted to spit on anything
which cannot be immediateh' disinfected, and
adds : "The spittle of persons suspected to have
consumption should be caught in earthen or glass
dishes containing the following solution : corro-
sive sublimate i part, water 1,000 parts." But
how is this to be effected ? Shall we have in the
future City of Health an army of emissaries from
the Department closely watching the footsteps of
each " suspicious wayfarer, and thrusting a regu-
lation glass dish under his nose whenever he
coughs ? Or will there be a special bureau of
auscultation and percussion to verify the suspici-
ous cases and isolate them in an aquarium of
bichloride solution?

Where the suspicious stage is past, and the
certainly consumptive patient is confined to the
house, it is prescribed that his rooms should have
"as little furniture as possible," and that "the
use of carpets, rugs, etc., ought always to be
avoided." The abstract advisability of depriv-
ing a mother or wife whose days are numbered,
and who is to be scientifically considered only as
a focus of infection, of all accustomed comforts
may commend itself forcibly to the strictly med-
ical mind, but the strangely .sentimental pre-
judices of the public at large will, we fear, pre-
vent the adoption of this rule by perhaps the

majority of those who can affiard the prescribed
luxuries.

The recommendation to ' ' catch the bowel dis-
charges of consumptive patients ' ' in vessels con-
taining the same solution advised for the sputa is
not likely to be observed among the poorer and
more ignorant classes, whose overcrowded tene-
ments enhance the proclivity to infection ; and in
view of the common carelessness of such folk, it
may be questioned if the domiciliary storage of
corrosive sublimate may not present .some counter-
acting disadvantages, and whether it be better
for their unkempt offspring to be poisoned in in-
fancy or to die of phthisis at a more advanced age.

Other rules are given, touching the nursing of
children by mothers suspected of consumption,
the washing of a patient's clothing, the marriage
of "suspected " persons, and divers more or less
relevant minutiae of antisepsis, the theoretical
propriety of which must be apparent to the mean-
est capacity, but the enforcement of which is
problematical. For, be it remembered, this circu-
lar is not addressed to physicians, who alone are
competent to appreciate the importance of its sug-
gestions, and who may usually be trusted to take
intelligent precautions as far as circumstances
will permit : but is spread broadcast among the
populace, who are neither educated to accept
scientific conclusions nor likely to recognize the
existence of tuberculosis until it has reached its
final stage.

WITH RIGHT IXTEXT.

With a politician at the head of the Health
Department of New York City, it is not surpris-
ing that such a bulletin should emanate from such
a source. That in its application it is impracti-
cable, we have already shown. Indeed it is easy
to assume the role of objective and even of destruc-
tive criticism when difficult problems are involved,
and to demonstrate the errors involved, but it is
another thing to point out with unerring certainty
the better plans and the methods to success.

While criticising its methods. The Journal
desires to emphasize its approval of the purpose
of this municipal legislation. Imperfect as its
work may be it is nevertheless expressi\-e of the
right intent.

A great fact underlies this action which is of
great importance to the citizen and to the State.

1889.]

EDITORIAL NOTES.

167

It involves this fact, that municipalities are
charged with the surv^eillance of the health of its
citizens. If so, it follows that when by any means
the general health is imperilled, legislation
should come to its rescue, and that as life is para-
mount to property, by so much the more should
commercial interests and personal convenience
yield to such restrictions as may be needful for
life-protection. In emergencies absolute quaran-
tine is the logical sequence of such legislation.

This brings us to the purpose of this article.
The public mind is becoming more and more en-
lightened with reference to the nature of diseases.
It is more and more apparent that while many
affections may not be subject to control, on the
other hand there is a vast amount of preventable
disease, and the conclusion is legitimate that
when prevention is possible, prevalence is evi-
dence of criminal neglect. Naturally the public
turns to the medical profession for the solution of
those questions in which human health is in-
volved. If we assume the responsibilities inci-
dent to the criticism of imperfect methods, we
should be prepared to indicate those that are
better. The province of the medical profession
at the present hour is not only to deal with those
that are sick, but with those that are well. And
by so much more as a man is valuable to the
State in health than in disease by so much the
State is interested in preventive medicine. It
has need, then, to be informed as to which are,
and which are not preventable diseases. It needs
to be correctly informed as to what may be done
legitimatelj', and also of the difficulties which lie
in the way of controlling contagious diseases.

The answers to these questions involve a vast
amount of painstaking investigation and perhaps
the work of years. But only by such investiga-
tion and by such patient observations can these
answers be reached. Only upon knowledge thus
obtained can intelligent and satisfactory legisla-
tion be based. If in their work medical men
shall come to correct conclusions the honors and
the benefits which shall inure to such labors will
be beyond measure. If, on the other hand, pre-
mature conclusions shall be involved with serious
errors, in practical application these errors will
surely become apparent, and in proportion to their
gravity will be the severity of criticism which the
medical profession must endure.

The question involved is this : Can the profes-

sion so wisely guide an intelligent public as to
assure an abiding loyalty, or shall it fail of its
true mission, and provoke infidelity to the funda-
mental facts of sanitary science ? If we are de-
structive in criticism, let us be also constructive of
the best methods of promoting the public health,
and let the necessities for correct conclusions
stimulate men that are equal to the demand to at
once and continuously put forth the needed
effort.

THE RESIGNATION OF DR. DE WOLF.

Chicago has sufitred a loss by the resignation
of the Commissioner of the Health Department,
Dr. Oscar C. De Wolf who, through his official
services as Health Officer for the past thirteen
3^ears, has contributed so much to the well-being
of its citizens, and, at the same time, has gained
for himself a National reputation as a man able
to successfully grapple with all the difficulties be-
setting such a position, political and sanitary.
The Sanitary News, editorially referring to his
resignation, says: "He has practicallj- created

the Health Department of this city He

has demonstrated fully his ability to preside in
this capacity by his efficient ministration in a field
of so great magnitude, confronting him with so
many and so great difficulties. Whatever his
future labors may be, his gain will not be so great
as the city's loss, but in whatever field his efforts
may be directed, we trust the same measure of
success may attend him. His successor, Dr.
Wickersham, will find a well organized depart-
ment, and we hope his labors will prove efficient,
and receive the hearty support of all the citizens. ' '

Dr. De Wolf is a member of the American
Medical Association, having joined at the Chica-
go meeting in 1886.

EDITORIAL NOTES.
HOME.

The American Dental Associ.\tion meets
at Saratoga Springs, commencing August 6th,
The prospects are said to be good for a large con-
vention.

The Cincinnati Free Hospit.\l for Women
has been organized by the election of the follow-
ing officers : Board of Trustees, Thos. H. Egan,
President ; Dr. H. Longstreet Hall, Secretary ;

i68

EDITORIAL NOTES.

[August 3,

W. H. Cumayhan, Esq., Treasurer; Dr. C. L.
Armstrong, H. M. Rulison, Rev. M.C. Lockwood.
Staff, Drs. Charles A. L. Reed, Rufus B. Hall,
Surgeons ; Charles E. Caldwell, Pathologist ; J.
A. Johnston and A. I. Carson, Assistant Sur-
geons. A large and influential Board of Ladj'
Managers has also been elected.

Dr. James F. Hartig.\n, of Washington, an
active and esteemed member of the Medical Soci-
ety of the District of Columbia and the American
Medical Association has been appointed to an
Austrian consulate.

The Act Requiring a License to Prac-
tice Medicine Construed and Held Con-
stitutional'.— The opinion of the Supreme
Court of this State, by Shope, J., holding that in
this case the validity of the statute was involved,
and the appeal was properly taken to the Supreme
Court, that this proceeding is not in its nature
criminal, being punishable by fine, and does not
come within the spirit of the law forbidding ajD-
peals or writs of error by the people, or the twice
putting in jeopardy. It is simply a civil proceed-
ing— an action of debt to recover a penalty. That
the subject of the Act is sufficiently set forth in
its title ; that the defendant travelling from place
to place with a band of music, and collecting the
people together, and vending remedies and nos-
trums for the cure of disease, etc., without a
license, was a violation of the section under con-
sideration of the Medical Practice Act. Although
this is a short opinion, there are several important
questions passed upon by the court of last resort.
In construing the law relating to the practice in
our police courts, this opinion will well repay a
careful examination and study. This opinion is
published in full in the Chicago Legal N'eu's of
July 13.

FacxjTLTY CHANGES.^The Faculty of the Col-
lege of Physicians and Surgeons of Baltimore, held
a meeting recently to fill the vacancies created by
the deaths of Professors John S. Lynch and Oscar
J. Coskery, and the retirement of Professor A. B.
Arnold, who has removed to San Francisco.
Prof. Thos. S. Latimer was transferred to the
chair of principles and practice of medicine and
clinical medicine ; Prof. Chas. F. Bevan to the
chair of principles and practice of surgery and
clinical surgerj' ; Prof. J. W. Chambers to the

chair of operative and clinical surgerj', and Prof.
George H. Rohe to the chair of obstetrics and
hygiene. Prof. Thos. Opie will continue as pro-
fessor of diseases of women and dean of the
faculty. To fill vacancies created by these trans-
fers new professors were elected as follows : Prof.
Henrj' Sewall, of the University of Michigan, to
the professorship of physiology ; Dr. George J.
Preston to the professorship of anatomj-, with the
diseases of the nervous system as a clinical branch
of instruction. Dr. N. G. Keirle was elected as
lecturer on legal medicine, in addition to his
demonstrations in pathologj'; Dr. George Thomas
as lecturer on diseases of the throat and chest ;
Dr. G, A. Liebig, Jr., of Johns Hopkins Uni-
versity, lecturer on medical electricit}-, and Dr. J.
H. Branham, demonstrator of anatomy-. Drs. L.
F. Ankrim, Frank C. Bressler and F. G. Moyer
were appointed assistant demonstrators, and Dr.
R. G. Davis, prosector of anatomy. As an evi-
dence of esteem on the part of his colleagues.
Prof. Arnold was elected emeritus professor of
clinical medicine on his retirement.

Milwaukee's G.^rbage Consumer. — Sani-
tarians and health officers have endeavored from
time to time to solve the problem of how to dis-
pose of the accumulation of garbage in the large
cities. Milwaukee has adopted a consumer
known as the Merz process, and which is de-
scribed b}' a contemporary as follows : About
thirty-five tons of garbage — "good, clean gar-
bage," free from ashes — is delivered at the works
every day at this time of year. The wagons
drive up an incline and unload upon the second
floor, where it is immediately thrown into the
drj-ers. The drj-ers are tanks about fourteen feet
long and five feet in diameter, having a double
cylinder — a small one inside of a larger. Be-
tween the shells, or the cylinders, is a steam
space of two inches, which has a boiler pressure
of eighty-five pounds on constantly. The cylin-
ders have cast-iron heads, and a large hollow
shaft running through the centre of the inner
cylinder. This is also filled with steam, and re-
volves by means of gear wheels, keeping the
contents in circulation until thoroughly dried.

The moisture is drawn off by means of a large
exhaust fan through a twelve-inch pipe and forced
into a spray condenser. When the material is
thoroughly dried it is discharged from the dr>-er

1889.]

SOCIETY PROCEEDINGS.

169

into a conveyer, which deposits it into square
tanks called extractors. After being sealed and
made air-tight benzine is introduced into the ex-
tractors and the grease is dissolved with a solu-
tion of hot benzine. After the grease has been
dissolved and washed out, the material is sold for
fertilizer.

The benzine is distilled out of the grease over
again and used. The grease is sold to soap and
candle makers.

FOREIGN.

Small-Pox and Tuberculosis. — At the late
Congress on Tuberculosis it was stated that per-
sons who have had small-pox are peculiarly liable
to tuberculosis. M. Landouzy deprecates the em-
ployment of persons pitted with small-pox around
the tuberculous wards of infirmaries and hospitals.

Wanted, an Editor. — The British Medical
Jour?tal says: "' I want a hero— an uncommon
want,' sang the poet. A still more uncommon
want, one would have thought, would have been
that of an editor for a medical journal. Yet from
this cause the Breslaucr iirztliehe Zeitschrift came
to an untimely end on June 29. It has been
impossible to find ' a commanding personality '
to supply the place of the late Professor Gscheid-
len, who founded the journal and gave it the
prominent place it held in German medical liter-
ature during the ten years of its existence. Those
interested in prolonging the life of the defunct
periodical should have sought for what they
wanted in this country, where would-be medical
editors grow on every bush."

Why not have crossed the Atlantic, where med-
ical editors are more plentiful than the "would
be ' ' ones in England ?

In England a London health inspector reports
a number of cases of diphtheria caused by cats
going from house to house and thus carr>-ing the
virus. Queen's Hospital, Birmingham, is the recip-
ient of $5,000 by the will of Mr. George Dawes, of
Smethwick. Dr. Burroughs lauds nitro-glycerine
as a quick stimulant in place of alcohol, and gives
as the ordinary dose i drop of i per cent. At a
recent meeting of the Royal Botanical Society Mr.
R. G. Lecky described, in a very interesting pa-
per, a new edible seaweed found on the coast of
Ireland, and which, according to the author, is a
nutritious, wholesome, and cheap food, so excel-
lent in taste that it may be called a luxury.

In Fr.\nce the students in Paris have decided
to wear distinctive badges to denote the courses
which they are pursuing. Dr. Gautier, while
pulverizing dry discharges for the purpose of
making experiments as to infection by tuberculous
germs, became himself infected and died. Dr.
Lancereaux, physician to the Hopital de la Pitie,
objects to the use of movable stoves, which are
apt to cause carbonic acid poisoning. The Societe
Medicale des Hopiteaux have recognized the ne-
cessity of isolating cases of whooping cough,
which the members consider far more contagious
than either scarlatina or measles, and have ap-
proved the organization of small wards, contain-
ing six or eight beds, instead of the large wards
which are now used.

SOCIETY PROCEEDINGS.

AMERICAN MEDICAL ASSOCIATION.

Foi'tietli Annual Meeting. Report of
Sections.

Section on Laryngology and Otology.
First Day, Tuesday, June 25.

Dr. W. H. Daly, of Pittsburg, Pa., delivered
the Chairman's address, entitled Marking an Era
in Laryngology . The author referred to this,
the first meeting of the Association of Laryngol-
ogy and Otology, as an exclusive and autonomous
Section, disassociated from the Section of Opthal-
mology. The laryngologists and otologists have
long agreed, that to be an able practitioner in
either speciality one must be well informed and
competent in both of these special branches.
While there is little call for the special skill of the
laryngologist in treatment of the eye, we are con-
vinced that there was no mistake in expressing
the opinion eight years ago at the International
Medical Congress that the laryngologist of the
future must be more of a rhinologist, and the
rhinologist more the surgeon than the physician.
As by far the largest number of inflammatory
diseases of the middle ear cannot be successfully
attacked without the skill of the laryngologist
and rhinologist, since the largest number of these
cases begin in the naso-pharynx and are only ar-
rested by the proper skill in treating these parts.
The new relation is close, rational and common
sense.

Dr. John McKenzie, of Baltimore, reported
A Case of Lymphoid Tumor Originating in the
Floor of the Pyriform Sinus, and threatening suf-
focation when the patient was in the recumbent

lyo

SOCIETY PROCEEDINGS.

[August 3,

position. A clergyman, aet. 42, had never had
am' throat trouble, and was other«'ise in perfect
health. There was no assignable cause for the
growth. On microscopic examination it was
found to consist entirely of the lymphoid tissue
of the pharjmx recently described by Waldeyer
and his pupils. The tumor was removed by first
exciting gagging, so as to throw it as far as pos-
sible up towards the back of the tongue. It was
then caught with a pair of lar>'ngeal forceps, and
with these as a guide, the large ecraseur was
passed over the tumor and it was rapidly cut
through. The reporter remarked that growths
of various kinds are occasionally found on the
pillars of the fauces, glosso-epiglotic fossa, and
upper phar>-nx ; but tumors originating in the
pyriform sinus are exceedingly rare, and that the
growth described is unique.

Dr. Solis-Cohen remarked that it was rather
curious that this unique growth originated in the
position from which some few cases of lipoma
had taken origin.

Dr. Jonathan Wright, of Brooklyn, N. Y.,
read a paper on A'asal Bacteria in Health. The
bacterial contents of the normal nasal chambers
in ten cases were examined by culture methods
and by cover-glass preparations, with the result
of finding the staphylococcus pyogenes in six of
the ten, and only air forms in others. The func-
tion of the nose as a bacterial filter of air passing
through it, was spoken of, and photographs
shown of one experiment which showed mold
growths on gelatin plates. As far as the limited
experiments of the author of the paper went,
about three-fourths or four-fifths of the total
number of the bacteria in the air find a lodging
place in the nose before the tidal air reaches the
lower phan.'nx. The paper was preliminan.- to
more extended bacterial investigations into nasal
diseases.

Dr. John McKenzie thought the solution of
many points in nasal pathology by bacterial in-
vestigations would not be an event of the imme-
diate future. The problem is an intricate one,
especially in view of the constantly changing en-
vironment of the individual. The dependence
of ozena on micrococci has not been determined.

Dr. W. Freudenth.\l. of New York, read a \
paper on The Connection Betuecn Chronic Dis- j
cases of the Upper Air Passages and Hernia. In }
continuation of former obser\'ations the author
found that in accordance with the frequency of
nasal disease, hernia are found : In the United
States in 50 out of every 1,000 conscripts; in
France, in 22.S9 ; in Italy, in 16.61 ; in Austro-
Hungary, in 14.09 ; and in Germany in even less
than 14. Furthermore, the author of the paper
proves the correctness of his theory, against Dr. 1
Schafinger who had affirmed that facts do notj
sustain it. In women hernije are rarer than in
men, on account of the weaker stress used in act

of hawking, clearing the throat and the like.

Dr. J. H. Bryan, of Washington, D. C, read
a paper, entitled Diagnosis and Treatment of Ab-
scess of the Antrum of Highmore. The author,
after describing the antrum and its relations, re-
marked that until recent years abscess of the an-
trum was thought to be very rare, but that we
now know that it occurs quite frequently. Of
surgical affections, suppurative inflammation
plays the most important part. It generally oc-
curs after the second dentition. Among causes
are traumatism, exanthemate, syphilis, extension
from the nose of inflammation of its lining mem-
brane, extension from inflammation caused bj'
carious teeth. Authors difier as to the relative
frequency of these causes. The author regards
sero-mucus accumulation or hydropsantri as the
result of nasal disease, but muco-purulent as
arising from carious teeth. The close relation of
roots of the second molar teeth with the antrum
affords ready communication of disease from
them. Symptoms vary in different cases. Some-
times there is distention of the walls of the su-
perior maxilla and swelling of the cheek, etc.,
tenderness on pressure, a springing deviation to
the finger on pressure over the distended cavity.
A narrowing of the field of vision by pressure on
the floor of the orbit, is regarded by Ziem as di-
agnostic in favor of disease of the ethmoid cells.
In some cases there is a discharge of fetid pus
from the nose. Pus from the nose may be due to
foreign bodies, disease of bone, secretion of pus
from the antrum or from the frontal sinus. Other-
wise suppurative inflammation of the nose is ex-
tremely rare. The author then pointed out the
indication which should guide in distinguishing
among these possible sources a given case.

A great deal has been v.ritten recently as to
treatment. The author noted the tendency to
return, after a centuni", to Hunter's method of
opening through the nose, instead of through the
mouth. Cooper's method through the alveolar
process has been in greatest favor. Extraction of
teeth may be necessary, and if sound ones this is
an objection to the method, and this is the case
with which foreign substance and bacteria from
the mouth may penetrate through the opening.
Its advantages are easy drainage and washing out
with antiseptics. Bertrand opened through the
hard palate. Hartman has revived Hunter's
method. This does not afford easy means for
evacuating thick pus and for washing out, etc.
Stoerk claims several cures by this method. The
author thinks its disadvantages will prevent its
general acceptance.

Miculicz advises opening where the lateral wall
of the nose is thin, and uses a special double cut-
ting knife, attached to the handle at blunt angle.
Local anaesthesia by cocaine is sufficient. By this
opening the floor of the cavity is well drained and
easily syringed out, and there is little danger of

?■]

SOCIETY PROCEEDINGS.

171

foreign bodies gaining entrance as when the open-
ing is through the mouth. Local treatment is
important — washing out with mild disinfectants.
The best for fetor is permanganate of potash.

Some cases will require where the inflammation
is obstinate, the author recommends, the use of pe-
roxide of hydrogen; or better, glycozone — a mix-
ture of glycerine and peroxide of hydrogen. It
destroys the septic material and stimulates at once.

The author gave the histon,- of several cases
treated bj* himself.

Discussed by Drs. Lippincott, E. Fletcher In-
gals, Daly and Boy an.

Dr. John O. Roe, of Rochester, N. Y., read a
paper on Glandidar Hypertrophy at the Base of
the To7is:ue. The author remarked that in the
near past this condition, which is not rare, has
been overlooked for the most part. Collections
of mucus and h'mphoid glands aggregated in va-
rious masses in the naso-pharj-nx, fauces, are of
the same general nature and have received the
name "tonsil." The lingual tonsil is so situated
as to be easily irritated by solids and fluids of dif-
ferent temperature and character. They are sur-
rounded and supplied with a system of blood-
vessels. By these exposures to irritation they are
especially exposed and become congested, enlarged
and varicose. This condition maj- also be due to
general plethora and may indicate portal conges-
tion, mitral disorders, or even cerebral tumors.
The diagnosis is easily made by inspection on
drawing the tongue forwards.

The treatment involves two measures : First,
to remove the growth. This is done with a
cur^-ed knife, by slicing ofi" down to the normal
level, or with a pair of scissors cur\'ed on the flat.
This operation is attended with very little bleed-
ing, the tongue heals quickly and is attended with
very little soreness. The galvanic cauterj- may
be used, either the knife cutting through the base
or by transfixing with a needle. The other mea-
sure of treatment is to destroy the varicose ves-
sels. This is best accomplished with the galvano-
cautery by use of a fine point applied along the
course of the vessels. Caustic is used by some,
nitric, chromic acid and Vienna paste — but when
a great amount of hypertrophy is present the op-
erative measures are best.

Discussed by Drs. Solis-Cohen and Green V.
Woolen.

Second Day, June 26.

The following were elected ofiicers for the en-
suing year: Dr. John O. Roe, of Rochester, N.Y.,
President ; Dr. Frank H. Potter, of Buffalo, N.Y.,
Secretary.

It was voted, on motion, that the Secretary se-
lect an A.ssociate Secretary-, familiar with otologi-
cal knowledge, and living at the place of meeting
of the Association next year.

On motion of Dr. Solis-Cohen, it was voted

that hereafter one meeting of the Section be
devoted to subjects of otological interest.

Dr. D. Bryson Del.wax, of New York, read
a paper entitled. Adenoid Hypertrophy at the Vault
of the Pharynx ; its Pathology a?id Treatment.
The writer stated that there were two principal
varieties of this disease. In one the growth was
soft, friable and rich in lymphoid elements, in the
other there was an excess of fibrous tissue. The
first was removable with ease and with little pain,
the latter was exceedingly tough and removal
caused much pain. The methods of operation
were alluded to and it was insisted that in the
more severe cases, even in 5'oung adults, the use
of anaesthesia was of the greatest importance, and
that the removal should be completed, if possible,
at one operation. The writer also insisted upon
the great importance of the proper after-care of
patients thus operated upon, and recommended
that they be kept in bed until the general effects
of the operation had disappeared, that they be
put upon a course of tonic treatment, that the
mouth-breathing habit be corrected, by special
attention thereto, that deformity of the chest, if
present, be remedied by proper physical exercises,
and, finally, that errors of pronunciation be erad-
icated. The paper was illustrated by numerous
instruments and bj' several fine colored draw-
ings.

Dr. Joseph A. White, of Richmond, Va.,
then read a paper entitled. The So-called Third
Tonsil.

The author's experience and obser\'ation led
him to believe that glandular hypertrophy in the
post-nasal space, however produced and however
little, is an active agent in keeping up a catarrhal
condition of the region and causing its extension
to neighboring cavities, especially the ear. To
get rid of naso-pharyngeal catarrh it was neces-
sar>' to destroj' hypertrophied tissue as a means to
this end, and to the same end chronic follicular
tonsilitis, so-called, must often be removed. We
do not know the exact function of these glandular
structures, but we do know that their removal is
followed by no disaster. Perhaps the third tonsil
plays a greater part with production of secondary
disease than the faucial tonsils. This is easily
understood when their relations to the blocking
up of the air-passages and interference with the
proper ventilation of the Eustachian tube is con-
sidered. Marked impairment of hearing is always
present in these cases of soft lymphoid tissue.
Besides the mulberry-like growths there may be
round or conical nodules, or several knob-like out-
growths, or flat, cushion-like nares, etc. Some-
times these are soft and easily removed. Some-
times they are dense and hard. The Eustachian
tubes are especially injured by tissues of the latter
character, the opening being seriously dammed
by their pressure. Such are more difficult to cure.
Statistics are unreliable, because slight deafness

172

SOCIETY PROCEEDINGS.

[August 3,

is overlooked in these cases. Careful tests will
usually discover more or less deafness where these
growths exist. Out of 565 cases during the past
eighteen months, treated for naso-pharyngeal af-
fections 197 had disease of the middle-ear. Of
the whole number, 134 had hypertrophy of the
the third tonsil, of whom 62 had impaired hear-
ing— 20 per cent. Perhaps the larger proportion
than reported by other observers is due to peculiar
climatic influence. An interesting point in these
cases is the large number of voice troubles found
among them, and larj'ugitis, resulting from these
hypertrophies in the vault of the pharynx. The
vaulted space should be perfectly preserved in shape
if resonance and timbre of the voice is to be pre-
served, as is well known from our experience with
singers and others who habitually use the voice.
Naso-pharyngeal troubles are always aggravated
by these glandular enlargements, causing increase
of secretions, etc., and this prevents the benefit of
other local treatment, unless the hypertrophies are
first removed. One of the serious results of the
neglect to do this is anterior turbinated hyper-
trophy. Another is the occasional paralysis of
the alse of the nose, causing serious impediment
to breathing. It matters little how the growths
are removed provided it be thoroughly done.
Large masses are best removed with the galvano-
cautery, snare, or cutting forceps. So also of the
denser growths mentioned above. The use of the
forceps is quite painful, even when cocaine is
used. Smaller hypertrophies and smooth masses
are best removed by galvano-cautery points or
moxa-electrodes. The author had found his pal-
ate-retractor of great help in such work.

The paper was followed by a report of cures and
exhibition of specimens.

Dr. Lawrence TuRNBULLread a paper On the
I a/i/e of Antiseptic Treatment, and Protection for
the Mcmbrana-Tympani, in Perforations the Re-
sult of Otorrhcca . He stated that it was not neces-
sary at this time to advocate or dwell at length
upon the great value, nay, absolute importance,
of antiseptic surgery. Its latest triumphs and
most brilliant results have been shown in
brain surgery. It is not onh' possible to reach
and drain abscesses in the tempo-sphenoidal lobe
of the cerebrum, but it is considered possible
to save life by opening into the cerebellar fossae
and remove pus from the neighborhood of the lat-
eral sinus. The antiseptic treatment of chronic
purulent disease of the middle ear was a natural
sequence, and was soon followed by the use of
boracic acid in powder and .solution, and still later
by the superior antiseptic agent, bi-chloride of
mercury, alone or combined in solution ; then by
the u.se of antiseptic wool, and gauze, with the
protecting agency of oiled silk, which protectors
act as artificial membranes and prevent the en-
trance of diseased germs from the air.

The author of the paper then dwelt upon the

various causes preventing the cure of chronic dis-
charge from the ear. Also the treatment of per-
forations of the membrana tympani by means of
grafts of skin, lining membrane of the chicken
egg, skin of the frog's foot, and nictilating mem-
brane of the frog's foot.

The paper concluded by reporting a few cases
in illustration of the subject.

Dr. C. W. Richardson, of Washington, D. C,
then read a paper on The Possible Danger of hi-
jiiry to the Middle Ear Cavity by the Use of Nasal
Atomisers, Illustrated by Three Cases.

The author expressed the expectation of excit-
ing criticism and skepticism. The object of the
paper was to call attention especially to danger to
the middle ear as a result of atomization of the
nasal cavities by such instruments as Davidson's
and Snowdon's atomizing tubes from direct pres-
sure. The fir.st case, that of a lad}', being treated
for rhinitis atrophica. During the use of the
spray with Dobell's solution, pain was experi-
enced in the ear. This was followed in a few
hours by serious ear trouble, pain radiating over
the side of the head and along the Eustachian tube.
Effusion set in and was attended with deafness,
roaring in the ear, etc., all the symptoms of acute
otitis media.

The second case occurred in a gentleman who
had great hoarseness and naso-pharyngitis. While
using the spray the patient remarked, "Doctor,
that certainly entered m^' ear." The spray was
stopped at once. Soon after great pain set in and
became almost unendurable. The pain was of
a throbbing character, intensified b}- coughing,
clearing the throat and swallowing. There was
tenderness over between the mastoid and the jaw,
hearing reduced R. lU, L. H- Cerumen was found
in R. E. It was removed, and hearing then was R.
fg-, L. i-g. The membrane of right ear then showed
evidences of morbid inflammation. It was a case
of acute middle ear inflammation, well marked.

In case third. Dr. L. consulted the author in
February, 1889, for severe pain in right ear, and
was constantly annoyed by obstruction to free
nasal respiration. The spray was tannic acid gr.
j to ,5j. This was followed, like the other cases,
with acute symptoms of middle ear inflammation.
Cases published by Dr. Ring in the Medical Record
of August II, 1888, were referred to by the author.

The author gave his explanation of the manner
in which the spraying under pressure excites mid-
dle ear trouble. He declared it a common expe-
rience with himself as he had no doubt it was
with other larj-ngologists, that under the spray
patients often express the .sensation that fluid has
entered the ear. The intention of the paper was
not to decry the use of the atomizer, but simply
to call attention to possible dangers. The author
also called attention to the fact noticed by him
that the use of the spray may be the direct agent
in producing otitis media hypertrophia.

1889.]

SOCIETY PROCEEDINGS.

173

Dr. Mackenzie believed that fluid may enter
the ear by any method of cleansing the nose, and
that the danger does not pertain specially to the
spray. He narrated a case of double otitis media
resulting from the use of intranasal spraying. His
remarks did not apply to the nasal douche.

Discussed by Drs. Wright and H, H. Curtis.

Dr. J. L. Thompson, of Indianapolis, Ind.,
read a paper entitled : Report of Cases of Dan-
gerous Middle Ear and Mastoid Inflamtnation
which followed Tiratment of the Naso-Pharynx,
in which he gave the historj' of, i, case of sup-
purative otitis media excited by the use of finely
powdered acetate of lead in epistaxis ; 2, case of
otitis media with extension to mastoid following
application of strong solution of nitrate of silver
to the nares ; 3, otitis media, following application
of caustics to the nasal mucous membrane ; 4,
case of suppurative otitis media of five years'
duration following applications to the nares ; 5,
case of suppurative otitis media with total loss of
right drum head and greatlj^ impaired hearing
following surgical treatment of naso-pharynx.
The history of twenty cases of similar nature
were reported by the author at considerable
length, of similar origin and of the same general
character as those above cited. The author re-
marked in conclusion; i, that from his experience
he was convinced that inflammations from said
causes are of very frequent occurrence ; 2, opera-
tions should never be made nor caustics applied
to the nose during acute catarrhal inflammation
of the parts ; 3, patients should be instructed to
report immediately on the first twinge of pain in
the ear after an application to the nose ; 4, the
operator should be prepared to leech, puncture
the drum, etc., promptly as soon as indication
arise, and the operation for puncturing the mas-
toid, when extension to it has taken place of the
inflammation, should by no means cause hesita-
tion.

Discussed by Drs. H. H. Curtis, Ingals, and
Woolen.

Dr. J. G. Carpenter, ol Stanford, Ky., then
read a paper entitled : Internal Ear Deafness,
Illustrated. Internal ear deafness, in many of the
cases, is due to nasal disea.se, and that by causing
the latter the former is relieved, and that nasal
disease should be cured before structural lesions
have taken place in the inner ear. Report two
cases in which in addition to chronic naso-phar-
yngeal catarrh for the predisposing and acute ca-
tarrh for the exciting cause, syphilis was an im-
portant factor in one and quinine in the other.
The air in the Eustachian tubes and middle ears
normally being in a rarefied state, that warm rare-
fied air should be used for inflation of the Eusta-
chian tubes in preference to cold air, the acute
and subacute congestion and inflammation should
subside, the chronic congestion of the upper air-
passages reduced to a minimum before inflation of

the middle ears. In the cases reported there had
been also aural catarrh and tympanic deafness
before the labrj-nthian deafness supervened.

Dr. J. A. LiPPiNCOTT, of Pittsburgh, then read
a paper entitled : A Case of Sclerosing Mastoiditis,
occurring subsequently to Primary Purulent Mas-
toiditis Interna. Opcntjig of Mastoid. Exposure
of Dina Mater. Recovery.

The mastoid process had been opened in Sept.,
1885, in a distant city, and an abscess found,
which was carefully cleansed. The wound soon
healed, and the severe pain was relieved for six
months, when it recurred, gradually becoming
more severe until July, 1886, when the case came
under Dr. Lippincott's observ^ation. All sorts of
treatment, local and constitutional, failing to af-
ford relief. Dr. L. made a pretty considerable
opening in the mastoid, in October, which unfor-
tunately accomplished nothing. The condition
of the patient now became more and more deplor-
able. Notwithstanding the administration of
large quantities of morphia, chloral, etc., pain
was never absent. The patient became emaciated
and haggard. Convulsions set in and occurred
frequently. Seven months after the last operation,
viz., in May, 1887, at the urgent solicitation of
the young lady, a second operation was made.
In the effort to make the opening this time suflB-
ciently large and deep to give relief, the dura was
exposed in the anterior part of the bottom of the
wound to the extent of % inch. On recoverj' from
the anaesthesia the pain was found to have disap-
peared. Convalescence was rapid and uneventful,
and the young lady resumed her work two months
after the operation. A final examination made a
few days ago reveals the same happy exemption
from pain. It should be added that the chief symp-
tom in this case was the extreme pain, there being
no inflammatorj' appearances about the ear or the
mastoid region.

Dr. Fred L. Crossfield, of Hartford, Conn.,
read a Report of Two Cases, illustrating Epilepsy
Caused bv Intra-Nasal Disease.

The first case came to my notice in 1886, and
had all the appearances of some severe lesion of
the lung. Emaciation, hacking cough, more se-
vere at night, headache, night sweats, and poor
appetite. Had epileptic convulsions past six
years, twice a month or oftener. In connection
with this condition he had marked na.sal hj^per-
trophy, both sides, with deviation of septum, left
side, and exostosis in form of sharp angle, which
pressed against the hypertrophied turbinated body.
Marked adenoid growth of naso pharjmx, slight
changes in the larynx. Epilepsy entirely disap-
peared when pathological condition removed.
Patient now perfectly well. Second case much
like the first, only slight enlargement of pharyn-
geal tonsil. The epileptic seizures much more
frequent. This case likewise full}' recovered on
removal of the cause.

174

SOCIETY PROCEEDINGS.

[August 3,

Dr. Charles H. Knight, of New York, read
a paper on Menthol in Laryngeal Phthisis. Twen-
ty cases, most of them of a severe type, treated
with menthol applications, furnish the author
ground for believing that this is a valuable agent
in tubercular laryngitis. The drug was dissolved
in fluid albolene, in the proportion of i drachm
or ly'z drachm to the ounce, and applied by means
of a laryngeal syringe, or in the form of spray, or
with a nebulizer or vaporizer. In nearh' all cases
the subjective symptoms and the local appearances
improved. In no case did complete healing of an
ulcer take place. In this respect the author's ex-
perience does not bear out the representations of
Rosenberg and others. Three propositions are
offered : i . Spontaneous cure of a tubercular
ulcer of the larj'ux ma}- occur. 2. A simple ero-
sion or ulceration may be mistaken for a tubercu-
lar ulcer. 3. The best results from local treatment
of the lar>'nx"may be expected in cases of incipi-
ent or limited pulmonary disease and in primary
laryngeal tuberculosis.

Dr. F. H. Potter, of Buffalo, N. Y,, then
read a paper On the Use of Menthol in the Upper
Air Passages, in which he reported the results 1
obtained from its local application during the past
three years. These results indicate that menthol
controls superficial inflammations : that it is an
analgesic and second applications can be made in
increasing strength without discomfort ; that it is
destructive of some of the low forms of life, espe-
cially the bacillus tuberculosis, and that it is a
valuable antiseptic in nasal surgerj'. It has an
important place in the treatment of atrophic con-
ditions. It can be used in strengths from i to 50
per cent., dissolved in an oil. The Oleum Petro-
lina, one of the petroleum preparations, the au-
thor considered the best for this purpose of dis-
solving the drug. It can be applied quickly by
the cotton applicator or by means of the spray, or
by vaporization. The direct method answers best
in the pharynx, the spra}- and the vapor for the
nose and larynx. Five cases of laryngeal phthisis
consecutive upon disease of the lungs were also
reported, in which the menthol treatment gave
satisfactory results, the local disea.sed processes
improving rapidly under its use.

Dr. E. Fletcher Ing.\ls, of Chicago, 111.,
read a paper entitled Electrolytic Treatment 0/
Cystic Goitre. \"arious conventional methods of
treatment of cystic goitre were referred to by the
author, and especially that of Sir Morell Macken-
zie, first published in 1872, and which is pro-
nounced in Holmes' System of Surgery as the
most efficient. It con.sists, as is well known, of
injecting into the cyst a solution of perchloride '
of iron, plugging the canula of the trocar and al- ;
lowing it to remain in three days, and repeating
the procedure until suppuration occurs, aided by
the use of poultices. The author claims that elec-
trolysis promises more rapid cure and better re- 1

suits, and is attended by less danger and objec-
tionable features. In support of this position he
gave the history of two cases treated by himself

In the first case, after the use of other methods
had proved inefficient, electrolysis was employed.
One pole, a needle, was introduced into the cyst,
the other placed upon the tumor. By previous
tappings the tumor had been found to be about
one-third solid. From six to ten Leclanche cells
were used for about ten minutes. This was re-
peated at inter\fals of a week three or four times,
when the tumor ceased to refill and has remained
cured. The solid part was unchanged and has
not increased since. The second case was one
which had existed for several years and had been
injected with iodine and other fluids. On Febru-
ary 23 the tumor was found not to have dimin-
ished in size. Electrolysis was now used as in
the former case. In a month from that date the
cyst had ceased to refill and had been completely
eradicated by electrolj'sis. The strength of the
current in this case was graduated by the ability
of the patient to bear it.

Dr. Holbrook Curtis, of New York, read a
paper on Ancemia and its Relation to Nasal Ste-
nosis. By a tabulation of cases he demonstrated
that nearly all patients with stenoses were anae-
mic, the percentage of oxyhsemoglobin being only
about one-half that of normal blood. In his ex-
periments he had used the hsematoscope of Hen-
ocque, and had again tested the blood after sev-
eral weeks had elapsed. The conclusions arrived
at were that the increase of oxyhasmaglobin in
the blood after operations on the septum is di-
rectly proportional to the relief afforded an im-
peded nasal respiration. This increase is constant
and averages about 2 per cent, in the six weeks
immediately following operations in which the
stenosis is about 50 per cent., or in which the
nose is doing but one-half its work. Cases should
not be operated upon whose blood shows by spec-
trum analysis less than 6 per cent, of oxyhemo-
globin, as profound haemorrhage is apt to occur.
Records had also been kept in regard to body
weight, chest measurement, and capacity of the
lungs by the spirometer. These factors also e.K-
hibited improvements after operation.

Third D.\y, June 27.

Dr. J. E. ScHADLE, of St. Paul, Minn., read
a paper on Cough in its Relations to Morbid States
of the A'asal Passages, in which he stated that the
symptomatology of morbid processes seldom pre-
sents a more perplexing subject for analysis as to
its primary cause, than that of cough. A chronic
cough, whose persistency will not yield to ordi-
nary methods of treatment, and whose ultimate
significance is sometimes difficult to understand,
is calculated as much as any other single condi-
tion to establish in the mind of the .sufferer ex-
treme anxiety. Au important interest belongs to

I889.J

SOCIETY PROCEEDINGS.

175

this subject, especially in its practical relations to
morbid states of the nasal passages. Three cases !
were reported in which chronic cough of long
standing was cured by directing proper measures
of treatment to a removal of the existing nasal
disease, consisting in one, of posterior hypertro-
phies of the inferior turbinated bodies, one nasal
stenosis, caused by deformity of the nasal septum,
and one, chronic nasal catarrh. The author !
maintains that when cough is thus pathologically :
connected with morbid states of the nasal pas- ;
sages it is usually produced by reflex ner\-ous in-
fluences or paresis of the vaso-motor blood-vessels
of the intra-nasal mucous membrane.

Dr. Charles Denison, of Denver, Col., read
a paper entitled A A'ccu Moiith Gag. Together
li'ith the consideration of other possible aids to better
results from Intubation of the Larynx. The author
presented a table of his intubation cases, num-
bering 25, with 7 recoveries. These were shown
to be a severe class of cases. The author had
experimented to construct a better gag than that
usually employed, and exhibited four of the new
varieties made. The next to the last one, made
by Tiemann & Co., is intended to be held close
to the left cheek of the child by the assistant,
and is calculated not to get out of place during
the operation. A new feature about all these
gags, an idea of the author's, is to have the teeth
troughs made somewhat swivel, so that they will
fit any angle of the jaws, /. c, any aged child.
The power to open the jaws is afforded by a lever
attached to a toggle-joint placed between the two
sidearms of the instrument.

The last gag was simpler in construction, more
compact, and gave greater power to open the
mouth of a rebellious patient, In fact it cannot
be resisted. A pin on one arm lies in an eliptical 1
groove attached to a circular plate, the center of
which is pivoted to the other arm of the gag.
By three turns of this plate the extreme disten-
sion required in any mouth is obtained. The
author had been bitten, and had other accidents,
from the loosening of the original gags sold with
the O'Dwyer sets of tubes. This last instrument
was made by H. Rauchfurs, of Denver. The
great necessity for earlier intubation than he
thought was customarj- with operators was then
shown. In two successful cases when the author
had intubated he had been led to avoid dela}- by
noting that the tension of the pulse was less dur-
ing expiration, showing that there was already
suction of blood back into the thorax during in-
spiration, in other words, an aspiration because
of the laryngeal constriction was taking place.
The author called this an aden/a of the air-cells,
and he was led to believe that this was the inau-
guration in young children of a catarrhal process
in the lung peripherj- and bronchial tract, usually
resulting in death in from twelve to forty-eight
hours after intubation.

In 9 of his 18 fatal cases death came in an
average of twenty-six hours after intubation, and
these deaths were by the writer attributed to this
aspiration oedema, or "aspiration pneumonia,"
as Dr. O'Dwyer calls it. A case in illustration
was given where the author desisted from intuba-
tion because the child was evidenth- dead. He
directed this patient, a little boy 4 years old, to be
laid back upon the bed, when noticing another
gasp he thought he would intubate anyway. He
did so as the child lay on his back upon the bed
and without the use of any gag whatever. Arti-
ficial respiration was then used and the child re-
suscitated. After half an hour the child drank
some milk, was bright, and the household was
filled with hope. However, as might be expected,
the child died in twelve hours. This counted as
one of his cases of " aspiration oedema."

Again the author introduced what he supposed
might be an important consideration, with refer-
ence to the remarkable fatality from pulmonary
complications, both after tracheotomy and intuba-
tion. After intubation the records thus far given
show 60 to 70 per cent, of the deaths to have oc-
curred from " extension to bronchi," etc. This
cannot otherwise be explained except that dam-
age had occurred before and at the time of opera-
tion, or else, as the writer suggested as possible,
after the operation, and because of the practical
abolition of the use of the lar\-nx. He wished
to ask that this latter point be investigated, and
that someone competent to give the answer would
state, ll7iat is the result of this substitution of an
iyiflexible metal tube for the delicately-organised
huma7i larynx, especially in extreme youth, a
period when most of these accidents occur? A
solution of this problem might lead to the use of
somewhat elastic or flexible tubes. While the
question of "aspiration oedema" might suggest
the use of the sphygmograph to determine the
need of an early operation, as well as after either
intubation or tracheotomy the substitution of con-
densed air for the inhalation of air at the ordinary
pressure. The use of the pneumatic cabinet may
here perhaps be most advantageously employed.
Judicious experimenting by those who have cab-
inets might result in good.

It was claimed that only in some new way of
management would this fearful mortality from
lung complications after intubation be greatly
lessened. The condition of sepsis does not ex-
plain it, nor does the entrance of food through
the tube.

Dr. D. N. R.\nkin, of Alleghany, Pa., read a
paper on the Effects of Natural Gas upon the Up-
per Air Passages. Natural gas was first used in
Pittsburgh as a fuel in 1883. The complaints
were loud and many that the heat that it produced
made the air too dr>' for breathing and produced
irritation of the throat and nose. Some ceased
to use it, others moistened the air with steam from

176

SOCIETY PROCEEDINGS.

[August 3,

kettles of hot water, etc. The dryness was not
imaginary-. It cracked furniture and joints in
woodwork — pianos and other expensive furniture
■was ruined by opening glued joints, etc., before
.■steam was used to moisten the air. It is of great
benefit for fuel and light in manufactories and
■dwellings on account of its cheapness. Before it
■was learned how to control it explosions occurred.
As now managed this rarely occurs. Natural gas
is not new. It is mentioned by the ancients,
"The Holy Fires of Baker." It was utilized in
Germany at Gollesgabe for illuminating purposes.
In Pittsburgh and vicinity there are now used
600,000,000 cubic ft. daily. The author gave a
■chemical analysis of the gas, which disclosed its
noxious properties when inhaled.

Patients usually complain first of dryness of
the nose and throat, followed by free discharge of
muco-purulent matter from these cavities ; after
which the drj'ness recurs, sometimes the irritation
extending to the larj-nx and producing consider-
able hoarseness. Examination with reflected light
shows considerable congestion in the nose and
phar>-nx. The extreme sensibility of these parts
is promptly relieved by 4 per cent, solutions of
cocaine, followed by the application of vaseline
to the nose and pharj'nx. At first gas pipes were
made of too porous metal and leaked. This has
now been remedied, and now those who have had
the gas removed from their dwellings are having
it restored.

Conclusion : Since the various improvements
in managing it have come into operation the gas
can be used without fear of suffocation or any
deleterious effects, such as result from inhaling
too dr>' atmosphere. Certainly it is not healthy
to breathe, but since it has been taught how to
use it, it is no longer breathed bj- those who use it.

Dr. George A. Rich.\rds, of New York, read
a paper: Empyema of the Frontal Sinuses. The
author reported a case of empyema of the frontal
sinuses due to obstruction of the infundibulum hy
polypi which had existed fifteen years. The em-
pyema had produced absorption of the lower wall
of the sinus and a small tumor had appeared at
the root of the nose about eight months before
patient consulted. Opening made into swelling
and tube passed through into nose, after about
twenty polypi were taken out. After thorough
•cleansing thrice daily for about a month, patient
recovered completely, sight improving at once
also a complete relief to a previously ven,- marked
aprosaxia and g^eat improvement in general
health, as well as in breathing and smell. Of
forty-eight cases collected from literature, only
fourteen cases were the result of injury, and but
seven the result of obstruction. Some cases occur
many years after injur}-. The majority occur
without known cause.

The symptoms are more or less tho.se of an or-
dinary coryza, together with a feeling of disten-

sion, exophthalmos, diplopia, failure of eyesight,
and the appearance of a tumor over the supercili-
arj- ridge or at the root of the nose. Hard at
first, this soon becomes soft and fluctuating. The
only treatment is to make an external opening
and an opening into nose through which a perfor-
ated rubber tube should be passed. Cleanliness
and free drainage are most important. Of twen-
ty-five cases so treated cure resulted in twenty-
three ; in two result was not stated ; while when
drainage into nose was neglected, the results were
not nearlj' so good. Death occurred in six cases ;
in four from secondary cerebral abscess, in another
from meningitis, and in the last from albuminuria.

Dr. a. B. Thrasher, of Cincinnati, read a
paper on Morbid Perforations of Nasal Septum.
The author reported sixteen cases of morbid per-
foration of septum narium, having special refer-
ence to the syphilitic theorj- of the origin of the
disease. Three of the cases occurred in syphilit-
ics, eleven where syphilis had not been present,
and two cases were doubtful. In the syphilitic
cases the vomer and at least one of the turbinates
was invariably attacked ; and pain was always
felt when this was the case. In the non-syphilitic
cases the perforation, as a rule, gave rise to no
symptoms ; at times seemed to have been caused
by picking the nose with finger-nail. There was
localized anaesthesia in the ulcerated area, the ap-
plication of the galvano-cauter}' producing no
pain. The treatment consisted, locally, in deter-
gents, caustics to the ulcerated area, and mild
ointments ; internal, in remedies addressed to the
underlj'ing dyscrasia.

Dr. Carl Seiler, of Philadelphia, read a pa-
per on Clinical Observations on some Cases of a
Peailiar Character, in which he describes the
symptoms of a disease not yet well known. He
had not seen Dr. W. C. Glasgow's paper read at
the Medical Congress at Washington last autumn
before the Larj-ngological Section, and therefore
confined his remarks to his own personal obser\-a-
tions.

The run of symptoms of cases obser\'ed by the
author are summed up as follows : i. Neuralgic
muscular pains, usually in the back and chest,
and often in the head, ears and limbs. 2. Ex-
treme debility. 3. Mucoid infiltration of the
submucous tissue and the formation of thin white
pseudo-membranous patches on the surface of the
mucous membrane. 4. Absence of febrile symp-
toms at first, and later high temperature and rel-
atively low rate of pulse. 5, Absence of albumen
in the urine and liability to heart failure. 6.
Gradual melting away of the pseudo- membranes
and the absence of any odor from them. 7. The
wide geographical distribution in this country and
the infectious, but not contagious, nature of the
disorder. S, and finally. The specific action of
benzoate of soda in relieving the symptoms
promptly.

1889-]

FOREIGN CORRESPONDENCE.

177

Dr. E. S. Shurley, of Detroit, Mich., read a
paper on The Hot Air Treatment of Phthisis. The
paper was for the purpose simply of reporting
progress in the use of the Weigert apparatus, and
suggesting certain indications for its future trial.
The author had used the apparatus in about
twenty patients, in about eight with that constan-
cy and exclusiveness that would serve as a test.

Case I. — Obliged to discontinue the treatment
from the pain experienced in the throat and chest
from the inhalations.

Case 2. — Administered three and four times a
day for fifteen minutes. Temperature 120° to
200° — the latter on three occasions only ; 130° to
190° on several. Immediate effects good ; left
hospital improi'cd.

being of a deep purple color and considerably
swollen.

Treatment consisted of ac. salicyl., which did
not prove effective. Internal laryngeal swelling
increased, embarrassing respiration. On Febru-
ary 29 a blister was applied to external larj-nx
and patient placed on iod, of potass., and by
March 6 had improved greatly in laryngeal sj'mp-
toms, but there still remained verj' little motion
of the right arytenoid and cord, and they were
both still very red.

FOREIGN CORRESPONDENCE.

Case

-Inhalations caused nausea and vom-

iting. Hectic fever decreased, gained strength
and flesh.

Case /, — Caused febrile movement, pain in
chest, breathlessness and nausea at 120°. Dis-
continued after ten days.

Case 5. — Larj-ngeal and pulmonarj- phthisis.
Administered for a week; could not bear it longer.

Case 6. — Advanced stage of phthisis. Admin-
istered three times a day for twenty-five minutes
at a time — could not bear it and it was omitted.

Case 7. — Effects good.

Case 8. — Obliged to discontinue after fourteen
days from loss of appetite, apparently resulting
from the administration of hot air.

The author had found it impossible to apply
the method of treatment for such a length of time
as reported to have been done in Germanj-.

Dr. W. K. Simpson, of New York, gave the
History of a Case of x4cute Rheumatic Laryngitis
of Go7iorrheeal Origin. The history is presented
on account of extreme rarity of the case — have
been unable to find references to similar case.
The patient was first seen on February 23, 1888,
at which time these notes were taken. Gave the
history of two previous attacks of gonorrhoea, has
iad present attack of gonorrhoea for last five
weeks. Three weeks ago began to have rheu-
matic pains and stiffness in both knees and hips.
Three days ago pain and swelling began in left
thumb and wrist, so that they now present the
typical swelling of acute rheumatic inflammation.
Laryngeal symptoms began three days ago, with
painful deglutition ; on following day there was
a painful swelling of lower external portion of
larj-nx. In the evening patient became ven,-
hoarse and breathing became verj' painful.

Februarj- 23, 1888. Examination of the throat
to-day revealed painful deglutition, pain on pres-
sure over right side of pharynx, ab.sence of cough.
Internallj' both arytenoids swollen and red, right
much in excess, it being somewhat cedematous,
and is, with the right vocal cord, immobile on
phonation. Whole of anterior portion of larynx
.more or less hyperaemic, the right vocal cord

LETTER FROM T.,OXr)OX.

(from oi'r owx correspondent.)

The Father Damien Memorial Meeting at the
Mansion House — Piaotoxin as an Antidote to
Morphine — Honors to Sir Andrew Clark — -The
Lord Mayor hiaug urates a Fund for the Pasteur
Institute — A Neiv Method of Disposing of the
Dead — A New First Field Dressing — The New
Commissioner in Lunacy — Consumption ca7i be
Transtnitted to Human Beitigs through Milk.

The first meeting of the committee for promot-
ing a memorial of Father Damien has been held
at Marlborough House, under the presidency of
i the Prince of Wales. The proposal is to erect a
monument to the deceased missionary- over his
grave at Molokai, to establish a leper ward in one
of the London hospitals, to endow one or two
traveling studentships for the special studj- of
leprosy, and finallj- to set on foot a full and ex-
haustive inquiry' into the whole question of
leprosy in India. It is calculated that there are
in the Indian Empire about 250,000 victims of
the loathsome .scourge, or about one-thousandth
part of the whole population, while in the British
Colonies it is infrequent, but it is said to be
spreading. The Prince of Wales mentioned one
startling instance of its presence in England :
"At this verj- moment," said he, "there is a
leper with his hands distinctly affected bj^ the dis-
ease, engaged at his business in one of the large
i London meat markets." Sir James Paget in a
I speech expressed the hope, that the designed
stimulus to trained investigation might lead
I ultimately to the abolition of leprosj-. At one
I time as he observed leprosy prevailed extensively
in England and in the west of Europe, and he
considered that its gradual elimination is after all
not an impossibility. At one time there were six
or eight hospitals for lepers in London. The
victims were scattered all over England, and there
were large numbers in France. Sir James
thought that the only way in which it could be
reached where it now prevailed was by scientific
inquiry, and by improved methods of treatment.

178

NEW INSTRUMENTS.

[August 3,

Looking back over the last fifty years, it certainly
might be said that more remarkable things had
been accomplished than would now be accomp-
lished if leprosy were abolished.

Picrotoxin is now recommended as the best
antidote to morphine. The effect of morphine is,
of course, to paralyze the action of the respiratory
centre ; picrotoxin on the contrarj-, when given in
small doses increases such action. Thus the two
drugs act in a directly opposite way. An over-
dose of morphine produces paralysis of the re-
spiratorj' organs, picrotoxin prevents such pa-
ralysis. Picrotoxin stimulates the vaso- constrictor
centre of the medulla, and thus counteracts the
diminution of the blood pressure due to an over-
dose of morphine. These two agents again have
an entirel}' opposite effect upon the cerebral
hemispheres. Experiments are being made as to
the use of the drug in the prevention of asphyxia
from chloroform.

The Duke of Cambridge has consented to pre-
sent to Sir Andrew Clark the senior consulting
physician of the London Hospital, his portrait by
the late Frank Holl, which was exhibited at the
Royal Academy exhibition last j'ear, and sub-
scribed for by the medical and surgical staff and
friends of the hospital. A replica of the paint-
ing will at the same time be presented to the Col-
lege of the London Hospital Medical School.

The Lord Mayor was so struck with the Pasteur
Institute which he visited while in Paris, that he
has called a meeting at the Mansion House to in-
augurate a fund for its benefit. The Prince of
Wales also paid a visit to the institute during his
recent stay in Paris, and was much interested in
all he saw. At the same time, as far as hydro-
phobia is concerned, many authorities on the sub-
ject are resolutelj' opposed to any Pasteur In-
stitute being established in England, contending
that by the strict use of the muzzle and a system
of quarantine with regard to all dogs imported
into Great Britain rabies can be effectually
stamped out, the insular position of the country
giving it an advantage in this respect not possessed
by Continental countries,

A physician whose name does not transpire,
has, it is stated, suggested a new method of dis-
posing of our dead, which to say the least, is
broadly original, even if it has poor opportunity
of becoming popular. In all seriousness the
following process is suggested . The doctor pro-
poses to deal with the deceased by means of
hydraulic pressure, and in a very short time to
reduce him to a cube of twelve inches, a solid
block of handsome material resembling veined
marble, tasteless, odorless and apparently im-
perishable. The doctor is stated to have on ex-
hibition a capital cross suitable for a lady's dress-
ing-room. It would at least be interesting to
know this gentleman's name, and to see the re-
sult of, say one experiment.

Anew "first field dressing" devised by Surgeon-
Major Bourke, of the Army Medical Staff, is
about to be generallj' adopted in the army. The
pad is about 5 inches by 3 '2 inches, and the
bandage about i '4 or i j4 yards in length, the
former being composed of layers of cotton-wool,
and the latter of soft cotton gauze. Both are
rendered antiseptic b}' being evenly impregnated
with double chloride of mercur>' and ammonium,
which for surgical purposes, has manj' advantages
as compared with sublimate. With each of these
pads is supplied a safety-pin and a little bag of
iodoform powder for ' ' dusting ' ' purposes.

The new Commissioner in Lunacj', Dr. Thos.
Clifford AUbutt, is one of the most distinguished
ph3'sicians in the whole of Yorkshire, and his en-
forced removal from Leeds is regretted by ever so
many people in that great manufacturing town.
Dr. Clifford Allbutt is a man of about 50, with
fair hair, and singularly light eyelashes. He re-
ceived his education, medical and general, at Cam-
bridge— -of which University he is an M.A., — St.
George's and Paris, and is F.R.S., F.S.A. He
has been consulting physician to various public
institutions in Leeds and the neighborhood, and
has enjo5'ed a ver}- large private practice, indeed,
it is said of not far off /^i 0,000 a year. As a
lunacy commissioner Dr. Allbutt will get onlj'
^1,500, but of course a man of his great scientific
attainments looks at the matter from the point of
view of Kudos as well as of Kerdos. Dr. Allbutt
has paid much attention to mental pathology.

Dr. Imlach, of Liverpool, who has given a
good deal of attention to the subject, has come to
the conclusion that consumption can be transmit-
ted from cows to human beings through milk.
His experiments prove that guinea pigs, rabbits
and monkeys fed on the milk of tuberculous cows
develop tubercular disease.

It maj- not be generally known that until the
sixteenth century alcohol was used only as medi-
cine. It was as a drug, and not as a beverage,
that it became known as aqua vita, from its great
restorative powers. In 1681 it was first intro-
duced as part of the food allowance of the British
Army in the Netherlands. G. O. M.

NEW INSTRUMENTS.

IMPROVED VAGINAL DEPRESSOR

SPECULUM.
BY HENRY O. MARCY, A.M., M.D., L.L.D.,

OF BOSTON.

The general adoption of irrigation during sur-
gical operations has materially modified the prac-
tice of most American gj'necologists in operative
measures upon the uterus and vagina ; the Sims'
speculum and semi-prone position often being
ver>' inconvenient.

1889.]

BOOK REVIEWS.

179

The patient upon the back, with the hips well
over the edge of the table, limbs held by the
Clevis' crotch, or some modification of it, fur-
nishes the most convenient position. The depres-
sor in more general use in the one known as the
Martin speculum, devised b}- Dr. A. Martin, of
Berlin. This has been found inconvenient and
objectionable, because the solid handle causes the
drip from the irrigator to flow over the hand and
.down the arm of the holder, and the breadth of
the blade is widest at the vulvar extremit3\ This
often produces overstrain of the vaginal outlet,
with frequent lesions, and also occupies valuable
space required for operative measures.

Dr. Marc}' has sought to overcome these objec-
tions in the instrument which he oilers to the
profession.

Because of its simplicity there is little need for
explanation. The vaginal portion is constructed
so as to cause a minimum of pressure upon the
vulvar outlet. It is irregularly broadened within,
so as to secure a firm hold upon the levator mus-
cular loop without slipping, and this allows of
depression without overstrain of the external
parts, and permits the foreshortening of the in-
strument to the minimum, scarcely more than one
inch in length.

When the uterus is of normal mobility the cer-
vix can be easily brought to the vulva. Bj' its
use the anterior vaginal wall and the uterus are
rendered much more accessible. The handle is
made hollow for the escape of the irrigating fluid
and roughened for a secure hold. The speculum
is well made and kept in stock by Messrs. Cod-
man & Shurtleif, of Boston, and Tiemann & Co.,
of New York.

NECROLOGY.

Francis M. Urquliart, M.I).

Francis M. Urquhart, Passed Assistant Sur-
geon U.S. Marine-Hospital Service, was born in
Southampton County, Va., December 3, 1857,
and died at Evansville, Indiana, February 14,
1889. Dr. Urquhart received his early education
in Hanover Academy, Hanover County, Va., and
subsequently entered the medical department of
the University of Virginia, from which he gradu-
ated in the spring of 1878. He pursued the study
of medicine one year in New York City under Dr.
John A. Hyeth, and there entered the Charity
Hospital of that city, where he remained two

years. In the spring of 188 1 he appeared before
the Board of Examiners of the Marine-Hospital
Service, which he passed successfully, and was
appointed to the Service as an assistant surgeon,
October 20, 1881. He was assigned to duty in
the Marine Hospital at New York, and served at
that station until April, 1882, when he was
transferred to St, L,ouis, Mo., where he remained
till January, 1885, except when upon temporary
details at other forts. In December, 1884, he was
promoted to the position of Passed Assistant Sur-
geon. During the summer of 1885, '86, '87 and
part of 1888, he was placed in charge of the
Quarantine Station at Cape Charles, Va. In Au-
gust, 1888, he was detailed for special duty in the
yellow fever districts of the South, and was suc-
cessively .stationed at Way Cross, Ga., Dupont,
Ga., and Live Oak, Fla. In November, 1888, he
was ordered to Evansville, Ind., on temporarj'
duty, and while under orders for Buffalo, N.Y.,
died at the former station, where he was taken
sick soon after his arrival. A low form of fever
of nearly two months' duration, followed by a re-
lapse and subsequent pneumonia, ended his
career. Dr. Urquhart took a high rank in the
Service, and enjoyed the confidence of his supe-
rior officers, whose orders he obeyed with alac-
rity. He married Lizzie M. French, of Boston,
Mass., in September last, while still on duty at
the South, and his bride was with him during his
long illness at Evansville, Ind., where he died.

BOOK REVIEWS.

The Radical Cure of Hernia. By Henry O.

Marcy, A.m., M.D., LL.D. The Physicians

Leisure Library. Detroit Mich.: George S.

Davis,

A highly interesting and well written volume
of 251 pages, illustrated by eighteen woodcuts.
In this work each form of hernia receives atten-
tion proportionate to its importance. Not only is
the subject taken up from an anatomical and
surgical point of view, but our obligations to our
predecessors are not ignored. The voluminous
history of this important subject is very ingeni-
ou.sly brought together, and so well told that we
trace its progress step by step, to the perfect
methods of to-day. The views and modes of op-
erating among the most eminent of modern sur-
geons both here and abroad are fully given. Im-
portant results have been brought about by simply
modifying the various steps in this operation so
that they are more consistent with the mainte-
nance of a perfect aseptic condition. There are
four steps to be considered :

I. The mode of incision. 2. The treatment of
the sack. 3. The application and choice of

i8o

MISCELLANY.

[August 3, 1889.

sutures. 4. The treatment of the wound. The
author advocates the open wound method. In
inguinal hernia he frees the sack, sutures it as
high up as possible with the double continuous
suture, and cuts away that portion below. All is
closed in with the buried animal suture, and kept
in a thoroughly aseptic condition. If this is
maintained no drainage has been found to be i
necessary. '

In studying the action of various forms of
animal sutures buried in the tissues, the author
has done no little to advance this branch of surg-
ery. As early as 1870 he had demonstrated ex-
perimentally that asepticallj' applied animal ,
sutures became so incorporated into the vital 1
structures as to be, in a large measure, replaced
by connective tissue. It was found that the ab-
sorption of catgut often progressed too rapidly,
and the parts were left too early without sufBcient
support, hence the tendon from many animals
was experimented with, and various modes of;
preparation tried. The author has used tendon '
from the tail of the kangaroo for the past seven 1
years, and finds it all that could be desired.

The reports of operators quoted give 779 cases
operated upon with only five deaths, and these '
are explained as being produced by causes other ]
than the operation.

MISCELLANY.

American Rhinological Association. — Owing to
the absence of a number of the Fellows of the American
Rhinological Association in Europe, and the Pacific
Coast, the annual meeting will be postponed until Octo-
ber 9, 10 and II, 1889, at which time it will be held at the
Palmer House, Chicago, 111.

Three Hundred New Readers. — The Journal has
added to its mail list, since July i, over 300 new names.
The weekly issue is now 5,200.

LETTERS RECEIVED.

Dr. A. D. Ruggles, New York; Dr. J. R. Shapard, Scott-
ville, Ky.; Dr. Ben H. McClellan, Xenia, O.; Hess Print-
ing Co., Omaha, Neb.; Dolliber Goodale & Co., Boston;
Dr. James Bullett, New York; Dr. Charles F. Fisher,
Clayton, N. J.; Dr. V. Mott Francis, Newport, R. I.; B.
Westerniann & Co., New York; Royal Medical and Chi-
rurgical Society, London, Eng. ; Dr. Henry O. Marcy,
Boston, Mass.; Dr. Archibald Church, Chicago; Dr. Wm.
B. Dewees, Salina, Kan.; Dr. G. L. Magruder, Washing-
ton; F. \. Davis, Philadelphia; P. Blakiston & Co.,
Philadelphia; Dr. L. T. Day, Westport, Conn.; Dr. R.
Harvey Reed, Mansfield, O. ; Dr. J. C. Hoag, Chicago;
The St. Paul Book & Stationery Co.; Dr. H. V. Swerin-
gen. Ft. Wayne, Ind.; Dr. Joseph Jones, New Orleans,
La.; Dr. William F. Waugh, Philadelphia; L Halden-
stein, New York; Dr. Thomas Opie, Baltimore, Md.; Dr.
L. T. Day, Westport, Conn., Fred. D. Van Horen, New
York; Oneita Spring Co., Utica, N. Y.; J. H. Bates, W.
P. Cleary, New York; Dr. L. F'. Billings, Barre, Mass.;
Obstetrical Society's Library, London, F'ng.; Dr. A. W.
Bower, Columbus, O.; Dr. H. W. Quirk, Cleveland, O.;
J. Walter Thompson, New York; Dr. J. C. Reeve, Day-
ton, O.; Rev. Wm. R. Scott, Sterling, Kan.; Dr. Maris

Gibson, Wilkesbarre, Pa.; Dr. E. H. Whitcomb, Green-
wich, N. Y. ; J. L. Hillmantel, Missoula, Mont.; Dr. L.
J. King, Visalia, Cal.; Dr. James Dudley- Morgan, Wash-
ington.

Official List of Changes in the Stations and Duties of
Officers Serving in the Medical Department, U. S.
Army, from July 20, iS8g, to July 26, jSSg.

By direction of the Secretary of War, Major William H.
Gardner, Surgeon, is detailed to attend the encamp-
ment of the National Guards of the District of the
Columbia, at Ft. Washington, Md., from July 22 to 29,
1889, for the purpose of giving instructions to the med-
ical officers and hospital corps in their respective du-
ties. Par. I, S. O. 164, A. G. O., July 18, 18S9.

By direction of the Secretary of War, Capt. Wm. R.
Steinmetz, Asst. Surgeon, now at Baltimore, Md., on
leave of absence on account of disability, will report in
person to the commanding officer of the Watertown Ar-
senal, Mass., for duty at that station, relieving Lieut.-
Col. James C. McKee, Surgeon. Par. 3, S. O. 166, A.
G. O., July 20, 1889.

Lieut.-Col. McKee, on being relieved at the Watertown
Arsenal, will repair to Philadelphia, Pa., and assume
the duties of attending surgeon and examiner of re-
cruits in that citv. Par. 3, S. O. 166, A. G. 0.,Julv
25, 1889.

Capt. Samuel Q. Robinson, Asst. Surgeon V. S. A., Ft.
Hamilton, N. Y. H.. is hereby granted leave of absence
for two weeks. Par. 11, S. 6. 165, Hdqrs. Div. of the
Atlantic, July 22, 1889.

Lieut. R. R. Ball, .\sst. Surgeon U. S. .A.rmy, leave of ab-
sence granted in S. O. 87, Dept. of the Missouri, July
9, is extended five days. Par. i, S. O. 167, A. G. O.,
July 22, 18S9.

PROMOTION,

Asst. Surgeon Charles B. Ewing, to he .\sst. Surgeon
with the rank of Captain, after five years' service, in
accordance with the .\ct of June 23, 18S4. July 5, 1S89.

By direction of the President, the State of Arkansas, em-
bracing Little Rock Barracks, is transferred to the De-
partment of the Missouri. General Orders No. 66,
Hdqrs. of the .\rmy, .\. G. O., July 19. 1S89.

Official List of Changes of Stations and Duties of Medi-
cal Officers of the U. S. Marine-Hospital Service.
Omitted from last Announconent.

Surgeon John Vansant, when relieved, to proceed to Mo-
bile, Ala. July II, 18S9.

P. A. Surgeon F. W. Mead, relieved from duty as acting
Chief Clerk and attending surgeon; ordered to St.
Louis, Mo., Julv II. 1 889.

P. A. Surgeon L. L. Williams, relieved from duty at Cape
Charles Quarantine Station; ordered to Baltimore, Md.
Julj- 10, 18S9.

Week Ending July 20, iSSg :

P. k. Surgeon P. C. Kalloch, granted leave of absence
for thirty days. July 15, 18S9.

Asst. Surgeon W. J. Pettus, when relieved, to proceed
to Marine Hospital, Boston, Mass., for duty. Julv
18, 1889.

Asst. Surgeon R. M. Woodward, granted leave of absence
for thirty days. July 15, 1889.

Asst. Surgeon G. T. Vaughan, relieved from duty at Bos-
ton, Mass.; ordered to Norfolk, Va. July 18, 1SS9.

Asst. Surgeon J. B. Stoncr. granted leave of absence for
twenty-five days. July 15, 1889.

Asst. Surgeon H. D. Geddings, relieved from duty at Bal-
timore, Md.; ordered to Kev West Quarantine Station.
Julv 18, iSSq.

Asst. Surgeon C. P. Wertenbaker, relieved from duty at
Norfolk; ordered to Galveston, Tex. July 18, 1S89.

J. T. Groenevclt, commissioned as .\sst. Surgeon July 14,
1889. Ordered to Gulf Quarantine Station for tempo-
rary duty. July 20, 1SS9.

/^/

THE

J ournal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.
PUBLISHED WEEKLY.

Vol. XIII.

CHICAGO, AUGUST lo, 1889.

No. 6.

ORIGINAL ARTICLES.

CONCUSSION OF THE SPINE IN ITS
MEDICO-LEGAL ASPECTS.

Read in the Section of Surgery and Anatomy at the Fortieth A n-

nual Meeting of the A merican Medical Association, held at

Neu'port,June 25, iSSf?.

BY HENRY HOLLINGSWORTH SMITH,
M.D., L.L.D.,

OF PHILADKLPHIA.

The legal liability of Capitalists and Corpora-
tions to be charged with claims for pecuniary-
damages in cases of injuries received by indi-
viduals through a claimed negligence, was estab-
lished by the English Parliament in the year 1846,
and is widely known as Lord Campbell's "Lia-
bility Act." Somewhat similar statutes were
subsequently enacted by the State Legislatures of
this countrv-, and this responsibility on the part
of carriers and employers is generally regarded as
wise and tending to the proper protection of life
and limb.

In Great Britain the "liabilitj' act" is the same
throughout the Kingdom, but in the United
States it varies somewhat in different States,
especially in the amount of damages that can be
claimed. In Michigan the limit of a claim is
fixed at $5,000 ; in New York it is $10,000; in
Mississippi it is such compensation as shall be
deemed fair and just in reference to the injury
sustained by the plaintiff. In Tennessee it in-
cludes mental and physical suffering, loss of time,
necessarj^ expenses of the deceased and damages
to the beneficiary, but in Pennsylvania, since i
the adoption of the new Constitution, there
is no limit. In one case, in Philadelphia, the loss
of a leg by a newsboy on a passenger railway
was assessed by a jur>' at $18,000 ; appealed to
the Supreme Court, a new trial was ordered and
a verdict for £20,000 given, and this verdict has
been paid. Another child, 8 years old, was
awarded $16,000 for injuries caused by tripping
over a stone left on the sidewalk by the City
Corporation, and very many other cases could be
cited.

So generally is this liability for injury caused
by negligence, admitted, that most corporations
or employers do not hesitate at a prompt settle-

ment of a just and reasonable claim, being influ-
enced thereto not only by a proper regard for the
suffering induced, but also as an acknowledg-
ment of " the Majesty of the Law," it being now
a well-settled principle "that they are liable for
past and future physical and mental suffering,
together with the loss of earning power where
the consequences are such as in the ordinar>'
course of nature may be reasonably expected to
ensue." '

It is, therefore, not unusual for conductors,
foremen, or other ser%^ants of corporations, to be
instructed in the event of injuries received, to do
all that is possible to ameliorate the sufferer's
condition. Many companies have also surgeons
regular^ employed to render immediate profes-
sional attendance.

A recent example of the disposition of a cor-
poration to promptly relieve suffering and settle
a just pecuniary demand for injuries received in
transit, is shown by the action of the Lehigh
Valley Railroad, of Pennsylvania, where, after
an accident to an excursion train at " Mud Run,"
in October 30, 1888, in which 63 persons were
killed and over 80 others wounded, the company
made a prompt and amicable settlement with
most of the claimants, at a cost of over $150,000,
though the Coroner's Jur\', after a rigorous exam-
ination of the case, failed to report anj- want of
care or proper vigilance on the part of those in
charge of the train.

Under the " liability law" a refusal to pay what
may be regarded as a doubtful or extravagant
demand, usually carries the claim into Court and
confides it to the judgment of a not over-intelli-
gent jur}-, who often appear to have an inate
prejudice against all corporations or capitalists.
In these cases the medical testimony as to the
nature and probable result of the injur\- claimed
to have been received, becomes often the turning
point on which a just award can be given. The
medical expert then, who correctly appreciates
his responsible position, should keep him-
self thoroughly abreast with the progress of
science and endeavor to exercise such judicial
power as will enable him to hold the scales of
justice so level that the preponderance of the
medical facts once established, may correctly in-

' Patterson. " Railway Accident Law, ' Philadelphia, iSS6.

l82

CONCUSSION OF THE SPINE.

[August io,

cline the balance to the right side and lead a j
jiirj' to a true and impartial verdict for that side
to which it properly turns.

As manj- corporations have surgeons regularly
engaged to serve them in these accidents, it is de-
sirable that the correct position of such experts
should be clearly defined, and the following judi-
cial opinion on the ' 'relation of scientific experts to
the administration of the law," has recently been
so well expressed by a Judge of the New York
Supreme Court^ (in regard to these duties and
relations), that I repeat them in a condensed form.
" In an action for damage," says Judge Willard
Bartlett, " arising from accidents on railroads, the
respective parties are often assisted by Surgeons,
who testify to the nature, extent and consequences ;
of the plaintiff's injurj-, and also often advise]
counsel as to the conduct of the surgical part of |
the case. A wise doctor should, however, take i
care not to act in both capacities. If he testify, [
he should not act as assistant counsel, and if he
acts as assistant counsel he should keep off the
witness stand, becau.se he will naturally become
prejudiced in favor of the party in whose service
he is acting, and the jury will regard such a wit-
ness as prejudiced and his testimony as that of a
partisan, thus materially detracting from the force
and effect of his evidence. The attitude of the
physician called as an expert, should be as nearly
as possible one of entire impartiality as between
the litigants," Judge Bartlett also says, " I have
every reason to believe that cases are not unknown
in which the plaintiffs counsel have said to a
phj'sician, ' I think my client's injuries are seri-
ous. Go and see him for me. If you find that
he is not seriously hurt, I shall not expect you to
charge me anything for making the examination,
but if you conclude that his injuries are incurable,
I will call you as a witness and pay you hand-
somely.' As this is manifestly incorrect, no such
proposition would be accepted by a really honor-
able professional man of high character.

Unfortunately for justice, the medical testi-
mony is often so conflicting that neither Judge
nor Jun,' can properly estimate it. This diversity
of opinion is sometimes due to the want of a
proper study of a case, or, the varied experience
and moral tone of the expert (and his views of
right and duty between man and man), as well as
to the fact that the science of medicine being
always progressive, there is no fixed point on
which an expert's opinion can be securely based,
and Pagf has well said,' " there must ever be dif-
ferences of opinion in matters so difficult as the
investigation of disea.se, but it is wholly possible
to be impartial," whilst Ericliscn says : (2)

'Jiidgf IVillaid Haillfll at the 6ist Meeting; of the New York
Society of Medical Jurisprudence and State Medicine. New York.
March 14th. (From the Philadelphia Kvening Telegraph, March
15. i8f9 )

15. '0^9 '

^ Injuries of the Spine and Spinal Cord without Apparent Me-
chanical I^e.sion and Nervous Shock, hy Herbert li''. fuge. Second
Hdition. London. iHS.s.

Conflicts of opinion on certain points are cred-
itable to the independence of thought and the
individual self-reliance that characterizes profes-
sional opinion."

The progress of microscopical, physiological or
pathological studies of tissues, especially of the
nervous system and the regional localization of
the functions of the brain and Spinal Cord, which
are peculiarly liable either directly or indirectl3'
to be affected by these injuries, also tends to show
that the professional opinions held twenty years
since are now in many points incorrect and unre-
liable and those of Mr. Erichsen on " Railway
Injuries and Concussion of the Spine," once often
quoted, are mistrusted by many, who deny the
correctness of his terms and object to his combi-
nation of different injuries under the one title of
"Concussion of the Spine."

As ever}' period of Court in our large cities
presents one or more claims for personal injury,
in which the results of concussion of the spine
are often presented in an exaggerated form by
Counsel (in what has been well designated as
"Litigation Symptoms") to cover or sustain
claims that could not otherwise be established as
of sufficient magnitude to justify punative or ex-
emplary damages, it becomes important to settle,
if possible, whether the so-called " Concussion of
the Spine," "Railway Spine," or "Railway
Brain," can exist, and if so, whether the so-called
' ' Railway Spine ' ' presents a special train of
symptoms differing in any point from those in-
duced by other forces than railway collision, and
although many local societies and individuals
have for years investigated these cases and their
results, I desire now to present the question for
the discussion of this Section in order to elicit a
wide expression of the sentiments of those who
here represent the surgical skill of the whole
United States.

It is unfortunate that the consideration of the
subject of "Concussion of the Spine" should be
so much handicapped by the legal aspect given to
it in the cases presented in claims in court ; these
cases frequently offering less marked symptoms
than those met with in hospitals or private life
where there is no prospect of the sufferer receiv-
ing an award from a jur}-. Formerly such claims
could not be presented by employes and suits by
them were rare. Thus prior to 1871 the German
railroads were not liable for injury to their em-
ployes and the latter, being anxious to keep their
places and gain their living, managed by an en-
ergetic effort of the will, to overcome and control
their nervous condition ; but as soon as the laws
of Germany made corporations liable to their
emploj'es, the number of suits instituted from 187 1
to 1876, on one railroad only, was at least nine
times larger than before. Thus in fifteen derail-
ments before 1871 there were but two injuries
leading to claims for disability, whilst subse-

1889.]

CONCUSSION OF THE SPINE.

183

quentl}' to 187 1 seven derailments occasioned
eighteen lawsuits.*

In all suits for damages for concussion of the
spine it should be recollected that fraud on the
part of a claimant is quite a common item in the
legal investigation of this injury, and thus Page
reports' " 234 cases, in a large majority of which
there was either fraud or an exaggerated claim, as
proved by subsequent histors'. Hodges reports,'
that "in 21 cases where so-called symptoms of con-
cussion of the spine were alleged to be present and
were under his personal care, 10 are believed to
have been proved deceptions ; whilst in 6 a diag-
nosis as to deception was doubtful. Of 28 similar
cases reported by Riglcr, 7 were found to be sim-
ulated and in 13 the diagnosis in regard to fraud
was doubtful. Of these 49 cases, 36, or three-
fourths of the whole number, were really or
probably deceptions." Hodges also cites' the
following cases illustrative of fraudulent claims
and unjust awards by juries.

" In 1872 the Metropolitan Railroad, of Boston,
Mass., W'as mulcted bj- a jury in a sum of $10,000
in the case of a man whose detailed symptoms
satisfied them that he was utterly enfeebled in
body and wholly unable to earn his own living.
At the close of the trial the plaintiff celebrated
his victors' by becoming uproariously drunk, and
it required the united strengh of three policemen
to take him to the Station House. In another
suit in which there was a claim of impotency re-
sulting from the injury, the jur}- expressed their
sympathj- by a verdict of $18,000, yet not long
afterwards the man was convicted of bastardy.''

Judge ]\'ilson, of the Court of Common Pleas,
Philadelphia, also says,* " I have in my mind a
case where a very badly injured person was substi-
tutcd at the trial and large damages obtained,
whilst the real plaintiff was not injured at all."

The following case in my own practice illus-
trates an exaggerated claim and the liability of a
surgeon to be deceived, either by a malingerer or
hysterical man, when he places faith in the sub-
jective symptoms presented by the claimant and
apparently seconded b}' circumstances.

Case. — W., age 35 years, married, in full health
at the time of the accident, claimed injuries from
colliding trains at Havre de Grace, P. \V.& B. road,
on June 21, 1887. On Sept. 14, 18S7, about three
months subsequently, he exhibited three scars,
one deep in the forehead and left eye-brow and a
deep scar on the left of the upper lip, which he
stated were the result of blows. He also exhibited
a superficial scar from a wound on the inside of
the right knee, not penetrating the joint ; the
patella bursa of this knee was also swollen, and
he claimed to have been struck in the back, re-

iR.M. Hodi^f^. M.D., Boston Medical and Surgical Journal.
April 14th to 21st. l8.'^I, page 363.
>0p. cilat. Appendix, p. 296.
'Op. citat , p. 353.
7 Op. citat., p. 364.
"Philadelphia Dailv Times. June 7, 18S9.

ceiving a dark bruise that extended from the top
of the shoulder to near the right hip. Of this
bruise there was, on September 14th, no evidence,
but there was apparent uer\-ous disturbance, his
right arm seeming to be paralyzed in motion and
sensation, though his grip was fair. His memon,\
he said, was enfeebled, and he denied knowing
what he had eaten for breakfast on the day of my
examination. He also reported having been in-
sensible for nearly four hours after the blow ; that
he was taken by train to Washington, D. C, and
treated there ; but that subsequently he was well
enough to travel to Maine to escape the heat of
the summer, and was improved by the trip. After
full consultation with his family phj-sician (Dr.
Mecray, of Camden, N. J.), I reported to the rail-
road company that he had received the above in-
juries, but that the permanent disability claimed
was not sustained by the evidence, as he was then
apparently recovering. This opinion not being
satisfactory to the plaintiff's lawj-er, I was again
requested to make a survey and report, on Sep-
tember 22, 1887. After a second examination
and consultation with Dr. Mecraj-, I reported a
slight improvement in the power and sensation of
his limbs, as he now walked downstairs to his
parlor and walked there with slight assistance,
dragging his right foot a little and with his right
arm drooping. His mind was also clear and he
recalled events during his stay in Washington,
D. C. I therefore gave an opinion, renewing my
former statement, and mentioned the benefit ap-
parent from his physician's treatment : that the
patient complained of the tediousness of his con-
finement and was anxious to return to work, and
that his doing so would probabh' advance his re-
cover}-.

Two months after this (November 11, 1S87),
Dr. Mecraj' wrote me :

' ' You will remember on your second visit to Mr.
W. we were both inclined to give a favorable prog-
nosis, as he was then able to walk about the house,
to take moderate exercise, and was free from suf-
fering, except from neuralgia of the left side of
his head. Since then there has been a marked
increase in the unfavorable symptoms." (The
settlement of his extravagant claim for damages,
$15,000, was now becoming doubtful, the claim
being for permanent disability.) " The paralysis
of the right side," said Dr. Mecray, " has much
increased, the right arm is entirely helpless, with
the exception of a slight grip of the hand. The
power of the right leg is totall}- gone, and there
are no reflexes whatever. The urine dribbles from
the bladder, the bowels are constipated, though
under his control ; vision in the left eye and hear-
ing in the left ear are now much impaired ; in
fact I look upon his case as one of progressive
and permanent paralysis,' the result of pressure
upon his spinal cord, possibly a breaking down
of some of its tissues. His memory-, I think, is

1 84

CONCUSSION OF THE SPINE.

[August io,

slightly improved. He is confined to his bed
and I fear will end his days there. Dr. D. Hayes
Agnew, of Philadelphia, has seen him with me
and concurs in my opinion. If you have any
suggestions I will be pleased to hear from you."
[Signed, A. M. Mecray.]

On November 12, 1887, I again visited Mr.W.,
and had a third consultation with his attending
physician, reporting to the company "that since
my former visit from some unexplained cause Mr.
W. had greatly deteriorated in health. For some
weeks he reported himself unable to leave his bed
for any purpose and is now apparently suffering,
as his physician states, from ' ' progressive paral-
ysis." He has no motion in either arm, except
in his fingers, nor is there motion in the lower
right limb. Sensation on the right side is nearly
destroyed, he giving no shrinking from the punc-
ture of the skin by a pin thrust in till it brought
blood. The left limbs are sensitive. His bladder
is partially paralyzed ; his urine dribbles from
him, and he uses a bed-pan to evacuate his bowels,
being unable to rise. He is very tremulous and
nervous, with depressed circulation and more
mental aberration." With this report I forwarded
to the company the suggestion of delay in the
settlement of the claim as the patient's condition,
though then unfavorable, might be improved by
time. Whilst giving much weight to the opinion
of his physician, who saw him daily, I was yet un-
able satisfactorily to account for the deterioration
in his condition, the respectability of his domes-
tic surroundings and his own standing precluding
the idea of malingering. The possibility of hys-
teria, as claimed by Charcot in such cases did not
occur to me at this time. With this evidence
from his medical attendants, his claim was abated
and compromised by the company on January 19,
1888, for $8,500. Six months subsequent to this,
being doubtful of the result of his case, and de-
sirous of satisfying myself of his ultimate condi-
tion, I wrote to Dr. Mecray asking his report to
date, "for the cause of science, ' and on the nth
day of April, 1889, was informed by him that on
i/ie dav after the payment of the claim Mr.W. arose
from his bed, travelled to Washington, and in a
a few weeks was able to attend to his usual avo-
cations. Was this a case of successful malinger-
ing, or was it paralysis from hysteria ? It cer-
tainly was not, as supposed by the surgeons,
"progressive paralysis;" though closely resem-
bling it.

Admitting the liability of a surgeon to be
misled in his Diagnosis and Prognosis of cases
claiming to be the result of spinal injuries, it may
be asked, ist. Can any force be .so applied as to
produce a concu.ssion of the spinal cord ? 2d.
How are the normal functions of the cord dis-
turbed by such injury? 3d. What pathological
changes in the cord result from its concussion ?

I, Can any force be so applied as to produce

concussion of the spinal cord and its nerves?
Concussion of the spinal cord from any violence
sufficient to disturb its functions, whether by falls,
blows on the back, or shaking and collision or de-
railment of cars, must be admitted as possible, as
it is now demonstrated by post-mortem examina-
tion ; but the violence must be greater than that
sometimes created in coupling a locomotive to a
train, claims for which I have frequently known
to be made.

2. How are the normal functions of the cord
disturbed b}' such injuries? Disturbance of the
normal functions of the cord, or the symptoms of
its concussion, can be recognized by evidences in-
dicating a modification of normal cessation or
motion in varied degrees as shown through the
peripheral nerves. H. Fischer has recently sug-
gested that the condition known to surgeons as
" slioek" is a traumatic reflex paralysis of the
vascular nerves, the "concussion of the brain '^
being simply a shock localized in the brain, a
traumatic reflex paralysis of the cerebral vessels,
and f '. Sr/zc/c applies this view directly to "concus-
sion of the spinal cord." Erb, however, regards
the symptoms of concussion of the cord as due to
"molecular disturbance, and thinks this is the
chief element in its concussion." ''

Reference to the normal action of the cord best
illustrates these symptoms.

According to Erb^" ' ' all impressions made in
any way on the peripheral ner\'es are conducted
to the posterior or anterior roots of the spinal
nerves and pass thence into the lateral columns of
the cord and thence to the brain, as touch, tem-
perature, tickling, etc. The sensation of pain is
conducted exclusively by the gray substance of
the cord. The sensory impressions decussate in
the cord and medulla oblongata and voluntary
movements pass from the brain to the cord,
through the decussation at the pyramids, medulla
oblongata and pons varolii."

The seat of the coordination of movement is not
.settled, but is supposed to lie only in the brain,
the cord only transmitting the coordinate impulse
to the muscles.

The centre of vaso-motor innervation lies in the
cord and medulla, and Charcot says, " the nutri-
tion of the peripheral ner\-es, muscles, bones,
joints, skin, hair, nails, etc., is dependent on the
action of the spinal cord," and of course these
are impaired by its injury.

The disturbance of the function of the cord by
injury or disease will, therefore, be noted (a) in
disturbance of the normal sensibility, as anaesthe-
sia, hyperiesthesia, paretsthesia ; or abnormal sen-
sations, as pain, either lancinating or neuralgic;
lyb) in disturbance of motility as shown in weak-
ness or paralysis, or ataxia ; or by increased mo-

*) Volkmati's Sammlung KUnische Vorlrager, Nos. lo and 27, as
quoted bv Hrb.

" ' Erh. Diseases of the Spinal Cord, p. 352, and from this mon-
ograph much that I liave stated is condensed.

1889.]

CONCUSSION OF THE SPINE.

185

tility, as in spasms or twitching; (<:) vaso-motor ! eight cases in the Moscow Military Hospital."
disturbance will be shown, in hyperaemia, in- ' The correctness of the opinion that concussion
creased redness with elevation of temperature and of the spine is common and creates special symp-
modified sensation, as in the old " rubor, dolor, i toms, has also been doubted by others; thus
calor " of inflammation, accompanied often by I j^ra/wwr// says : '* " Whilst I am not prepared to
modified nutrition of the tissue affected. i deny the occurrence of simple concussion of the

3. What pathological changes in the cord are spine, I am disposed to doubt whether organic
found as due to its injury or disease? Pathological disease can or does result from it. Indeed, every-

changes may be noted first, in the disordered action
of the blood-vessels concerned in the nutrition of
the membranes and of the cord as {a), congestion
or hyperasmia ; haemorrhages or effused blood ;
inflammation of the membranes or of the compo-
nent cells of the spinal cord ; (i), in anaemia ; or

thing seems to show that when disease of the cord
results from external violence, the disturbance of
its functions depends, from the first, on definite
and distinct alterations of structure ; and there is
good reason for supposing, that undoubted and
severe disturbance of the spinal function rarefy

we may have myelitis followed by softening or I results from violence ; the ordinary type of chron
sclerosis; or (r), there may be changes due to ic disease of the spinal cord verj- rarely following
malignant diseases or tumors, omitting all refer- railway concussion. Nothing in the whole range
ence to changes from mechanical action, as of inquiry stands out more prominentlj' than the
wounds, fractures, or luxations of the bones form- fact that the lesions which become the subject of
ing the spinal canal. medico-legal inquirj% are met with only in a fe7a

The disturbed function of a .spinal cord may, isolated cases."
however, also be " due to a diseased or neuropath- Page says,'° " In fact, serious and undoubted
ic disposition, either inherited or acquired, as by derangement of the functions of the spinal cord
sexual excesses, which are common ; exposure to \ as the result of simple concussion of the spine, is
cold and wet ; intoxication ; syphilis ; excessive ' probably rare ; whilst cases in which the symp-
exertion and overtaxed muscle ; acute diseases, toms of spinal shock do not appear for weeks or
as the exanthemata; fevers and pneumonia," so months after an accident, are twrct'd/n^fy rare."
that in studying the results claimed as due to a He also remarks, " that there is no evidence that
concussion of the spine from injury, and especial- the victims of raihvaj' collisions, numbering thou-
ly in litigation cases for damages, too much care sands, have afforded a larger proportion of the
cannot be exercised in obtaining a full and correct degenerative conditions of the cord which have
histor)' of the claimant before the accident and in for years engaged the searching attention of pa-
a careful analysis of the subjective sj'mptoms, so thologists, than those members of the community
as to prove that the injury did not create them. . who have not suffered the same influences. There

If the disturbance is functional \i can be cured and
there may be no permanent disability. When a
claimant is impecunious and seeks to repair his
fortunes by a demand on a corporation or capi-
talist, the expert should carefully eliminate all
symptoms not evidently free from the disorders
of the spinal cord due to preexisting diseased I
conditions, or show to what extent the accident j
was connected with them. '

is no evidence that they have." Bramwell^" says,
" I think the chronic diseases of the cord claimed
to be developed by railway collisions are infin-
nitel}' more rare than has hitherto been supposed. ' '
Reynolds describes" "cases in which a patient
has no intention to deceive, but really believes
that he is the victim of serious organic disease.
He is usually of a highly nervous temperament
and often verj' active, mentally. His fixed belief

As Neurasthenia or functional disorder of the induces functional disturbances, as twitching, mus-
cord can produce all the symptoms often ascribed cular pain, excitable action of the heart, palpita-
to violence, may we not doubt the correctness of tion, exhaustion after slight exercise, and he be-
Erichsen'sopinion'Mn ascribing such symptoms to comes impressed with the idea that he is unable
"concussion of the spine." Such doubts are daily to do anything ; that he is paralyzed and that he
becoming more numerous, and the varied nervous cannot sleep, awaking unrefreshed." Such cases
symptoms alluded to by him are assigned bj' more I have often seen,
modern authorities to other causes. Thus Char-
cot says;'' "The obstinate symptoms resulting
from railway injuries are hysteria (or hysterical)
and nothing else," and hysteria, according to Dr.
Ozeretokofski, of Moscow, "is by no means an
exceptional occurrence in men, presenting the
same diversities in them that it does among wo-
men;" he having studied no less than thirty-

'1 On the Concussion of the Spine, Nervous Shock, etc. By John

c Erichsen. Revised Edition. New York, 1886.

'2 L^9ons sur les maladies du systeme nerveux, par Charcot.

Reynolds' opinion and my own corresponds
with that of Charcot and also of Grasset, who
has described such cases" "as hystero- traumatism
or nervous affections sometimes resulting from
wounds." Knapp says,'' "Whether there is a

'3 The Lancet, February 16, 18S9, as quoted in N. Y. Med. Record,
May 4, 1S89, p. 504.

14 Bramwell on Injuries of the Spinal Cord, p. 305, 12, 13, 19.
'5 Op. citat. p. 107.

16 Op. citat.

17 Quoted in Bramwell.

'3 L^^ons sur rHystero-trauraatisme par Grasset. Paris, 18S9.
^9 Nervous Aflfections following Injury. By Philip Coombs
Knapp, p. 5. Boston, 18S8.

i86

CONCUSSION OF THE SPINE.

[August io,

true concussion of the spinal cord is still a matter
of doubt. I mean a paraplegia following injur}',
where the cord has sustained no coarse mechani-
cal lesion, where molecular changes in its finer
nerve elements have occurred, giving rise to im-
mediate and complete functional paralysis."

Although this evidence shows doubts as to the ,
results often claimed as those of spinal concus-
sion, it has been recentlj- demonstrated that the
spinal cord maj' be occasionally so shaken as to ul-
timately induce molecular changes in its structure ;
without any injur>- to the canal, this being proved
by post-mortem examination and the investiga- 1
tion of the minute structure of the cord under
coloring, hardening and microscopical sections ;
but such cases are certainly ver\' rare.

As muscular nutrition is dependent on a proper
nerve supplj', its deficiency will indicate such
changes in the cord as atrophy, softening, etc.,
and Gower in his recent work says,=" " Any de-
struction of the nerve cells will also cause degen-
eration of the motor fibres proceeding from those
cells, with wasting of the muscles to which these
motor fibres proceed, ' ' Hence, injury to the spinal
cord should always be indicated by muscular atro-
phj- in a more or less marked degree, and when
no change is noted in the nutrition of the mus-
cles, doubt maj- well exist in the mind of the ex-
pert as to there having been any concussion of
the spinal cord.

A demonstration of the muscular development
and power of a claimant may then well be made
to a jun,', in explanation of the condition of the
plaintifi"'s nerves claimed to be impaired by the
concussion. Gower also states that " Visceral
control especially of the bladder and rectum
(though the latter is sometimes under the imme-
diate control of the branches of the sympathetic
nerve), is also related to centres in the spinal
cord, and although the action of the bladder and
rectum can to some extent be controlled by the
will of the patient, yet the latter cannot control
the reflex processes when the volitional path in
the cord is iuternipted above the lumbar centre,"

When the damage to the cord also involves the
sensor}' tract, the claimant maj' be unconscious of
the state of his bladder and the urine will dribble
away. Pain in the spine, which is often spoken
of b}' a patient, is no evidence of concussion of
the cord, as it is occasionally present in organic
disease of the cord, and more frequently in cases
of disease of the meninges or bones.

Page regards this pain in the back, .so often
claimed as a symptom of concussion of the cord,
as being due to the strain of the muscles or liga-
ments of the spinal articulations, and not necessa-
rily indicative of cord injury. Go-wer S2,ys "soft-
ening of the cord is common ; derangement of its
functions few and rare. A severe concussion of

» Manual of the Diseases of the Nen'ous System. By W. R.
Gower M D Americaa Edition. Philadelphia. iSSy, p. \yifl supia. 1

the cord may cause instant and grave damage
usually by haemorrhage, or it maj' cause no im-
mediate efi"ect and the symptoms appear at the
end of a few days and progress rapidly or slowly."
It is therefore apparent that in such cases, symp-
toms of injury to the cord should be found soon
after the accident and not (as is sometimes claimed
by lawj'ers prosecuting a claim) several months
after the occurrence.

Hodges states : "It is characteristic of concus-
sion of the spinal cord, that its phenomena are
immediate though the recognition of them may
not be equally prompt."

The development of an injury from spinal con-
cussion should therefore be speciallj- studied in
reference to the lime after the accident when the
claimant first begins to complain. This time
should be a few hours or days after the injury,
and not weeks subsequently, when his mind, by
dwelling on the accident and being posted as to-
the symptoms of successful awards made in other
claims, has induced that emotional, hysterical or
decidedly fraudulent condition of the body and
mind which constitutes malingering.

POST-MORTEM EX.4.MINATIONS IN CONCUSSION OF-
THE SPINE.

The following cases illustrate the pathological
conditions noted in well developed concussions of
the spine, and prove that such an injury though
rare, is possible :

In the Catiadian J/ediea/ atid Surgical Journal
for Oct., 1884, p. 156, Dr. J. Campbell, of Seaforth,
Ontario, states, "That serious and even fatal ef-
fects arising from injuries of the spinal cord even
when it has not received any direct injury, is
proved by a case reported by Dr. Edmunds in the
current number (October, 1884) of the journal
"Brain," where a soldier struck in the back by
a bullet which entered three inches from the .spine,
immediately fell, was carried off" the field, and
was found to have lost complete control over both
of his lower extremities, with paralysis of the
bladder and rectum. Cystitis and a bed-sore over
the sacrum supervened and he died five months
after the injury. The autopsy showed that there
was no fracture of the vertebrje ; that the theca
vertebralis was intact : but the spinal cord was
found much atrophied and softened about the
level of the wound. On hardening the cord in
Miiller's fluid, universal myelitis was noted, with
softening for aliout two inches opposite the wound;
this gradually pas.sed downwards into sclerosis of
the lateral and anterior pyramidal tracts and up-
wards with sclerosis of the posterior median col-
umns. There was no indication of haemorrhage,
either internally or externally in the substance of
the cord, and its surface was uninjured.""'

A marked illustration of a similar pathological
condition showing that degenerative changes in
the cord do sometimes, though rarely, follow con-

1889.]

CONCUSSION OF THE SPINE.

187

cussion, has been kindly furnished me by my friend
Dr. Arthur V. Meigs, of Philadelphia, one of the
Attending Physicians of the Pennsylvania Hos-
pital. As the details of the case, with its micros-
copical illustrations, have not yet been published
by Dr. Meigs, I give his account of it from a let-
ter recently sent me ;■"

A sailor, 35 years of age, was admitted into the
Surgical Wards of the Pennsylvania Hospital
August 20, 1888, and died September 15 of the
same year.

History. — During a storm ten days before his
admission to the Hospital, he was struck by a
wave and dashed against the bulwarks, striking
the back of his head and neck against the rail.
On being picked up it was at o7ice found that he
had lost all sensation of power and motion from
the clavicles downwards, and that he had reten-
tion of urine. When admitted to the Pennsylva-
nia Hospital (ten days after the accident) he had
a large bed-sore on his back. His temperature
varied from 100° to 1031!°. Examination of his
urine showed nothing abnormal, and there was
no violence or signs of fracture or luxation of the
vertebrae. He was treated on a water-bed ; a
poultice was applied to his chest becau.se sonor-
ous rales were heard on examination of his lungs,
and iodide of potash was administered. The
rales increased in his chest until the lungs were
full and he became unable to expel the secretion;
abdominal tympany supervened and he became
comatose, dying apparently of heart failure. The
autops)- showed that there was neither luxation
nor fracture of the spine, and though the spinal
cord was carefully examined at various points by
the unaided eye, no sign of its diseased condi-
tion was noticed. The cord was then placed in
Miiller's liquid^' for hardening and microscopical
examination. After having been thus preserved
in the fluid for a few weeks, the gross evidences
of disease became very manifest and the histolog-
ical appearances still more so ; the lower part of
the cervical swelling being almost disintegrated,
there being at this point an almost complete trans-
verse myelitis, the greater part of the tissue con-
sisting of the so-called granule-cells with swollen
and extended fibres ; corpora amylacea and large
nucleated cells that stained very red with carmine;
whilst there was much space apparently empty,
which had been probably filled with albuminoid
material or liquid, for if this had not been the
case the ti.ssue would have collapsed instead of
hardening in Miiller's fluid. Above this region
there was marked secondary' degeneration, the
section being taken only a short distance above
the myelitis, though this was general in a slight

2' I am indebted to Dr. Campbell for a written account of this
as I did not have access to the printed report in the Journal. The
report was made to the Medical Association of Ontario and printed
in their Transactions.

-■: MS. dated April 26. 1889.

-1 Miiller's liquid consists of 2 to 2.5 parts of potassium bi-cliro-
mate, i part of sodium sulphate, and 100 parts of water.

degree throughout this portion of the cord. But
in a part of the posterior columns, it amounted to
a complete destruction of the nerve fibres. Below
the region of the myelitis there was descending
' degeneration of the lateral pyramidal tracts, this
extending downwards into the lumbar region.
These areas of degeneration were very evident to
the naked eye after the cord had been in Miiller's
fluid, the degenerated part of the white substance
of the cord having taken a yellow color, exactly
similar in shade to that taken by the gray matter,
while the portions of the white substance that
j remained healthy were of a greenish hue." My
i examination of some of the sections fully confirm-
ed Dr. Meigs' description of the pathological
changes.

That diseased molecular changes in the struc-
ture of the spinal cord have been occasionally seen
without apparent mechanical injury, is shown in
the following case, reported"' by Dr, Wm. Hunt,
of Philadelphia, "where a gentleman who traveled
verj- frequently in railroad-cars, but never received
any injuries as the cause of his disease, began to
complain of pain in the posterior root of the neck.
Paralysis, at first of the upper and subsequently
of the lower extremities, was developed, and
within a year he died, and the autopsy revealed
spinal meningitis, with softening and destruction
of the cord to the extent of 2 Ji inches in its bra-
chial enlargement. As there was no other cause
known, it seems as if 2'j inches of the spinal
cord had been softened and atrophied without
any mechanical cause;" yet if this man had re-
ceived even a slight jar and presented such symp-
toms, his autopsy might have indicated "Concus-
sion of the Spinal Cord." There are some persons
who believe it possible to impair the functions of
the cord, and even induce paralysis, from the jars
created in the spine by constant travel ; but if
this were true there ought to be very many in-
stances of it found in commercial travellers, none
of whom are known to thus suffer. Nor is it
true of such men as engine drivers on express
trains, who are more exposed to jars on a loco-
motive than would be the case in a passenger car,
and I am assured by an experienced General
Superintendent of one of our largest railroads,
that engine drivers do not show any evidence of
concussion of the spinal cord after years of service
on express trains. Constant travel as the cause
of spinal degeneration is, therefore, not proven.

CONCLUSIONS.

I. Concussion of the spinal cord is no longer a
matter of doubt, but may sometime occur as the
result of various forms of violence, their being
nothing peculiar in the application of the force to
the bod)% as the result of derailment or collision
of railroad trains.

-■»" System of Medicine," by Pepper. Vol. 5, page 915, Phila-
delphia, 1S86.

i88

CONCUSSION OF THE SPINE.

[August io,

2. The pathological changes noted in the molec-
ular structure of the cord as the result of shak-
ing, jarring, or so-called concussion of the cord,
when attended bj- paralytic sj-mptoms, may be
due to a haemorrhagic effusion, or be shown
post-mortem, in softening and localized or limited
atrophy. In cases due to haemorrhage, the symp-
toms may be improved by judicious treatment,
and permanent disability prevented.

3. The possibilit}' of preexisting neurasthenia
or hj-steria or fraud on the part of a claimant,
should be carefulh- noted in forming a diagnosis
in these cases.

4. As the question of permanent disability
justifying exemplarj' damages is frequently raised
in claims of the kind alluded to, it should be
recollected in forming a progjiosis that numerous
cases are reported of recoverj^ or marked improve-
ment in a few weeks, and one in three years even,
after the occurrence of paralysis."

5. No physician should go into court and
swear that a plaintiff has had a concussion of the
spinal cord, or of its ner\'es, unless he has proved
the disturbance of the normal functions of the
cord, as shown in sensation or motion or both,
and that the symptoms appeared soon after the
injury.

THE MEDICO-LEGAL ASPECT OF CON-
CUSSION OF THE SPINE.

Read in the Section of Snrgety and Anatomy , at the Fortieth An-
nual Meeting of the American .\fedical A ssociation , June 25, t88^.

BY HERBERT JUDD, M.D.,

OF GALESBURG, ILL.

The facts stated in this paper are drawn solel}'
from vay own experience as a surgeon — being
cases resulting from or suggested to the patient
by accidents ; cases in which all objective signs
of injury, if any ever existed, had passed away ;
cases in which the question of supposed or al-
leged concussion of the spine were under observa-
tion from a medico-legal aspect ; cases in which
compensation for personal injury was sought. In
bringing this paper to 3-our notice I do so with a
feeling somewhat of duty. It is plainlj' evident
to all thinking, practical surgeons that the ques-
tion of the concussion of the spinal cord, if such
a disease can exist, has become a matter of busi-
ness interest — a business transaction in which the
extent of the disea.se or injury is to be determined
in the currency of the country. I say this, be-
cause of my experience during the last twenty
years, I have found but two cases of alleged con-
cussion of the spinal cord, except those resulting

-.'; Injuries to the Spine and Spinal Cord, by y/<ri*f>y (/'. fhige,
F.R.C.S. Second Edition. London, 18.S5, p. 20.^, who says : "Happily
the record of cases which we have been able to collect, is conclusive
that recovery is usually very coniplele and the patient able to re-
sume his occupation and carry on his business as well as lie did-be-
fore being iiiiured."

Sec also. /5a«d. New York Medical Record, November 21, 1SS4.
page 617.

from accidents caused by actual or constructive
negligence of others, and where, if an injury^
existed, there was an opportunity to recover com-
pensation in mone}-. This is the history of all,
or nearly all, the reported cases, and, as stated by
Erichsen, " the consideration of these cases from
a medico-legal point of view is a matter of the
greatest importance bj- reason of the difficulties
with which they are surrounded and the obscurit}'
in which they are enveloped."

It is demanded bj- the honest business interests
of the country, by cities, transportation, mining
and manufacturing companies and by all em-
plo5'ers of laborers, that the subject of spinal con-
cussion receive the most thorough attention at
our hands. If we do not expose the cheats and
frauds, and protect the deser\nng claimant, who
can do so ? That cities and corporations are
robbed of vast sums of money yearh- by malin-
gerers, aided by unscrupulous legal talent, and by
ignorant or dishonest surgeons we all know to be
true. This subject has reached this disagreeable
status. A person can claim to be injured in a
collision of trains, or bj- other accident, no ob-
jective symptoms or signs can be discovered, nor
upon close examination found. Nevertheless,
such person never fails to find abundant medical
testimony, and the assistance of friends which
with the required legal talent, will be sufficient to
successfully prosecute a suit. Especially is this
true when the defendant is a corporation. Such
cases can be and are based upon, and carried to
the end upon only a few vague subjective
symptoms, even,- one of which depends alone
upon the word of the claimant who seeks
damages.

I make these statements, not as a partisan, not
as a corporation surgeon, but assert them as
truths determined by my own personal experi-
ences in cases in which I have been interested as
the attending physician from the choice of the
patient, in some of which the patient hoped to
I secure my aid in collecting damages. In some of
j these cases I have been sorely tried, and, I con-
fess, for a time deceived and misled, in trj-ing to
, determine whether or not any injury to the spine
existed. Some of these patients, where lapse of
time had proved conclusively that they had re-
ceived no injury, had always been considered
good neighbors, fair citizens and reasonably
honest men. How, then, can we account for such
cases ? Until the statutes of the various States were
enacted, favorable to such claimants, and the
laws of fellow servants practically abrogated,
symptoms were perhaps seldom deliberately and
purposely manufactured, but we all know that
patients are apt to greatly exaggerate their com-
plaints. This is no doubt done in many cases
unconsciously. In cases of this kind, surgeons
and physicians are ven,- liable to be deceived and
imposed upon, and made the tools of designing.

iSSg.]

CONCUSSION OF THE SPINE.

189

unscrupulous men, if not well schooled in read-
ing character and determining motives. Definite
opinions of imposture in many cases must be non-
medical. We may reasonably suspect imposture
where there is no organic disease, and where
there is obvious motive or money consideration
for deception. We might perhaps remain quiet
and permit our patients and neighbors to rob cor-
porations on the ground that it does not concern
us, just as we take no active part in enforcing the
criminal laws of our States for the reason that we
are not charged with that duty. But when we
find such an increase in imaginary diseases, and
find members of our own profession deceived, or
deliberately aiding these malingerers, it is time
for us to protest as a class. But this is not all.
The facility with which damages are collected
from corporations is breeding a large class of dis-
honest persons. It is infectious ; men grow more
and more to disregard the obligation of an oath.
The government itself is a victim ; patriotism and
sentiment aid. All this tends to demoralize
society, and to wrong the honest claimants for
damages or for pensions.

Railroad attorneys inform me that it is now
their custom to take the names and address of
every passenger on a train that has met with any
serious accident, because their experience is that
at least one-half of the passengers who re-
ceive no injury will, before claims are barred by
statutes of limitation, bring suit, and claim con-
cussion of the spinal cord. They learn that
those who receive trifling injuries recover large
sums, and then comes the temptation to extort
money, because they ran the same risk as those
who were injured, and they quiet their consciences
by assuming that although uninjured the railroad
company ought to be made to pay for putting
them in jeopardy. In some of these cases there
may have been trivial injurj-, and then the con-
science of the patient is somewhat relieved and
he finds excuse for deception, and the temptation
is so great that few seem to have sufficient moral
courage to resist. Many a man who had pre-
viously had no public stain upon his character
has yielded to the great temptation. Can we not
do something to save these men from themselves,
and to save our profe.ssional brethren from temp-
tation, and from becoming the victims of unscru-
pulous malingerers ?

It is no pleasant task for me to bring cases be-
fore you, but in doing so I cannot be charged
with being partisan, or with having any desire
to prevent any honest claimant from securing just
and full compensation for all actual injuries sus-
tained through the fault or misconduct of another.
vSeveral years ago I withdrew from all connection
with the railroad company I had for some years
been connected with.

The knowledge I have sought and which I
think I have gained in connection with cases of

alleged concussion of the spinal cord and other
cases of malingering, forbids me from remaining
silent, especially when I see that the tendencj- of
such pretended injuries or disease is to lower the
standard of the medical profession, and to cause
the people who see the results of these cases after
the money consideration has been paid, to lose
faith in the honesty and integrity, or in the skill
and knowledge of physicians. I append state-
ments of a few cases that have come under my
observations ; cases followed by me carefully
after judgments were paid or claims settled, and
in which recover^' was complete in a surprisingly
short space of time, without the aid of surgeons
or physicians. Such cases have of recent years be-
come so common that the medical profession is
brought into ridicule, and it is not rare that in-
telligent men of a community assail us with the
jocular information that railroad officials with no
knowledge of medicine or surgery, succeed in
producing speedy and permanent cures with
money, where our skill and care produced no im-
provement in the patient.

It is said, and it is probably true, that more
people are injured every year by riding in car-
riages and by farm work than by railroads. Yet
injuries that are pure accidents, or injuries where
a corporation of some character is not at fault,
never result in concussion of the spinal cord.
And where injuries occur through accident, for
which no liability can attach, we find no malin-
gerers.

Cases I and 2. — May 10, 1889, I was called to
see Mr. and Mrs. C. G., aged respectively 62 and
63 years. They had been riding in a spring
wagon ; the horses were frightened by cars and
ran away, throwing the occupants out. There
were no visible wounds or fractures, but the
patients were suff'ering from shock. I surrounded
them with blankets and jugs of hot water, and
after four hours of rest, sent them to their home
five miles distant. These people were disciples
of Hahnemann, and the next day sent for their
family physician, and in a short time concussion
of the spine was alleged in both cases. Damages
were paid. The mau is still living and in aver-
age health for one of so great an age. The
woman was alive and in good health three years
ago.

Case J. — E. H. H. was walking on a sidewalk
and fell into a pit eighteen inches deep, extend-
ing from a basement window. I saw him a few
days afterwards. His thumb was swollen, and
that was the sole objective symptom. The patient
at once talked of the amount of damages he could
recover, and complained of his back. This man
was a hanger-on about the courts, and had some
ideas as to how to proceed, and his subjective
symptoms were in the line of his desire to recover
a judgment. This case was properly attended by
a skilled surgeon and physician, a man who stood

I go

CONCUSSION OF THE SPINE.

[August io,

above reproach. Through his care and -daniing
the spine recovered, although the patient's friends
asserted positively- that he suffered severel)^ from
concussion of the spinal cord, and other alleged
doctors were called to examine the patient. The
phj'sician in charge became disgusted with the
malingering and abandoned the case, and through
fear of his testimony, no doubt, the concussion
theory was abandoned, and the thumb grew
worse. The thumb and hand were firmly ban-
daged, until there appeared to be permanent con-
traction and disfigurement. Suit was brought
against the city, and good legal talent was em-
ployed, for lawj-ers as well as doctors can be
found to work in such cases for a consideration.
The city was mulcted several thousand dollars,
although competent and reputable physicians
testified that the sprained thumb wouid have re-
covered in a short time without treatment, if it
had been left alone and not bound and poulticed.
Within one month after the judgment was paid,
the man, to the disgust of his friends, was at
work on his bench as any shoemaker should be,
and the recoverj- was complete. This case would
have gone through the courts as an aristocratic
case of concussion, instead of a plebian case of a
sore thumb, had not the honorable ph3'sician who
first attended the case stood in the way.

Case 4. — Concussion of the spine — so-called
and treated by two reputable surgeons. Liabilit}'
conceded by a railroad companj-. Damages esti-
mated on the basis of permanent injurj- and the
presumption that the man could never walk
again. A complete book case. A large sum of
money was paid, and a few days thereafter the
man u'alked to the cars in the night time and left
the State. The case was as follows : The claim-
ant was an engineer. In making a rapid switch
a rail was broken, and the engine left the track
and tipped over. The fireman was killed and the
engineer thrown out and stunned and bruised.
His family physician was called, and he in turn
called a surgeon, who justly ranks high. There
were no objective symptoms. The man was ap-
parently scared. There had been no shock. The
case gradually grew to be a case of concussion of
the spine, a " book case." In justice to mj- es-
teemed medical brothers who attended the case, I
will say, that under the circumstances, and with
death resulting to the companion of the patient,
other surgeons would have been likely at that
date to have been deceived. I rejoice at my
escape from this case, for I .sadly fear that witli
the experience I then had I should have believed
the patient's statement and symptoms related.
The recovery in this case was complete, and the
man last heard from, some five years after the
accident, was in robust health.

Case s. — F. P., age 18, brakeman, habits ques-
tionable, health undermined, inclined to con-
sumption, was on top of box car in a train under

way. Head end collision. P. jumped from train
and fell some distance from the track ; when
found he lay in a depression in the ground on his
back, with his back across a railroad tie. He
was brought a distance of 23 miles to his home.
He was met at the station on his arrival by the
writer, four hours after the accident, and was car-
ried home on a hand stretcher. When met at the
station reaction was progressing naturally. He
had received a great shock. Two hours after
seeing the patient at the station, I again saw him,
and being the attending physician of his father's
family, and the residence being a short distance
from my office, I saw him often. In this I made
a mistake. There were no objective sj-mptoms.
The subjective sj-mptoms were pain in the back
over the dorsal vertebra. My directions in the
first instance were to keep him warm and let him
alone until I again called. The pain being ap-
parently so great, I called to my assistance a very
painstaking physician. We carefully examined
the patient and found curvature of the spine,
bold and distinct. We abandoned further exami-
nation at that time and regarded the case as
hopeless. To our great surprise, however, dur-
ing a later visit the same da}- we found reaction
fully established, with no complaint of pain. We
then again examined the back. The deformity
of the spine was decidedly marked, but there was
no tenderness upon pressure. We made no
further examination for several days, and in the
meantime I described to his mother the condition
of the spine as we had obser\-ed it, and our fears
of a serious injury and fatal result. This was my
second mistake in this case. The information I
communicated to the mother, to my surprise, did
not greatly disttirb her, and here my suspicions
were aroused. I had long been her attending
physician, and the patient was her son, and yet
my opinion of her son's condition was received
quite calmly. From this time on the curvature
of the spine became in the minds of the family
more pronounced, and the money question began
to be considered. To protect myself and guard
against an outrage being committed, and for the
purpose of saving the reputation of the family I
had so long attended, I procured skilled help and
made a correct plaster cast of the whole back. I
had seen lawyer's tracks. Secret meetings had
been held in the back parlor, as was reported to
me. I was quietly interviewed and informed that
the case was all clear if I was all right. The
whole family asserted to me that prior to the acci-
dent no deformity of the back had existed. I was
in trouble, and consulted with the physician whom
I had called in consultation, and we took such
steps as we could to save ourselves from being
either parties to a contemplated robbery, or from
wronging the family that had trusted me. A
brother of the patient, a bright boy, had .some
years before been m>- office boy. He was absent

1889.]

CONCUSSION OF THE SPINE.

191

from home at the time of the accident. When he
returned he told me that his brother's back had
been that way since he was a little fellow.

I devoted m}' labors after this to getting my
patient out of bed and on to his feet, but he in-
sisted upon the necessity of crutches. I could do
no more ; the spine grew worse ; suit was brought
because a fair and, in truth, a generous offer made
by the railroad company was indignantly rejected.
Foreign surgeons were called to examine the pa-
tient preparatory to testifying. I knew the case
was one of malingering, and so informed the at-
torney of the railroad company. The surgeons
who had no knowledge of the case, except as re-
lated to them by the patient and family, would
readily have testified to the permanent injury and
that the accident was the cause. When the ca.se
was set for trial I was so beset with difficulties
that I was compelled to exhibit the cast of the
back, and to urge that surgeons for the railroad
company might make an examination. This was
done. It is sufficient to say that Dr. J. Adams
Allen cured the case within the half hour before
Court convened. So thorough was the cure that
a reasonable sum for the actual injury, le.ss than
the amount previously offered, was greedily ac-
cepted. On the evening of the same day the
crutches were abandoned, and the afflicted spine
was supporting the bod}' of an intoxicated man.

This, gentlemen, is a true history of a case that
occurred in a family that had mj' confidence and
respect. It cost me many gray hairs.

Case 6. — A middle-aged man of nervous tem-
perament, of health feeble for years, tripped and
fell from a defective sidewalk. Accident happened
in front of his own house. He immediately took
to his bed. A reputable physician of long expe-
rience in general practice was called. The patient
remained in bed — as was supposed — for some
months, when suit against the City was brought,
based upon permanent injury to the back, on ac-
count of spinal concussion. The case was on
trial with the plaintiff in bed, unable to attend,
as was alleged, when the writer and another phy-
sician were solicited by the plaintift's attorney,
who had faith in the honesty of the case, in order
to further the ends of justice, to go and examine
the plaintiff, and testifj- to his crippled condition.
We found the man in bed, and evidently prepared
for our coming. Not the slightest objective symp-
tom could be found, but the subjective symptoms
were perfectly in accord with all the recorded
book cases. With careful effort we got the man
out of bed. The imperfect walk, the peculiarity
of gait and carriage of body, were just what a
student would expect to find after having freshly ]
read these cases and never before having seen one. |

I am not naturally suspicious. I want to have
faith in mankind, I want to be just, but there [
were many things which I cannot full}- explain ; |
the manner of the man, his guarded language, his

suspicious glances, that caused me to suspect that
we were being misled, and being entangled in the
trap set by designing lawyers, or credulous and
ignorant physicians. I informed the plaintiflTs
attorney of my suspicion, which after some tests
had become a conviction, of the plaintiffs dishon-
esty- in this case. I was nevertheless called to
testify, because, as I was informed, my silence
after it was known that I had made the examina-
tion, would be more damaging than my neo-ative
testimony. I testified substantially that I had no
positive means of knowing or satisfying any one
else that the man was simulating all his symp-
toms, that I had never before had cause to sus-
pect him of dishonest practices, that there were
no objective symptoms or signs of injury, that
the whole case depended upon the symptoms
which could be simulated, and upon the state-
ments of the patient, and upon these alone. I
was asked by the attorney for the City to answer
that had the accident happened within his own
dooryard, or where no one would have been lia-
ble, would the symptoms have been the same? I
answered, "No, I certainly think not." This
testimony was, however, "ruled out" by the
Court. The surgeon who made the examination
: with me corroborated my opinion. I did not hear
the testimony of the attending physician, but was
informed that he thought it improbable that all
the symptoms could be manufactured ; that in all
such cases the physician had to relv upon the
I statements of the patient, and that he could not
be properly treated if symptoms stated were ig-
nored, etc. Judgment was given in favor of the
cripple, and the money paid. A few weeks after-
wards I was much surprised — or would have been
had I believed the man's story — to see this same
plaintiff riding about the city ; and about five
months after the trial I ought to have been again
surprised beyond belief I suppose, to see this
same man, permanently crippled from concussion
of the spine, put a heavy stove into a lumber
wagon. To be certain that I was not mistaken
in the person I went to him and shook hands with
him. He is not now a strong man, and was not
before his fall on the sidewalk, but, knowing him
well both before and after the fall, I can state
positively that he is in better health and in better
physical condition than before the accident. It
is certainly ven,' unpleasant for me to record this
case. I have no personal ill will against the man.
He was the victim of his cupidity, and only fol-
lowed the precedent set by many other "honor-
able men." I was recently called to his fireside
to treat a member of his family.

Case 7. — A young married man, jeweler by
trade, had occasion to go hurriedly to a railroad
station. Unknown to this man, as he claimed,
the station platform had been partially removed
for repairs. The sidewalk, which was in place,
had formerly terminated in the platform. The

192

CONCUSSION OF THE SPINE.

[August 10,

removal of the platform left the end of the side-
walk about 14 inches above the level ground.
The man stepped off the end of the walk, and
fell to the ground. This is the history' of the ac-
cident given b}' the patient — no one else witnessed
it. He got up, went into the telegraph office,
sent a message and returned home. The case
was brought to my knowledge some weeks after-
wards by the attorne3' of the railroad company,
who desired me to examine the man together with
the doctor in charge. At my suggestion, permis-
sion was granted bj^ the attorney for the claimant
to call a third physician. I called Dr. H., an old
practitioner, and a man beyond reproach profes-
sionally and otherwise. I found the histor}- of
the case as stated above, and that permanent in-
jury was claimed ; that suit had been brought in
one County and that the attorney who brought
the suit had abandoned the case because he be-
lieved the man dishonest in his pretenses of in-
jury. This put us on the watch and compelled a
critical examination. The desertion of one at-
torney did not deter the claimant, nor seriouslj-
discourage him. Law3'ers are no more virtuous
than physicians, and a speculative lawyer was
soou found read}^ to take the case, and a new suit
was brought in another County. The physician
who had been treating the case was employed
specially because of a reputation he had previ-
ously acquired as an expert witness for the claim-
ants in spinal concussion suits. The attorneys
representing both plaintiff and defendant were
present. This was a mistake, and was chargeable
to me. No proper or satisfactory examination
could be made under the circumstances. The
case presented in all its aspects the appearance of
chronic disease, or permanent injun,- : the general
appearance of the patient was bad, suggesting
rheumatism. Aside from this there were no ob-
jective symptoms. I stated that if his present
condition was due to the fall, he was certainly in-
jured. He finally admitted, because it was sus-
ceptible of proof, that he had repeatedly suffered
from rheumatism for some years. It did not seem
possible to Dr. H. and myself that this person
could be in his present condition from any injury
a person could sustain from the accident related.
The doctor in charge of the patient and his claim
stated that it was a case of permanent injurj^ to
the back. The case came to trial, concussion of
the spinal cord was the plea. It was shown by
his own testimony how much he had suffered and
was suffering. The doctor in charge either dis-
honestly or ignorantlj' corroborated his patient,
although admitting that no medicine had been
used. Some of the most candid and intelligent
surgeons of the State of Illinois, all members of
this Association, were called by the railroad com-
pany as witnesses, The track gone over in this
case was the same old beaten path, the only road
possible to travel, that is the man's own word and

subjective symptoms. Book cases were rehearsed
to the jurj' of concussion of ths spinal cord by a
professor of the Physio-Medical College — formerh'
of Cincinnati — the pale face of the rheumatic pa-
tient, the prejudice of a jury in favor of a claim-
ant and against a corporation, succeeded, and
damages were awarded to a large sum. After
payment of the judgment, the patient recovered
from all trouble, except rheumatism, so rapidlj^
as to abash and disgust the innocent jurors and
sympathizing friends, and finally taunts and
charges of dishonestj' became so numerous that
the claimant felt it safer to emigrate from the
County, and the doctor, who was also a druggist,
has removed, but before going, instead of plead-
ing ignorance to the discredit of his skill as a
physician, admitted that it was a little scheme to
get even with a soulless corporation. The claim-
ant had not sustained the slightest injur}'; indeed,
it is believed bj' the citizens of the village that he
did not even fall from the sidewalk.

I will not burden you with reference to any
further cases. It would be but a repetition. You
have no doubt had similar cases. I have been
unfortunate, it may be, in having a number of
other cases brought to my knowledge, a number
in excess of what might seem usual ; but I have
no doubt no greater number or kind, as regards
the subject of concussion of the spinal cord con-
sidered in its medico-legal aspect, than have come
under the observation, in the practice of a large
number of those present.

If a j-oung man can begin life with the truth
visiblj- laid before him, and be warned of the
snares set for him, and be helped to avoid decep-
tion, some of the obstacles to his honorable fame
maj' be removed, and his path be made easier.
If the 3'oung men in the profession could realize
that cheats and frauds are not rare, much good
might be accomplished and less harm done.

I must certainly question if there be such a disor-
der or injury as concussion of the spinal cord, as
some of the books tell us, or describe it. I have
certainly been a hard worker after the truth in this
matter, and have not exaggerated the cases I
have reported, and have withheld reports of other
now notorious ca.ses of pure fraud and malinger-
ing, in which honest but credulous physicians
were misled, deceived, and their reputations in-
jured,

I trust that members of the profession more
skilled with the pen than I am, more capable of
expressing their ideas to others, will give the sub-
ject careful study, and give their views to the pub-
lic. To learn the tnith these cases must be fol-
lowed and observed, not only before judgments
are paid, but for months afterwards. I would be
happier if I could be convinced or could convince
myself that I have been mi.staken in all these
cases, and that the remarkable cures effected ap-
parently by juries, were really cures effected by

1889.

CONCUSSION OF THE SPINE.

193

the kindness of Divine Providence, or by the la-
bors of Christian Scientists.

If in my awkward way, and by my crude lan-
guage I shall succeed in creating enough interest
to cause others to be on their guard and to study
this class of cases when damage suits are brought,
I shall be content.

DISCUSSION.

Dr. Wm. Brodie, of Detroit, Mich., cited two
cases, in one of which his testimonj^ was for the
plaintiff ; in the other, against. The jury gave
the plaintiff heavy damages in both cases. Con-
clusions : Immediately after a man is hurt the
railroad surgeon should advise the company- to
settle, for if injury of spinal cord has. occurred
the patient will continue to give evidence of his
injury; and if not, the damages received from
the compan)' will prove immediate cure, and thus
demonstrate that no injury had taken place. Ju-
ries cannot be made to see the difference. It is
only necessary that the defence be a rich corpor-
ation. He also cited a case at Cobourg, Ontario,
wherein the G. T. R. W. was defendant. The
injured man recovered in less than ten days after
the verdict in his favor and was married. Has been
in perfect health since, although he played par-
alyzed for near two years, with loss of sensation
in his extremities. Such perfect control did he
have that neither needles nor electricity could
make any observable impression upon him when
applied even without his direct knowledge. Of
course he was aware that he was being put to
some test, and his will controlled.

Dr. B. a. Watson, of Jersey City, N. J.:
Spinal concussions are not so frequent as would
seem from court decisions. I have observed as
the most frequent injuries following railroad acci-
dents : I. Hsemorrhagic infarction in lungs. 2.
Lacerations of liver, spleen, lungs, or kidneys.
3. Rupture of blood vessels and bladder.

Dr. Charles B. Penrose, of Philadelphia,
said : I think that we are all in accord with the
principles expressed in the papers which we have
heard todaj', and we protest against the robbery
of corporations and the consequent discredit
brought on our profession by supposed victims of
spinal concussion.

The rarity of any serious injury to the spinal
cord, unaccompanied by injury to, or lesion of
the surrounding bony or ligamentous structures, is
shown by the records of large surgical hospitals,
where simple spinal concussion analogous to tran-
sient cerebral concussion is exceedingly rare, if
not altogether unknown.

In the Pennsylvania Hospital, where there are
treated yearly about 700 cases of fracture, luxa-
tion, sprain and contusion of sufficient gravity to
demand in-door hospital treatment, simple spinal
concussion is one of the rarest conditions met
with. And yet these injuries are produced by

falls, blows and collisions, which must cause more
or less jarring of the whole body, besides the
local fracture or contusion, or sprain for which
the patient is admitted.

I am familiar with the details, and have ex-
amined the specimens of the verj^ interesting case
of spinal concussion referred to by Prof Smith,
as that of a sailor admitted to the Pennsylvania
Hospital, who had been thrown violently upon
the nape of his neck. The autopsy- was made
most carefully with the special object in view of
determining the existence of any injury to the
bones or ligaments of the spinal column, as in
such cases there is always a probability that an
unrecognized fracture is present, or that disloca-
tion has taken place and been immediately re-
duced, so that no deformity is afterwards appar-
ent. But in this man no fracture of bone or
laceration of ligaments was found. Nor does it
appear, from the nature of the accident, that anj'
sharp flexure had occurred and produced undue
tension upon the cord ; nor was there any indica-
tion of haemorrhage from the vessels of the cord
or of the membranes. It seems, therefore, to be
a simple case of injury or concussion and subse-
quent degeneration of the cord, produced by di-
rect violence without any fracture or laceration
of the surrounding structures.

Women at the menopause are frequent malin-
gerers of spinal concussion, or spinal shock, and
their nervous sj'mptoms sometimes really deceive
themselves and friends, being falsely attributed
to some more or less severe injury coincident
with the real physiological cause of their trouble.

I have examined two such cases, where, in
court, trifling injuries were aflirmed to have
caused spinal concussion, and were held respon-
sible for all the hystero-neuroses of the meno-
pause. In one case the plaintiff was non-suited,
in the other a compromise was effected. In both
women all symptoms of spinal concussion prob-
ably disappeared as soon as the menopause was
over.

An important point which Prof. Smith has men-
tioned, is the impossibility of giving a certain
prognosis with regard to permanent disability
after spinal injur\'.

An exceedingly interesting case, where recov-
ery of muscular power occurred after prolonged
paralysis from a very severe spinal injur>^ and
probable fracture, came under my observation
about two years ago. The man had been a
soldier, and in the battle of Cross-Keys had
been struck by a bullet on the cartridge belt and
had fallen backward from a height, upon the but-
tocks. He was not wounded by the bullet ; but
his back was so injured by the fall that he was
immediately paralyzed and he was obliged to lay
for three years on a water-bed, with paralysis of
the legs and incontinence of urine and faeces.

He afterwards regained muscular power suflB-

194

TUBERCULAR OSTEO-MYEUTIS OF TIBIA.

[August io,

ciently to lead the laborious life of a peddler,
tramping, with his pack for twentj- years subse-
quently, through Pennsylvania and Xew York.
The only mark of injury now apparent is a slight
prominence of the lower dorsal vertebra. He has
never recovered control over the bladder and rec-
tum, or sensation in the skin of the buttocks on
the posterior aspect of the thighs.

Dr. J. H. Murphy, of St. Paul, Minn., said :
Erichsen has cost the railroads thousands of dol-
lars. He cited several cases of malingering.

Dr. Wm. H. Pancoast, of Philadelphia, said :
The question under discussion has two heads.
First, is there such an injurj- as concussion of the
spine, and are there malingerers who assume the
symptoms. That there can be cases of concus-
sion of the spine followed by serious consequences,
I firmly believe, for I have seen them. I have
seen cases where a violent concussion in a rail-
way accident has so afifected the contents of the
spinal canal as to cause effusions, or such altera-
tions of the membranes of the cord or of the
cord itself, as to be followed by paralysis more or
less complete. Many members of this Section of
Surgerj'and Anatomy must, in the course of their
lives, from missteps or other accidents, have rec-
ognized the force and painful effects of concus-
sion. I have within the past few weeks been en-
gaged in a medico-legal case, where a delicate
lady, the wife of a physician engaged in a large
and active practice, was thrown from a carriage
in which they were both driving. A careless
coachman driving a heavier carriage ran into
them, and the collision threw her to the ground
and against a wheel, with such violence that she
became insensible. She has remained an invalid

siring to be honest, and giving a truthful scien-
tific diagnosis from their standpoint ; then why
should not we also recognize the statements of
the surgeon of the injured, as being inspired by
the same motive, even if some one may occasion-
ally be deceived by an ingenious and artful ma-
lingerer.

From my experience I think that very many
railwa}' injuries can be satisfactory adjudicated
and the sufferers properly compensated by the ju-
dicious surgeon acting as mediator between the
opposing lawyers, to the honorable satisfaction of
both parties.

TWO CASES OF TUBERCULAR OSTEO-
MYELITIS OF TIBIA.

Read be/ore the North Texas Medical Association, June J2, rSS^.
BY J. T. JELKS, M.D.,

OF HOT SPRINGS, ARK.

PROFESSOR OF SIRGICAL DISEASES OF GENITO-IRIN-ARV ORGANS

IN COLLEGE OF PHYSICIANS .AND SL'RGEONS,

CHICAGO. ILL.

Case I. — In the Spring of 1888, Mr. — , aet. 40,
consulted me for great and constant pain in the left
tibia. I found him in a hovel, poorly ventilated,
poorly warmed, and poorly lighted. The odor in
the room was simply unbearable, but with burn-
ing tar in the room I examined the patient as best
I could. Found him greatly emaciated, with
large ulcer on left leg, several inches in length,
with the presence of pieces of dead bone. He
was being cared for by some of the charitable
ladies of the place and consented to an operation.
Assisted by Drs. Thompson and Gebhart, I pro-

ceeded to operate. After the anaesthetic was given
ever since, with marked symptoms of paralysis 1 I washed and scrubbed his leg with soap and
on one side. In neither of these cases was there

hysteria or malingering.

There are malingerers, and we must be on our
guard against them, and L have such faith in the
honor of the members of our regular profession
as a class, that I do not believe they would be
parties to such a deception. I have been called
as an expert in several such cases, and have some-
times settled the medico-legal questions in my
office to the satisfaction of both sides. I feel as-
sured that this learned body recognizes the exis-
tence of .such an injury as concussion of the
spine, and also that while the great railroads who
do so much for the benefit of the countrj', should
be protected from suits inspired by fraud and
ignorance, that the great public should also
have protection. I think that if corporations
would give fair compensation for injuries received
at their hands, through accident or the careless-
ness of their employes, and not insist that such
injury should be proved to be permanent, that a
cause exciting to fraud or malingering will be re-
moved.

water, then with solution of bichloride of mercur>',
1:1000; wrapped his feet with towels wrung out
of the bichloride solution, and also covered his
body with antiseptic towels. An Esmarch band-
age was applied above the knee-joint — about 6
inches — to make a bloodless operation. I then
proceeded to cut down to the tibia, making an in-
cision from near the insertion of the tendon of the
patella to within a few inches of the ankle-joint.
Peeled the periosteum back on both sides of the
line of the incision, and then with mallet and chisels
I proceeded to remove the anterior surface of the
bone, finding the focus of the disease not far from
the head of the tibia. I continued the use of the
chisels and mallet until I thought all the abnor-
mal material was removed, and when through I
had a trough six inches or more long, half inch
wide and half inch deep in some places. It was
now scraped out with the sharp spoon of Simon,
irrigated with solution of sublimate 1-1000.
Again irrigated with solution of sublimate 1-500,
and when this was through with a quantity of
1-5000 solution was used to wash out the stronger

I give credit to the corporation surgeons of de- liquid. The operation by being bloodless was

1889.]

TUBERCUI.AR OSTEO-MYEUTIS OF TIBIA.

195

made more thorough, because I could inspect
every crevice and corner of the large trough.

A Schede'ri dressing was applied — that is, the
cavity was sprinkled with powdered iodoform,
the skin stitched together where it would meet,
and over the line of incision a strip of antiseptic
oiled silk was placed, overlapping the incision
one inch on each side and about the same at each
end ; over this was placed a strip of iodoform
gauze, then a thick layer of sublimated cotton,
and over that several layers of sublimated band-
age, tightly applied ; over all a protective of oil-
ed silk, previously soaked in sublimate solution.
When all this was done the constrictor was
loosened, and the cavity I had made allowed to
fill with pure blood, the leg being held as near
vertical as we could get it. He had no fever from
the operation, The leg was dressed in one week
and found almost healed by the organization of
the blood clot. In six weeks he was well and
upon the streets.

Case 2. — Mrs. H., set 30, widow, consulted me
for enlargement of left leg, with two ulcers near
the upper extremity of tibia. Constant pain in
leg, so much so that she had resorted to frequent
use of morphia to relieve it. One of the ulcers
opened down on the tibia. I proposed opening
the bone and turning out the diseased mass. She
consented, and I asked Drs. Haffner and Thomp- !
son to assist me in the work. After the use of
the antiseptic precautions detailed in Case No. i,
I proceeded to cut down on the tibia in the mid- ,
die line, turning back the periosteum on each side
of the line of incision. This was not verj- readilj^
done at the upper part of the wound, a previous
operation, similar to the one I was doing, having
been performed on her in Detroit, Mich. This
operation was rendered bloodless by the use of a
constrictor about the middle of the thigh, and
hence in the use of the chisels I could follow the
diseased ti.ssue wherever it went. I chiseled
away until I had a trough of the tibia leaving its
sides and bottom. This was well curetted with
a sharp spoon to remove any shreds of diseased
material left, its entire removal being absolutely
essential to success. This was rendered aseptic
by use of sublimate solution 1-500, and then
i-iooo; finally it was irrigated by solution
1-5000, and a Shede's dre.ssing applied. Con-
strictor was now removed and leg suspended in
upright position until the blood clot could form,
when it was let down on the bed. Few hours
afterwards blood was noticed oozing from the
bandage near the ankle-joint. A rubber bandage
was tightl}' applied for two or three hours and
then removed. When the haemorrhage had ceased
the wet spots on the bandage were sprinkled with
idoform, and a fresh antiseptic roller bandage ap-
plied.

This dressing was taken off at end of ten days,
and not a drop of pus was found, but the upper

third of the cavity in the tibia was empty, lower
two-thirds filled with well organized clot, skin
united over it so that the line of union was
scarcely perceptible. The bandage was not ap-
plied tightly enough to prevent the loss of part of
the blood clot, hence the empty third at the up-
per part of the wound. I tried to persuade her
to let me fill this cavity with blood from her arm
but she would not consent. About once in seven
or ten days this cavity was filled with iodoform
gauze, and it granulated until healing took place
requiring three months. Had not the blood clot
been lost the entire cavity would have been healed
in a few weeks.

When another opportunity oflfers to make this
operation I shall utilize the decalcified bone chips
of Senn — that is, I'll fill the cavity with these
chips and allow the blood to cement them to-
gether, using the Shede's dressing as above de-
scribed.

Tuberculosis of bone is a subject that has not
been understood until the last few years. For-
merly, caries, necrosis, and tumor albus were the
disea.ses we had to contend with, when the bones
were involved. Thanks to the labors of Koch,
Volkmann, and others we now know that what we
formerly regarded as diseases are but the results of
disease. Dropsy was once a terrible disease, and
is so regarded to day by the laity and some of the
profession. We know it only as a symptom. So
with caries, necrosis, and tumor albus. They are
but the results of inflammation of the bone, or
rather of the bony envelope — the periosteum, en-
dosteum, or medullary matter. Practically, in-
flammation of bone means inflammation of these
substances ; they are practically one. The bony
material itself is not inflamed, but the endos-
teum, or periosteum, swelling, the resulting press-
ure cuts off the blood supply of the bone, and
caries or necrosis is a result.

The causes of bone inflammation may be set
down as trauma, cold, and fever. Upon this
trauma we have engrafted an infection with the
microbes of pus, tuberculosis, syphilis, rheu-
matism, or gout. The pus microbes, the staph-
ylococcus aureus or albus, or the streptococcus
pyogenes, are very vigorous and active and pro-
duce a very violent inflammation ; whereas the
bacillus tuberculosis is a slow growing coccus — it
is not a pus producing coccus — and hence its
effects are slower in manifesting themselves, and
when only the bacillus tuberculosis is present in
a joint or bone, only granulation tissue is formed.
It may be said also that the bacillus of syphilis
and rheumatism are not pus producing bacilli,
and that their effects are slower in manifestation,
and hence chronic. It follows that the acute
bone inflammations are produced by the pus mi-
crobes, and the chronic inflammations by either
the bacillus of tuberculosis, rheumatism, or syph-

196

MEDICAL PROGRESS.

[August 10,

ilis. Ninety-two per cent, of these inflammations
of bone are so produced, leaving 8 per cent, for
the pus microbes. Volkman, the greatest living
authority on tuberculosis, says that go per cent
of the cases of caries are tubercular in their ori-
gin. When the trauma is slight the resulting
bone inflammation is tubercular : when the injury
is severe the inflammation following it is produced
by the pus microbes. If the skin is not broken
whence comes the microbes ? We may say that
they are floating in the blood current at all times,
and, thanks to the leucocytes are being constantly
destroyed, but when an injury results the effusion
of leucocytes outside of the blood vessels renders
them inactive, and a fine culture fluid is produced
in which these microbes of disease have an oppor-
tunity to develop. If the injury is slight the
inflammation resulting is tubercular or rheu-
matic ; if severe, the pus microbes take possession
of the field.

MEDICAL PROGRESS.

On Injections of Testicular Liquid. — In
the Societe de Biologic de Paris M. Variot report-
ed three experiments which had been made to
ascertain the physiological action of fresh testicu-
lar liquid injected subcutaneoush', after the man-
ner of Brown-Sequard. The liquid used was ob-
tained by crushing and triturating the testicles of
a rabbit or of a guinea-pig in 10 cubic centimetres
of distilled water. After .separating this liquid
from the residual pulp by simple decantation two
Pravaz syringes of it were injected under the skin
of the abdomen at a dose, the injections being
repeated every forty-eight hours.

Variot operated on three men, of 25, 56, and 68
years, respectively, who were much debilitated
from various causes. The efiects produced in
these three cases were satisfactory from the first,
and continued so after subsequent injections.
Sixteen injections were made in all. No harmful
symptoms requiring any attention were noticed.
The injections proved painful but harmless. The
pain following the injection is considerable for
several hours, it is even accompanied by a general
feeling of uneasiness, but not bj^ fever. The first
injections are especially painful, the subsequent
ones much less so. The positive efiects (which
were the same in the three men, the nature of the
substance injected not being known to them)
were as follows : a general state of ner\-ous
excitement, an increase of muscular strength,
regulation of the functions of the digestive chan-
nel, and some cerebral excitement. An increase
of virility was found in two of the three cases.

Variot is unable to answer the question :
whether the.se phenomena were an effect siti;j^es/eii
merely by the operation, or whether they were

actually due to the action of the liquid, as claimed
by Brown-Sequard. The number of experiments
is as yet too small.

Brown-Sequard claims that the conditions
under which Variot made the experiments prove
that there was no imaginary effect in these cases,
but that the liquid reall}' possesses the properties
that he ascribes to it.

Brown-Sequard also made experiments with
liquid obtained from other glands, and proved
that a liquid obtained by trituration of the lungs
contained a toxic substance. Liquids obtained
from trituration of the liver and spleen had no
effect whatever upon the animals treated with
them. — La Semaitie Medicale, No. 27, 1889.

On the Etiology of Pericarditis. — In the
bacteriological examination of three cases of peri-
carditis G. Banti (Deutsche Mcdicinische Woch-
enschn'ff. No. 44, 1888) found, in the first case,
no microorganisms at all in the fibrinous exudate,
for which reason he considered that an example
of non- infectious pericarditis. It was the case of
a man 48 years old who had been suffering for
years from a chronic nephritis, and had died dur-
ing an attack of urfemia, symptoms of pericarditis
having appeared a week before death. The au-
thor thinks that here pericarditis was ascribable
to the kidney disease, and that its cause might be
of a chemical character, or might be looked for in
the ursemic attack, as it is known that acute in-
flammations are often complications of acute urse-
mic attacks.

Two other cases of pericarditis belonged to the
group of infectious pericarditis and developed in
consequence of fibrinous pneumonia. In the first
of these cases the diplococcus pneumoniae was
found in the pericarditic exudate, as expression
of a secondary localization of the latter ; in the
second case the pericarditis appeared as a mixed
infection caused by the staphylococcus aureus and
albus. In this latter case the inflammation prob-
ably spread directly from the pleura to the peri-
cardium, as there existed at the same time an
extensive pleuritis, and the staphylococci were
also found in the pleural exudate.

Regarding the first case the author .supposes
that the pericarditis was of ha;matogenous origin,
and to prove this he tried to produce, with the
diplococcus pneumonia;, pericarditis in animals.
For this purpose he created an artificial pericardi-
tis by injecting oil of turpentine into the pericar-
dium, or by cauterizing the latter, and then in-
jected pneumococci under the skin. Numerous
capsulated cocci were sub.sequently found in the
pericarditic exudate thus obtained. This peri-
carditis was most easily produced if from twenty-
four to forty- eight hours were allowed to elapse
between the injury to the pericardium and the
injection of the pneumococci, in which case al-
ways an isolated inflammation of the pericardium

1 889. J

MEDICAL PROGRESS.

197

was found which did not extend to the pleura,
the peritoneum or the mediastinum.

These experiments show that a hsematogenous
pericarditis maj' be produced in animals by means
of the diplococcus pneumoniae. — Centralblatt fi'ir
Klinischc Median, No. 20, 1889.

On Pulsating Pleurisy. — Millard com-
municates the ca.se of a man, 36 years of age,
who was taken, in Maj% 1887, with pleuri.sy of
the left .side, which soon became complicated with
pneumothorax. Nevertheless he improved, and
could resume his occupation, until, in December,
1887, after a run, he was attacked by a sudden
dyspnoea, with evident return of the symptoms of
pneumothorax. In July, 1888, a tumor appeared
on his back, to the left of the spinal column, on
a level with the last ribs, which grew rapidly and
soon pulsated synchronously with the heart.
August 10 an incision was made into the thorax
and 2i]i litres of pus were extracted. The tumor
fell and the pulsations ceased immediately. From
August 28th to September 22d, during Millard's
absence, five more incisions were made, and from
1,300 to 1,500 gr. of pus extracted each time,
each operation being followed by the injection of
a dose (which was then gradually increased
from 80 to 115 gr.) of tincture of iodine. These
operations were well borne. November 6th a
puncture was made, with successful results, but
the next morning all the symptoms of pneumo-
thorax had reappeared. Then Dr. Peyrot per-
formed pleurotomy. The ninth rib was resected
for 3 centimetres, and again about 3 litres of pus
were removed ; rinsings with iodized and alcohol-
ized water were made repeatedly, as often as four
times a day, but hectic fever and diarrhoea con-
tinued, and November 27th the patient died. An
autopsy was not made. Millard thinks that
Feriol will be inclined to cite this case in support
of his theory, inasmuch as the patient, before
showing the symptoms of pulsating empyema,
had had pneumothorax twice ; he (Millard) is of
the opinion, however, that experiments will be
necessary to arrive at a true explanation of pul-
sating pleurisies. — La Seinainc Mcdica/c, No. 27,
1889.

Treatment of Diabetes. — In an article by
Albert Robin on this subject the following
points are discussed : i. The modifications which
the laws of exchange undergo in disea.ses, explain
the pathogeny of the latter and become the source
of certain therapeutic indications. The knowledge
of the effects upon normal exchanges produced
by a drug renders it possible to foresee its
real therapeutical application. There is reason
for a revision, from this double standpoint, of the
physiologj' of disease and of that of drugs. This
revision made, the science of therapeutics will
enter upon a new era ; it might then reclaim the

epithet "rational" and repudiate forever the
fumbling of the past.

2. Biological chemistry shows that there exists
in diabetic patients an exaggeration of all the
acts of general nutrition, and also an increase of
activity in certain special organs, especially in the
liver and the nervous system. The undeniable
fact of overactivity of the general nutrition and
of the hepatic cells influenced by a direct or reflex
nervous irritation, should be the starting point for
the therapeutics of diabetes. It may be aiBrmed
in advance that ever}- drug which slackens, in
whatever manner it may be, the general changes
and that of the ner\'ous system, will diminish im-
mediately the glycosuria. But a drug will only
have a beneficial elfect in diabetes if it retards the
general excitation through the intermediation of
its primitive action upon the nervous .system, and
if it does not exert too energetic a suspending in-
fluence upon the functions of this system. Thera-
peutic substances which accelerate denutrition
should be done away with. It has been shown,
clinically and experimentally, that they have pro-
duced no favorable results whatever.

3. The therapeutical indications in diabetes may
consequently be formulated as follows : a. With-
draw from the organi.sm, by a proper diet, the
materials assisting in the formation of sugar, and
free the hepatic cell from the agent irritating its
functions, b. Slacken the general dis-assimulation
and the formation of glycogen by the aid of thera-
peutic means which diminish the clinical actions
of organic life through the intermediation of their
primitive action upon the nervous system. — Ga-
zette Midicalc dc Paris, Vol. vi, No. 26, 1889.

On Sciatic Neuritis in those with Vari-
cose Veins. — Numerous observations attracted
the attention of OuEnu to the seemingly not rare
coincidence of varices with a neuralgia appearing
in the clinical form of a typical ischias. The
symptoms in question are not the troubles
complained of by most persons afflicted with
varix, heaviness, sleeping of the lower extremi-
ties, cramps in the calves, etc. , but neuralgic pains
in the whole length of the nervous ischiadicus,
which may be produced also by pressure upon the
well-known points. Of 61 patients afflicted with
varix, 6 consulted Quenu not on account of the
latter, but for the neuralgia ; in 31 out of 56 other
cases in which the patients did not complain of
spontaneous pains, pressure upon certain points
of the sciatic produced them. The neuralgias
were not ver>- acute and did not manifest them-
selves in the form of attacks, but existed continu-
ously in a moderate degree, and were felt es-
pecially after a walk or after standing for a long
time. In the anatomical examination of the
ner\'es Quenu repeatedly found varices in the veins
of the sciatic, but he thinks that the pains were
caused by a genuine neuritis, originating from a

198

MEDICAL PROGRESS.

[August io,

phlebitis, not by the pressure of the varices upon
the nen'e-fibres. This neuritis gradually spreads
from below upward, from the nervous tibialis post
to the ner\-ous popliteus, and to the sciatic. A
disturbance of the peripheral nen,'ous sj-stem
caused by the obstruction of the circulation in
the veins might give rise to trophic troubles in
the skin, from simple erj-thema to varicose ulcers.
Everj^ patient suffering from ischias should, there-
fore, be examined for deep varices. If such are
found a well-applied elastic bandage will often re-
lieve pain more effectively than all other means.
— Centralblatt fur Chirurgie, No. 26, 1889.

Examination of the Blood for the Exis-
tence OF Typhus-Bacilli as a Diagnostic
Means. — Dr. Janowski, of Kiew, did not suc-
ceed in proving the existence of typhus-bacilli in
even a single one of the blood -samples taken from
patients in whom abdominal typhus has been di-
agnosed with certaint}'. This fact, as also the
results of the experiments of other investigators
convince us that the probabilitj' of discovering
typhus-bacilli in blood taken from the skin of a
finger, of a roseola, or of a vein of a typhus pa-
tient, is but little. Janowski thinks it is so for
this reason : "In the first place, the parenchym-
atous organs, especialh- the spleen, are the places
where the typhus-bacilli accumulate : from here
they are carried by the blood-stream into the gen-
eral circulation onlj' in small quantities, as is
proven bj- post-mortem examinations of the blood
of t^'phus patieuts ; and we can take but little
blood for diagnostic purposes. Perhaps more fa-
vorable results might be obtained if considerably
more blood could be taken, in short, if a patient
could be actually bled ; but such a measure, even
if not carried to the extreme, seems inexpedient
in a di.sease as debilitating as typhus. For this
reason the examination of the blood of tj-phus
patients has no significance for diagnosis." — Cen-
tralblatt fiir Bakteriologie und Parasitenkunde,
No. 20, 1889.

On Pleurisy c.\used by Diplococcus Pneu-
moni.E. — Netter, reports in the Bulletins et
Memoires de la Societe Medicale des Hopiteaux
de Paris, 46 cases of pleurisy, 40 of which were
caused by diplococcus pneumonias ; he distin-
guishes two kinds of pleurisy. The first kind
occurs after pneumonia. It is generally of a puru-
lent character and susceptible to cure, but fre-
quently leads to perforation into the lung and
pneumothorax. It often occurs epidemically dur-
ing the months when pneumonia is most frequent.
It occurs oftener in young people than in old peo-
ple. As a mark of distinction from other pleu-
risies the author mentions that the exudate is
creamy and does not easily separate into plasma
and serum. Often the exudate accumulates in a
circumscribed pleural sac and the disease takes a

chronic course. In 5 cases of this kind of pleu-
risy the author was enabled by the plate-cultures
to prove the diplococcus pneumoniae.

The second kind of purulent pleurisy caused
by diplococcus pneumonia originates independ-
ently, i. ('., without pneumonia. The author
called attention to the occurrence of this disease
as early as 1886, and has observed 10 cases so far.
He also mentions the observations made on this
subject by Weichselbaum and Serafini. In 8 of
his cases he instituted bacteriological researches
and experiments on animals ; four times he found
the diplococcus pneumoniae alone, and four times
he found it associated with the staphylococcus
and streptococcus pyogenes. Supported by his
observations. Netter believes that the greater
number of purulent pleurisies occurring in chil-
dren is caused by the diplococcus pneumoniae. —
Centralblatt fur Bakteriologie und Parasitenkunde,
Vol. vi. No! I, 1889.

On the Tre.\tment of Juxta-articular
Fractures with Massage. — A. L. Laper-
venche says : The vicinity of a joint enhances
the gravity of a fracture and demands appropriate
treatment. As it must be our aim to aid the re-
sorption of the blood discharged which, playing
the role of a foreign body, is capable of causing a
subacute plastic arthritis, massage appears cer-
tainly indicated. Facilitating the functions of
secretion and excretion of the skin, rendering the
afflux of blood easier, favoring nutrition and the
contractility of the muscles, one of its most bene-
ficial results will certainly be the avoidance of
stiffness of the joint. Practice has begun to con-
firm this theory. Fractures of the lower limbs,
of the radius, femur, humerus, elbow, knee-pan
are treated with massage to the best advantage.
In this way not only atrophy of the limb is avoid-
ed and the movement of the joint reestablished,
but the cure is also more rapid. — Gazette Medicale
de Paris, Yo\.v'\, No. 26, 1889.

On the Semiotic Significance of .\ Red
Line Bordering the Gums in Tuberculous
Phthisis. — In an article on this subject published
by G. Sticker in the Munch. Med. Wochenschrift,
No. 37, 18S8, the author declares that the symp-
toms which — as experience has shown — may pre-
cede phthisis ( pseudo-chlorosis, different kinds of
dyspepsia) are to be taken with great probability
as a manifestation of latent phthisis if the red
line bordering the gums exists simultaneously with
them. In persons of youthful age it is undoubt-
edly so. The absence of this red line, under the
circum.stances, is without significance for the di-
agnosis in female patients ; but where young male
patients are concerned the probability of latent
tuberculosis is very small if that red stripe on the
gums is missing. The author illustrates the ap-
plication of this theor}' by several observations. —
Centralblatt fur Klinische Medicin, No. 26, 1889.

1889.]

EDITORIAL.

199

Journal of the American Medical Association

PUBLISHED WEEKLY.

StTBSCRiPTioN Price. Including Postage.

Per Annum, in Advance $5.00

Single Copies 10 cents.

Subscription may begin at any time. The safest mode of remit-
tance is by bank check or postal money order, drawn to the order
of The Journal. When neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
letters.
Address

Journal of the American Medical Association,

No. 68 Wabash Ave.,

Chicago, Illinois.
All members of the Association should send their Annual Dues
to the Treasurer^ Richard J. Dunglison, M.D., Lock Box 1274, Phila
delphia, Pa.

London Office, 57 and 59 Ludgate Hill.
SATURDAY, AUGUST 10, 1889.

THE NEW CESAREAN SECTION.
Two notable papers that relate to the " New
Csesarean Section" have appeared at a recent
date. Fritsch,' of Breslau, has modified the
method of Sanger in two important particulars.
In the first place, he has rejected the sero- serous
suture. In a case of Csesarean section, according
to Sanger's method, he loosened the elastic tube
after the insertion of the muscle suture, to restore
the circulation, when he was surprised to see the
arrest of haemorrhage before the introduction of
the sero-serous suture. Observation of the con-
duct of the uterine walls after the enucleation of
myomata and the insertion of the etage suture
confirmed tlie impression that the Sanger sero-
serous stitch is superfluous. The way for this
step, however, was prepared bj' Schroeder, who re-
peatedly asserted that the welting-in of the peri-
toneum was not only unnecessary, but also a
source of danger, that best union could be effected
b)' the juncture of the cut edges of the peritoneum.
The second change in the technique of the opera-
tion is not less significant. Fritsch recommends
that the uterine suture be used to include all the
tissues — decidua, muscle and peritoneum — instead
of the muscle and peritoneum only as practiced by
Sanger. If the case is operated on early, the cavum
uteri is aseptic, and its sterilization by irrigation
and iodoform is purposeless. The decidua is as
sterile as the muscularis. Moreover, when the
stitch is tightened, the thread rubs through the
decidua and comes to lie upon the muscularis.
The advantages of this simple suture are substan-

■ Ceutralbl. f Gyn., No. 23, i&Sg. (Original— Mittheilung.i

tial. Much time and trouble are saved — of mo-
ment in such an operation. Then, it is possible
to effect a more exact apposition of the cut sur-
faces, and a firmer line of union by reason of the
amount of tissue included. Haemorrhage is also
better arrested, when the entire thickness of the
uterine parenchyma is embraced for some distance
from the edge of the cut. Fritsch inserts the su-
ture about I centimetre from the edge of the cut
on the left side, passes it through all the tissues
to a point distant about ' j centimetre from the
internal edge ; on the right side, the suture is
passed from within outwards. The sutures are
separated b)' a distance of i centimetre.

Against these modifications, but little on a pri-
ori grounds can be urged, seeing that Fritsch re-
ports two successful cases. The chief danger in
connection with the second item — the insertion of
the suture through the decidua — consists in the
liability to infection of the suture material, par-
ticularly if silk be employed. This danger is
present even when the cavum uteri is aseptic at
the time of operation ; obviously, the risk is
greatly' increased, when the decidua is infected
after attempts at delivery per ■vaginam and the
like. On this subject. Dr. Bayard Holmes" has
well said : "It makes no difference how small an
amount of infection gets into a solid spongy ma-
terial like a piece of silk. Cells do not migrate
into the silk suture far enough to drive out the
infection and, as it were, granulate it off. There-
fore, when the least end of a buried silk suture
becomes infected, it is only a matter of time until
colonization of the whole suture takes place. In
the tissues surrounding the suture granulation
tissue will appear, and a coagulation-necrosis of
the wall of this sinus will cause a collection of
pus to appear at the point of least resistance."

If further experience supports Fritsch's modifi-
cation, the old classical Cassarean section will be
rehabilitated after its notable substitution first by
Porro's supra-vaginal amputation and secondly by
Sanger's ingenious method. This fact, however,
will not lessen the merit of the work of the ob-
serv^ers just named. As remarked by Fritsch,
"Sanger's great ser\'ices are universally recog-
nized, they depend neither upon silver wire nor
sero-serous suture."

The second paper, by H. Thomsen,' contains

2 Transactions of the Gynaecological Society of Chicago, June

3Centralb. f Gyn., No. 24, iS

(Original — Mittheilung.)

200

PRURIGO SECANDI.

[August io,

the results of an experimental study of the best
suture material that may be used in intraper-
itoneal operations, in general, and in Caesarean
section in particular. The experiments were per-
formed on rabbits, cats, and bitches, immediately
after they had cast their young. Incisions several
centimetres in length were made through the
right and left horns of the uterus, and these cuts
were united with the suture materials under inves-
tigation. Different material was used to unite
each cut. Sutures were also placed in the omen-
tum and abdominal wall, to test not only the be-
havior of the ligature, but also the relative ab-
sorptive powers of the sites selected as compared
with the uterus. The materials used were carbol-
ic catgut, chromic acid catgut, silk and silk-
worm-gut. All materials were sterilized, as de-
monstrated by control cultures.

Thomsen draws the following conclusions: i.
Silk is the safest and best suture material, because
it can be absolutely sterilized, and in time is ab-
sorbed. 2. Chromic acid catgut, silkworm-gut,
like silver wire, are incapable of resorption, and
ought not to be used. 3. Carbolic catgut, like
all forms of catgut, ought to be rejected on ac-
count of the danger of infection. Moreover, car-
bolic catgut is unfitted for large intra-peritoneal
wounds by reason of its rapid absorption.

The methods of this investigation are well
chosen, and the conditions of the experiments
eliminate common sources of error. Thomsen's
conclusions, accordingly, may be accepted as de-
cisive in the vexed question of suture material,
for the time being at least.

PRURIGO SECANDI.
Professor Lkon LeFort, editor, or more ac-
curately speaking, author of successive issues of
Malgaigne's Surgery, and one of the leading op-
erators in France, is not a person whom even the
most venturesome of recent graduates will be apt
to accuse of undue timorousness in matters chi-
rurgical. Much weight may, therefore, happily be
attached to a warning from such a source against
the reckless and ill-considered abuse of the knife,
which has unfortunately been rendered possible
b\' the introduction of anaesthetics and antiseptic
measures, and which has reached so far that the
legitimate field of surgerj- has often been aban-
doned in an apparent endeavor to a.scertain how

much vivisection is compatible with the tempor-
ary maintenance of life.

Among the things which have almost become
afi"airs of everyday routine, L,eFort remarks,
cancerous stomachs have been resected, the spleen
and the kidney extirpated, vesical tumors re-
moved, the uterus and tubes ablated ; multitudes
of women hav-e been castrated, even when the
ovaries were healthy ; the knee-joint has been
opened to suture a simple fracture of the patella ;
the abdomen opened to fasten to its wall a pro-
I lapsed uterus, or even solely for diagnostic pur-
j poses, etc. ; and he cites an instance- wherein a
, surgeon, to spare a young woman's modest}^ the
inconvenience of a vaginal examination, preferred
an exploratory laparotomy, with the satisfactory
result of discovering that there was no abdominal
lesion. Certain operators of established notoriety,
or even their junior imitators, find occasion to
perform their favorite procedure hundreds of
times within a few months ; be it thyreoidectomj%
nephrectom3% hysterectomy, salpingotomy, rad-
ical cure of hernia, or aught else. Of this, the
author says : " When I see the multiplication of
successive operations for affections which a hos-
pital experience of more than fortj- years has
shown me to be either relatively rare or curable
by non-operative treatment, I am led to believe
that man)' of these surgeons, instead of asking
themselves what operation the disease and the
hopelessness of any other treatment compels them
to perform upon the patient, inquire rather who
is the patient whom thej' can induce to undergo
the operation just then under consideration not
to say in fashion."

Several influences combine to encourage this
operative craze, and of these the first to be men-
tioned is the pecuniary appetite which threatens
to degrade the healing art to the level of a trade.
Vemeuil is quoted as intimating that some sur-
geons who persuade a patient to risk the speedier
possibilities of the knife, with argument that
" time is money," may be suspected of a mental
reservation which whispers "operation is money
also," and it is even alleged that in Paris — let us
hope nowhere else — a commission on the op-
erator's fee is given to the physician who pro-
cures the ca.se, so that the latter is tempted
rather to seek the specialist who will insist on the
most lucrative, if unnecessary, operation, than to
consult the surgeon who can give the wisest ad-

1889.]

EDITORIAL NOTES.

201

vice. The public, hearing of brilliant successes,
but ignorant of possible dangers and disastrous
failures, and impatient of the tediousness of
safer and surer medical treatment, is readily in-
duced to fly to evils that it knows not of, and
thus aids skilled hardihood in bringing needlessl}-
heroic measures more and more into vogue.

A fanatical and exaggerated confidence in anti-
septic methods plays no small part in perpetuat-
ing the abuse. If ovariotomy be fatal in one
seventh of the operations performed, hysterectomy
in one fourth, nephrectomy in one-third, or lapar-
otomy' for myomata in one-half, the deaths are at-
tributed to neglect of some minor detail — to the
employment of an ill-prepared ligature or the
omission of this or that petty precaution against
the entrance of a few stray "germs," — and the
blame is ascribed to the individual surgeon, not
to the operation.

The principles which should guide the true
surgeon's intervention are these : The fact that
an operation is capable of curing a disease is not
in itself a justification for operating : the gravity
of the operation must be compared with the
gravity of the disease ; the benefit to the patient
must be proportional to the danger to which he is
exposed. It is not admitted that the mortal
character of a malady is a sufficient reason for
desperate expedients. There are cases where the
surgeon must recognize the impotence of his art ;
his first consideration should, be to avoid doing
harm, and he should learn to abstain whenever
the immediate dangers of active interference are
greater than the temporary^ amelioration that may
be hoped for. He .should not imperil life to re-
lieve an infirmity or deformity which does not
menace existence, unless it be such as to in-
capacitate the sufferer from earning a livelihood.
Ankylosis in a position rendering a limb useless,
extreme genu valgum, exaggerated rhachitic
distortions, ulcerated talipes preventing walking,
maj' warrant resection, osteotomy, or even ampu-
tation, but it is a different thing to expose a patient
with reducible hernia to the risk of immediate
death in order to save him the anno^-ance of wear-
ing a truss, or to avert the improbable chance of
a strangiilation twenty or thirty years later.
The interest of the patient is to be placed above
all other considerations ; a cure sought bj' the
surest and least hazardous therapeutic means
rather than by dangerous displays of dexterity ;

solicitude for the sanctity of human life, should
override professional ambition or monetar}' covet-
ousness. If any case give cause for doubt, let
the surgeon pause and ask himself "what he
would do, what he would advise, if the question
concerned his mother, his wife, his child ; and let
the answer dictate his conduct. So will he often
reject perilous heroic exploits ; he will perform
fewer operations ; he will acquire notoriety less
easily, and fortune, perhaps, not at all ; but he
will be sure of fulfilling his duty as a good and
honest surgeon, and of being regarded by his pa-
tients as vir bonus medendi peritus.'"

The warning which we have briefly transcribed
from its foreign source is reproduced in all its
fervid eloquence by the Gazette Medicate de Mo?i-
treal from the latest edition of the Mcdecine Op-
cratoire, of Malgaigne and LeFort, and most of
our readers will be willing to admit its pertinence
— at all events, to France. In displaying the
beam which obscures the surgical e)-e of conti-
nental Europe, it would, of course, be invidious
to suggest the possibility that ophthalmic intro-
spection might detect a mote in our own.

EDITORIAL NOTES.
HOME.
Dr. Thoji.\s W.\TERjr.\N, of Boston, is said to
be the most skilful ventriloquist in that city.

Dr. \Vili,ia:m Warren Potter, of Buffalo,
N. Y., has had conferred upon him the degree of
Doctor of Medicine, Honoris Causa, by the Ken-
tuck}' School of Medicine.

The American Society of Microscopists
commences its annual meeting at Buffalo on the
20th inst.

Ephr.\im Cutter. M.D., LL.D., F.S.Sc, has
received a gold medal from the Society of Science,
Letters and Art of London, for his paper on " The
Relations of Medicine and Music," and also for
one on " Hygienic Drinks " and one on "Cleaned
Wholewheat."

Dr. William Hailes, Jr., of Albany, N. Y.,
will read a paper on " Intubation of the Larynx "■
before the meeting of the British Medical Associ-
ation.

An Epidemic of Dysentery. — Dysentery has
become epidemic at Warsaw, 111., and the people

202

EDITORIAL NOTES.

[August io,

are becoming greatly alarmed. Fifteen deaths
liave occurred since the 29th nit, Fonr died on
the ist inst. and four on the 2d. It is now esti-
mated that at least 180 cases exist in Carthage,
111., and it is feared many of them cannot recover.
The victims are taken suddenly and die in a short
time. The disease has appeared at Hamilton,
and is said to be epidemic at Canton and Cahoka,
Mo.

Association Items. — Drs. D. Webster Pren-
tiss, of Washington, and L. Duncan Bulkley, of
New York, are the delegates to the meeting of
the Canadian Medical Association. The name
of Dr. Kinyoun should have appeared in the An-
nual Report of the Committee on State Medicine
in place of Dr. S. T. Armstrong. Dr. Charles
W. Brown, New York, is a member of the Com-
mittee on Necrology, not "J. W. Brown."

The Canadian Medical Association. — We
again call attention to the fact that the annual
meeting of the Canadian Medical Association will
be held at Banff, a station on the Canadian Pacific
Railway, in the heart of the Rocky Mountains, at
the entrance of the "Canadian National Park."
The meetings will be held on August 12, 13 and
14. The British Medical Association and many
societies of the United States have been invited
to attend. Special rates are oflFered by the rail-
way company. Application should be made to
the General Secretary of the Association, Dr. Bell,
whose address is Union Avenue, Montreal.

Sanitary Progress. — Why is it that our State
Legislatures do not take more interest in enacting
laws to secure immunity from preventable diseases
arising from inadequate sanitary regulations or
the enforcement of existing laws? The Sanitary
Ne7vs in commenting on this subject says : ' ' Leg-
islation seems to be the greatest obstacle in the
way of sanitary progress. Science has made
plain the duties of officers and citizens, but legis-
lation is tardy in providing means for their en-
forcement."

FOREIGN.

Father Conrady has been stricken with
leprosy at the leper settlement in Molokai.

A University under British tuition is being
established at Pekin, China, and the College of
Medicine in affiliation therewith is in working
order.

Female Medical Practitioners in Russia
are forbidden to attend adults of the male sex.

In Germany the Government has come to the
conclusion that there are enough medical colleges
in the country and refuses to allow any more to
be organized. Prof. Fresenius, of Wiesbaden,
after a long series of chemical analyses, declares
that an egg contains as much nourishment as a
pound and an ounce of cherries, a pound and a
quarter of grapes, a pound and a half of russet
apples, two pounds of gooseberries, and four
pounds of pears, and that 114 pounds of grapes,
127 pounds of russet apples, 192 pounds of pears,
and 327 pounds of plums are equal in nourish-
ment to 100 pounds of potatoes.

In France the Director of the Assistance
Publique has distributed among the iiijirmiers
and infirmicres of the Paris hospitals 2,000 tickets
for the Paris Exhibition. The decoration of the
Legion of Honor has been conferred upon Dr.
Allan Herbert, physician to the British Embassy
at Paris. The French Society for the Advance-
ment of Science is now in session. The practical
sanitation of the Paris Exhibition is said to be
execrable. The Minister of the Interior has
given 1000 francs to the Paris Ambulance Organ-
ization.

In Gre.\t Brit.\in the Privy Council has
issued an order in the City and Metropolitan Dis-
trict of London that dogs are to be muzzled, except
those actually eniplo3'ed as sporting dogs or in the
capture of vermin. The spread of rabies has
brought forth the order. Unmuzzled dogs will be
slaughtered, as also will those with or suspected
of rabies, or having been bitten by a rabid dog.
The Princess of Wales has accepted the Presi-
dency of the National Pension Fund for Nurses.
The weekly issue of the British Mcdica! Journal
has reached 15,550 copies. Professor Struther
has resigned the Chair of Anatomy at Aberdeen
Universit}'. An exhibition of electrical appli-
ances is now open at Birmingham and will con-
tinue for three months. Deputy Surgeon-General
Francis Day, a distinguished officer and natural-
ist, died at Cheltenham on the loth ult. The
sanitan,- condition of Glasgow is ver\' bad, and
the Corporation is considering the necessity of
applying to Parliament for increased sanitary
powers. The London Hospital has become affili-
ated with the National Pension Fund for Nurses.

1889.]

TOPICS OF THE WEEK.

203

TOPICS OF THE WEEK.

PHYSIOLOGICAL LIMITATIONS.

From the able address of Dr. David W. Cheever at j
the annual meeting of the American Surgical Association ]
held in Washington, Ma}- 14-16, 1889, we make the fol-
lowing brief extract: j

" When we consider physiology we are struck both by
its great progress and by its imperfections. The older
physiology is obsolete and discarded, but in the newer
physiology the functions of some large and important
organs are still undetermined. The ductless glands, for
instance, the spleen, the thyroid, the thymus and the
supra-renal capsule.

" An ignorance of their function renders the surgeon
unable to predict the consequences of their removal. Of
what avail the brilliant operation to excise a double goi-
tre if it is to be followed by an obscure degeneration of
the nervous or glandular system? Again, in organs of
known function the limit of the digestive power of dif-
ferent portions of the alimentary canal is not yet defi-
niteh- learned.

" How can we get along without a gall-bladder? How
important is the pancreas? Can the duodenum supplant j
the stomach in nutrition? How much ileum can be re- j
moved without starvation? What will the rectum digest? j
All these are pertinent questions for the physiologist,
and have a direct bearing on modern surgery."

PRESIDENTIAL ADDRESSES.

At the last annual meeting of the Ohio State Medical
Society the President, Dr. P. S. Conner, dealt with the
conventional "President's Address" after this fashion:

" As is the appendix to the intestinal tract, a useless
survival of a once important organ, so is the presidential
address to the annual proceedings of the State Medical
Society. In the days when books and journals were few,
communication slow, professional work physically hard-
er than at present, there was, I doubt not, good reason
for requiring of the recipient of high honors an abstract
of the year's progress, suggestions of the work that might
and should be done, or reports of diseases and injuries
carefully investigated and successfully treated.

"Now that to each one of us what appeared in print
but a short time ago in San Francisco, Boston, Vienna or
St. Petersburg is familiar talk, it may be well asked of
the inaugural address, Cui bono.' Hardly yours; surely
not his to whom the months of prospect of its prepara-
tion are as the flj- in the ointment of the apothecary.
But custom is imperious and we are all its slaves. Like
my predecessors, I obey its mandates."

CAFFEINE AS A TONIC.

Dr. Henri Huchard has some good observations to
present on the use of caffeine as a tonic or excitant in
adj-namic states. He considers it much superior to ether,
which may be more exciting but is much less tonic in its
action. The diuretic action of caffeine is now admitted
by everybody, but its cardiac action is still contested.
One point in the use of caffeine in adynamic states is

that it can be given in considerable quantities without
danger. In one case of extreme weakness (with from
forty to fifty stools a day) as many as ninety-five hypoder-
matic injections of caffeine were given in a month. Dr.
Huchard uses these injections with great freedom in tj--
phoid fever at the Bichat Hospital, as well as in cases of
serous pneumonia, and reports a number of cures in very
grave cases. In experiments that M. Huchard made on
animals, he found that the drug acted on the nervous sys-
tem, and Semmola, (of Naples) states that its principal
action is on the medulla oblongata. In any case two im-
portant facts are evolved from Huchards' experiments :
First, that caffeine has a remarkable efficacy in large
hypodermatic injections in all adynamic cases. Secondly,
it can be given in large doses without danger. M. Huch-
ard employs the following formulas: R. Caffeine, 2
grams ; benzoate of sodium, 3 grams ; and distilled water,
6 grams. The solution must be made while hot. Each
s\ringeful contains 20 centigrams of caffeine. Sig.: In-
ject 6 to 10 syringefuls/>c> dietn. The second formula is:
Caffeine, 4 grams ; salicylate of sodium, 3 grams ; dis-
tilled water, 5 grams. Here the syringe contains 40 centi-
grams of caffeine, and from four to five injections are
given each day. — Paris Correspondence New York 3fed-
ical Journal.

LEPROSY IN MADRAS.

According to census returns, the proportion of lepers
amongst the population of Madras 4.4 per 10,000 against 5.2
in Bengal and 8.5 in Bombay; but there is reason to believe
that these figures fall short of the actual extent of the
disease. In Madras it is on the whole slightlj- more
prevalent in coast districts than in inland, the ratios being
4.9 in the former, and 4.4 in the latter per 10,000 of popu-
lation. The proportion of lepers in the several districts
ranges from 2.0 in Coimbatore to 10.5 in Madras City.
The districts showing the highest ratios next to Madras
are Nilgiris S.o, Tanjore 7.0, and Chiugleput, Malabar,
and North Arcot each 6.0 per 10,000. The disease at-
tacks Europeans and Eurasians as well as natives, but is
most common in natives. The propagation of leprosy
is no doubt largely influenced by heredity, but recent ob-
servations appear to show that it is also contagious. In
localities in which lepers are at large with the disease in
an active state, and having open sores, there seems to be
an increased tendency to fresh cases amongst the general
population. As regards the part which heredity plays in
the transmission of leprosy, we know that persons with
the disease in an active state have diminished fecundity,
and that mortality* runs high amongst the offspring of
lepers. These two peculiarities, therefore, tend to keep
in check the leprous population, but I have no doubt that
it is increased by contagion and probably other influ-
ences. That segregation is of value in holding the dis-
ease in check seems well established, but to be of much
value in India it would require to be carried out on a
more extended scale than at present. — Surgeon-General
Bidie, British Medical Journal.

CHLOROFORM IN OBSTETRICS.

In regard to the use of chloroform in obstetrics, M.
BUDIN gives numerous cases to prove that labor pain can

204

TOPICS OF THE WEEK.

[August io,

be lessened by quite small doses of chloroform in most
cases. It is given here in the manner called " (P«^c'«V
chloro/orini}!g" that is to say, just enough to dull sensi-
bilitj-. In a few cases, however, it is necessary to proceed
to complete anaesthesia, which does not prevent labor
going on to a successful issue. The principal indication
for the use of chloroform in labor is found in extreme
pain. Often it is only during the period of expulsion
that it is needed, but when the pains are intense during
dilatation it may also be used. Rigidity of the os uteri
is an important indication. There is an estraordinar}-
degree of tolerance in parturient women for chloroform,
so that the contra-indications are extremely few.- — New
York Medical Journal, July 27.

NA.TUR.4L ELECTRICITY.

An extraordinary tale comes from Burmah. Mr.
Ronald H. King, an electrician well-known to the Bur-
mese, while on a prospecting and shooting expedition in
the island of Labuan, is said to have discovered a mineral
from which electricity can be obtained without apparatus
of any kind whatever. The mineral is described as being
in the form of a black stone, of excessive hardness, and
very great specific gravity, being nearly as hea\T,- as plati-
num. A small block in the shape of an irregular cube,
measuring 4.3 inches one way, b\- 5.2 inches the other
way was brought away, and on bringing it into the test-
ing room, a strong effect was noticed upon the galvan-
ometer. At first it was thought that the mineral was an
ordinary loadstone, but on tests being made, it was found
that the force was more akin to that of au electro-magnet,
and that a strong current would flow when the mineral
was connected in a circuit. Further tests revealed that a
difference of potential of forty-seven volts could be de-
tected at the extremities, the internal resistance of the
mass being twenty ohms. The block appears to waste
away very slightly, leaving a slight gray powder upon the
surface when connected up for some time. The elec-
trician now uses the block to light a couple of incan-
descent lamps in his laboratory ! — Times and Register.

SPECIAL HOSPITALS.

The Boston Medical and Surgical Journal of July 25th
devotes a page to a review of an address recently deliv-
ered in London by Sir Andrew Clark, President of
the College of Physicians. After an eloquent plea for
the generous support of the larger hospitals, he pays his
respects to a class of special hospitals who seek to divert
and divide the public charities, after this wise :

"A doctor who cannot get on in the ordinary way takes
to studying the great toe, and he discovers something
about it never before known. In the course of his studies
he ascertains that the diseases of the organ are not only
supremely important in themselves, but that they have
the most intimate relation to all the other serious diseases
of the body. He also invents a wonderful instrument,
whereby he can look into the great toe and sec what is
threatening, and prevent all those terrible things which
happen in the organ and affect the whole system. He goes
to his friends, shows them his instrument and tells them
of his discoveries. They then club together and establish
a Hospital for the Treatment of Diseases of the Great Toe.

They soon get patients who are convinced of the vast im-
portance of the diseases of the great toe. Marvelous
cures are effected, and all sorts of frightful diseases are
prevented. They have an annual meeting. They have
a Chairman who sets forth bashfully in the presence of
the great physician the diseases of the great toe, the won-
derful things that have been done, the service which has
been rendered by the hospital, the terrible prejudice it
has had to encounter, and the determination that this
great institution shall be liberally supported, notwith-
standing the prejudices of the medical profession and of
those who herd with them."

In all seriousness he raises the question whether special
hospitals have not been overdone in London, and the
contributions of benevolent people directed to unwise
uses. And the journal from which we quote raises the
question whether there is not a growing tendency in this
direction in our own large cities.

POISONING WITH ACETANILIDE.

Before the Baltimore Medical Association, Dr. J. E.
Gibbons recently read a paper on the results of a mis-
taken dispensing and administration of a onedrachm
dose of acetanilide where five grains of antipyrin had
been intended. The Maryland Medical Journal for Julj-
6th contains a brief account of the symptoms, which were
those of cardiac depression, cyanosis, and nausea. The
treatment, which removed the threatening prostration,
consisted of the use of tincture of belladonna and brandy.
The headache, for which the dose was takeu, was not re-
lieved, and Dr. Gibbons holds that if the second dose had
been repeated in two hours, as the mistaken directions
ordered, death would have been the result. There was
an error on the part of an apothecary, it is alleged, in
writing out the copj- of a prescription, causing the sub-
stitution of three drams of acetanilide for half a drachm
of antipyrin. It was a case of unauthorized " borrowing"
of a prescription by a neuralgic person who had not been
prescribed for by a physician. The antidotal doses of
belladonna consisted of four drops of the tincture, every
half-hour, for four hours, and at wider intervals after-
wards.—.\'. }'. Medical Journal, Aug. 3, 1SS9.

wilkesbarre's bad w.\ter.
A despatch from Wilkesbarre, Pa., states that the ty-
phoid fever epidemic in that citj- does not appear to be
on the decrease. The total number of deaths within
three weeks is thirteen. According to a well established
rule in typhoid, that the death-rate runs at from 10 to 12
per cent., this makes a certain existence of over 100
cases in the city. It is highly probable that the total
number of cases is largely in excess of that number.
Dr. L. H. Taylor, representing the State Board of Health,
made an examination of the water-supply system of the
Wilkesbarre Water Compau}-, and his report confirms the
first theory of the cause of the disease. He finds there
are twenty-five or thirty houses along the course of Lau-
rel Run, the stream from which the water is taken, and
holds the belief that the excessive rains of last month
washed the refuse of these houses into the stream. In
addition to the typhoid fever cases there are a great num-
ber of cases of malarial fever, dysentery, and kindred
diseases.

1889.]

SOCIETY PROCEEDINGS.

205

SOCIETY PROCEEDINGS.

AMERICAN MEDICAL ASSOCIATION.

Fortieth Ajinual Meeting. Repoi't of
Sections.

Sedio7is on Diseases of Children.
First Day, June 25.

The Section was called to order by the Chair-
man, Dr. John A. Larrabee, who delivered an
able and eloquent address. He congratulated
the Section on the opportune time and pleasant
place of the meeting, and said that none could be
more fitting for the burial of professional animos-
ities. An earnest plea was made for the rejection
of the amendment to the constitution pending
before the Association to abolish the Section on
Diseases of Children, and spoke highly of the
good work that the Section has and can ac-
complish.

On motion of Dr. Christopher, of Ohio,
the Section unanimously resolved to continue as a
distinct Section, and a committee of three were
appointed to bear the resolution to the general
Association, and defend the continued autonomy
of the Section.

On motion of Dr. E. F, Brush, of New York,
the recommendations of the Chairman's address
were referred to a committee, composed of Dr.
Brush, of New York, Dr. Christopher, of Ohio,
and Dr. Watson, of New Jersey.

Dr. T. B. GrEENley, of Kentucky, read a
paper on The Majiagement of Infants during the
First Year. The doctor gave statistics of the
alarming mortalitj' during the early years of in-
fant life, and carefull}' reviewed the causes for it.
He recommended the better education of mothers,
and advocated greater care of the infant in every
particular, Syphilis, in his experience, was a
frequent di.sease.

The paper was discussed by Drs. Senta, of
Texas, Whitney, of Rhode Island, Watson, of
New Jersey, and Latimer, of Maryland.

Dr. E. F. Brush, of New York, read a very
valuable paper on Cow's Milk for Infant Food.
The doctor took the position that cow's milk was
thp best and only practical substitute for the
mothers, and showed that if as great energy were
bestowed upon improving the quality of it, by
overseeing its source and its can after milking, as
has been given to the manufacture of various
chemical foods, great improvement in infant feed-
ing would result.

Dr. J. A. Jeffries, of Massachusetts, com-
mended Dr. Brush's paper, and advocated steriliz-
ing, when the milk cannot be obtained perfectly
fresh.

2:15 P.M.

Dr. Christopher, of Ohio, commended the
points made by the doctor on the management of
dairies. In Cincinnati he had seen some deplora-
ble instances in the manner of caring for milch
cows.

The paper was further commended and dis-
cussed by Drs. Sheldon, of New York, Latimer,
of Maryland, Gates, of Pa.

On motion of Dr. Watson the Secretary was
instructed to preserve the records of the Section,
and to give them to his successor.

On motion of Dr. W. P. Watson a committee
of three were appointed, to bring in nominations
for Chairman and Secretary of the Section for the
ensuing year.

Second Day, June 26.

The Section was called to order at
Dr, J. A. Larrabee, Chairman,

A paper by Dr. N. Guhman, St. Louis, Mo.,
on Summei Diarrlura and Dysentery was read by
title.

Dr. Peter Hooper, of Philadelphia, Pa.,
read a valuable paper on The hitestinal Diseases
of Children during Hot Weather.

The paper was discussed by Drs. W. P. Watson,
Jersey City, I. N. Love, St. Louis, Mo., and the
Chairman.

The paper, Heart Failure in Diphtheria, by
Dr. G. W. Jones, was read by title.

The paper on Intubation of the Larynx ivith re-
port of Cases was read by Dr. F. E. Waxham, of
Chicago. The doctor reported continued success
in the operation.

The paper was ably discussed by Drs. G. W.
Gay, of Boston, and Whitney, of Rhode Island.

Dr. H. D. Chapin, of New York, read a paper
on Pseudo-Me7nbraneoiis Hhinitis. The doctor
held that there was a pseudo- membraneous
rhinitis which was distinct from diphtheria, and
that it was a comparatively mild affection.

Dr. Cohen, of Philadelphia, agreed with the
doctor in there being each a disease distinct from
diphtheria,

Dr. Whitney thought the gentleman had
j described cases of nasal diphtheria.

Dr. C. R. Early, of Ridgeway, Pa., read an
j exhaustive paper on Scarlatina.

The committee on nominations reported the
name of Dr. I. N. Love, of Missouri, for President,
and Dr. E. F. Brush, of New York, for Secretary
of the Section for the coming year.

The Report was unanimously adopted.

Third Day, June 27.

Section called to order by the Chairman.

The committee on the Chairman's address re-
ported that they had met with the Committee on
Dietetics of the Association, and had adopted the
following preamble and resolutions :

Whereas, Certain garbled extracts from the proceed-
ings of this Committee on Dietetics, and the Section on

2o6

SOCIETY PROCEEDINGS.

[August io,

Diseases of Cliildren, have been published in medical
journals as advertisements, and thereby have reflected
upon this Association ; therefore be it

Resolved, That the Committee on Dietetics and the
Section of Diseases of Children, have not in the past, or
do they now, commend any of the proprietary prepara-
tions used as foods, and

Resolved, That the said Committee and Section ear-
nestly protest against the action of manufacturers in charg-
ing partiality for any food, and they hereby, condemn the
action of those medical journals which have published
such advertisements, and further,

Resolved, That a copy of these resolutions be sent to
The Journal of the American Medical Association
for publication.

E. A. Wood, M.D., Chairman Committee on Dietetics ;
Frank Woodburv, M.D., Secretary. J. A. Larrabee, M.D.,
Chairman Section on Diseases of Children; C. G. Jen-
nings, M.D., Secretary.

A paper by Dr. M. P. Hatfield, of Chicago,
on T/ie Value of Hydrogen Dioxide in the Treat-
ment of Children, was read by title.

A paper by Dr. D. S. Booth, of Sparta, 111.,
on Penal Rule in Public Schools, was read by title.

Dr. S. p. Deahofe, of Potsdam, O., read a
paper on Polio-myelitis Anterior Acute, in which
he related cases showing the difficulty in diag-
nosis often experienced, and the inutility of most
forms of treatment. He had seen no benefit from
electricity.

Discussed by Prs. King, of Chicago, and Peter
Hooper, of Philadelphia.

Dr. I. N. LovK, of St. I^ouis, read a valuable
paper on One )'ear of Acetanilide in Pediatric
Practice, in which he commended the remedy very
highly in various febrile diseases, chorea and
whooping cough, and praised the drug above anti-
febrin as an antipyretic and analgesic.

The paper was further discussed by Drs. Dixon,
of Kentucky, Hill of New Hampshire, King,
Watson, New Jersey, Atkinson, larrabee, and
Osier,

Dr. J. C. Wilson's paper on I'isceral Neic-
ralgias in Children was read by title.

Dr Wm. Perry Watson, of Jersey City, read
a paper on Atropin in Enuresis. Had found
usually good results from the use of the drug.
He had given the remedy in thirty cases, i gr. to
I oz., one drop each year.

The papers were discussed by Drs. Love,
Larrabee, Knapp, of Boston, and Jeffries, of
Boston.

Section of Dental and Oral Surgery.
First Day, Tuesday, June 25.

The Section was called to order by Dr. E. S.
Talbot, Secretary' of the Section, who announced
the fact of the death of Dr. F. H. Rehwinkel, of
Chillicothe, O., Chairman of the Section, which
occurred on June 8, 1889.

On motion of Dr. Jacob L. Williams, of Bos-
ton, Dr. W. W. Allport was elected Chairman
pro tempore.

Dr. J. S. Marshall, of Chicago, moved the

appointment of a committee of three to draft suit-
able resolutions upon the death of Dr. Rehwinkel.
The following committee was chosen : Dr. W.
W. Allport, of Chicago, Chairman ; Jacob L.
Williams, of Boston; and W. X. Sudduth, of
Philadelphia.

Dr. W. H. Atkinson, of New York, read a
paper on The Origin of Pus. A resume of the
paper is as follows :

1. Inflammation is a disturbance of nutrition
of a tissue causing a recurrence of the embryonal
condition of the tissue involved.

2. The embryonal condition is established by
the breaking up of the tissue into those medullary
or indifferent corpuscles which at an early stage
of normal development have built up the tissue.

3. The medullary corpuscles arise not only
from the protoplasmic bodies of the ti.ssue, the
so-called "cells," but also the intercellular or
basis substance is productive of such corpuscles,
as these have shared in the formation of basis
substance in the process of normal development.

4. The medullary or indifferent corpuscles will
still represent a tissue so long as they remain in-
terconnected and continuous. By a simple reap-
pearance of basis substance the most favorable
termination is established, so-called " resolution."

5. If the inflammatory or medullary corpuscles
have largely augmented, a number thereby re-
maining in original connection, the result will be
productive, viz.: with a newly formed tissue of
unusual size, a so-called "hyperplasia."

6. If the inflammatory corpuscles spring from
previous "cells," basis substance and blood-ves-
sels break asunder and become isolated, they will
be suspended in an albuminous liquid, they will
henceforth represent pus corpuscles.

Pus, therefore, is a destroyed tissue broken up
into its constituent elements, and as such unfit for
production of a new tissue, although the single
pus corpuscle will remain alive and amoeboid al-
most indefinitely, as long as they are sufficiently
nourished.

8. The emigration of colorless blood corpuscles
certainly participates in the formation of pus and
in the purulent discharge of proud flesh or gran-
ulation tissue, and is probably the main source of
the pus.

9. Suppuration is caused by the presence of
certain microbes, mainly the three varieties of
staphylococcus, only when a previous inflamma-
tion be present in the tissue, furnishing a favor-
able soil for the development of the before men-
tioned microbes.

10. Staphylococcus is not the only antecedent
of suppuration, it having been proved by exper-
iments that the introduction of certain chemical
agents unfavorable to the development of microbes
may likewise be followed by suppuration.

The paper was discussed by Drs. Sudduth, Wil-
liams and Brackett.

1889.]

SOCIETY PROCEEDINGS.

207

Dr. Wm. Carr, of New York, then read a pa-
per on Diseases of the Antrum, in which he re-
futed the statements frequently made by rhinolo-
gists that a large majority of the cases of antral
diseases are caused by chronic rhinitis, polypi and
other nasal diseases. The author claimed that 80
per cent, of all cases of abscess of the antrum
were the result of diseases of the teeth, usually
that of pericemental alveolar abscess, alveolo-
pericementitis and necrosis. He has operated
during the last eighteen months upon fourteen
cases referred to him by a nose and throat special-
ist, of which none were caused by chronic rhini-
tis, none from hypertrophic rhinitis, one from
dentigerous cy.st, two from polypi, and eleven from
diseased teeth.

The paper was discussed by Drs. Mar.shall, Sud-
duth, Atkinson, Williams, Talbot, and Brackett.

Dr. W. W. Allport, of Chicago, read a paper
upon Facial Neuralgia Associated with Pregnancy.
The author was not satisfied with any definition
of the term "neuralgia" that he could find or
any that he could make himself. He believed
that neuralgia of the face, and especially of the
teeth, was largely due, not to reflex neuroses but
rather to the hypera;mic condition of the upper
half of the body so constantly present during
pregnancy. This hyperremic condition is a pro-
lific source of irritation to the nerve filaments of
the mucous membrane, the skin of the face and
the pulps of the teeth, and through this irritation
most of the cases of neuralgia of the fifth pair of
nerves had their origin.

The paper was discussed by Drs. Williams,
Brackett and Atkinson.

On motion a committee on nomination of offi-
cers for the Section was appointed by the Chair-
man, consisting of Drs. Talbot and Marshall.

The Section adjourned to meet at 2 o'clock on
Wednesday afternoon.

Second Day, June 26.

Section called to order by Dr.W.W. Allport.

The Committee on Nominations reported : For
Chairman of the Section, Dr. Jacob I,. Williams,
of Boston ; for Secretary, Dr. E. S. Talbot, of
Chicago.

Dr. J. S. Marshall, of Chicago, read a paper
entitled. The Oral Cavity of Pregnatit Wo/nen.
The author described the changes which take
place in certain cases of pregnancy in the blood,
bones, teeth, excretions and secretions. Special
attention was given to the conditions of the secre-
tions of the mouth and the diseased conditions of
the mucous membrane, gums and the teeth. The
author claimed that in certain cases of pregnancy
nutrition was impaired and as a result the bones
and the dentine became abnormally soft, and that
this softening of the dentine predisposed the teeth
to decay. Overwork and mental strain also ren-
dered the teeth predisposed to caries. The acid

condition of the salivary secretions augmented the
action of the bacterium lactis in the production of
caries.

The acids found in the mouth during pregnancy
are the acetic, hydrochloric, uric and oxalic.

Lactic acid was the exciting cause of caries, as
proved by Miller, of Berlin, but that he believed
that the acids just named greatly augmented its
action. Gingivitis and phagedenic pericementitis
were often associated with pregnancy. The author
called attention to the fact that in patients affected
with phagedenic pericementitis there was often as-
sociated with it rheumatic afiections.diabetis melli-
tus or albuminuria, and that during pregnancy these
diseases of the mouth ran a more rapid course than
in other cases. The exalted nervous state of the
patient precluded severe or extended operations
upon the teeth as miscarriage might be the result.
Temporary fillings only should be inserted at such
times.

This paper was discussed by Drs. Williams,
Sudduth, and Andrews.

Dr. E. S. Talbot read a paper on Statistics 0/
Constitution and Developmental Irregularities of
the faivs and Teeth of Normal, Idiotic, Deaf and
Dumb, Blind and Insane Persons. He gave some
of the theories which are generally held up to
the present day. He then gave tables of irregu-
larities of the teeth of healthy persons, one made
by Dr. Ottofy, of Chicago, in which 317 males
and 306 females were examined, showing that the
largest percentages of irregularities was observed
at the age of 8 years. The cuspid teeth appear-
ing at this period was the cause, and that nature
corrected most of these irregularities later in life.
The author has examined the mouths of 1000
patients, showing 78 per cent, of normal cases and
22 per cent, of irregularities of the teeth. In
1,977 idiots 55.3 per cent, were normal, while
44.97 per cent, were abnormal. In 1,935 cases of
deaf and dumb cases showed 45. 5 per cent, normal
and 54.95 per cent, irregularities.

In the examination of the mouths of the blind
it was difficult to examine their mouths because
of their sensitive nature. There were however
enough examinations made to give a fair idea of
the condition of the teeth and jaws. Out of 207
cases 50.7 cases were normal, while 49.97 cases
irregularity. In 700 cases of insane cases 620 were
normal and only 80 cases of irregularity. It will
therefore be observed that in neurotic patients in
which the disease is present at birth about one-
half are afflicted with irregularities of the teeth,
while in normal individuals, and also in insane
cases, in which the disease is manifested after
maturity, only about 20 or 25 per cent, of cases
are noticed.

Third Day, June 27.

The Section was called to order at 9:30 a.m. by
the Chairman, //v tern.. Dr. W. W. Allport.

208

SOCIETY PROCEEDINGS.

[August io,

The reading of the minutes of the previous j
meeting was dispensed with, and the Chairman i
introduced Dr.W. X. Sudduth, of Philadelphia, |
who delivered a very interesting lecture upon The \
Products of the Epiblast, giving special attention
to the rete malpighii as the formative layer in the ;
development of glands, hair, teeth, nails, etc., 1
also its relation to certain pathological conditions, ]
such as epithelioma, carcinoma, and of the skin
diseases. He laid particular stre.ss upon the fact
that the initiative step in the development of all
the glands and tissues directly related with the
skin was to be found in the deepest layer of the
rete malpighii ; which, as he plainly showed, was
composed of oval and round cells, the bioplasts
of Beale, and not of columnar cells as is generally
understood.

The development of glands, sebaceous and su-
dorific, hair, and wool, the enamel organs of
the teeth, etc., is the result of the evolution of a
solid epithelial ingrowth which probably begins
in the division of a single cell of the infant layer
of the epiblast, which results in the formation of
one of the above-named tissues, according to the
hereditary tendency of the cell itself. The essay-
ist dwelt on the fact that histologically it was
impossible to differentiate between the several
cells, as to whether they would form a hair, a
gland, or the enamel organ of a tooth. They all
have the same morphological appearance and give
the same chemical reaction — and are also divided
from the same layer of the epiblast. He held
that each and ever^- cell was a separate and indi-
vidual unit, holding within itself an heredity
tendency which governed the form of the result-
ing product. This was beautifully shown by the
series of photo-micrographs, ranging from 200 to
1,250 diameters, in which the cellular structures
were clearly defined — the development of a hair
was followed from its incipiency to the comple-
tion of a full}^ formed product, also the develop-
ment of a tooth. The analogous development of
the two up to the time when calcification begins
in the latter, was graphically portrayed. It was
also shown how that a new hair was derived from
an epithelial bud which was thrown off from the
deepest portion of the previous hair-bulb, and
also that the cord for the formation of the perma-
nent tooth arose in a similar manner from the side
of the enamel organ of the temporary tooth. The
speaker also showed the special connection of the
deepest layer of the epiblast in the development
of epithelioma and carcinoma. He said that the
whorls of ejiithelial cells found in the former were i
not necessaril)' pathognomonic of epithelioma, in \
that similar ne.sts of epithelial cells were to be!
found in embrjonic ti.ssues where rapid develop-
ment was in progress, and that they were indica-
tions of the latter condition only. He-showed a
number of nests taken from sections of embryonic
tissues, which were identical in their appearance

to the pearl nests found in epithelioma. In dis-
eases of the skin he held that the deepest layer of
the rete malpighii formed a verj" interesting field
for investigation. The lecture was amply illus-
trated, and replete with information.

Dr. Andrews' paper on Pits and Fissures of
the Enamel, considered the etiology of decaj- at
these points. He showed that pits in the enamel
led to undermining decay of this tissue, and stated
that these defects were more frequent than is gen-
erally supposed. These cavities, enlarging, reach
the dentine, when infection and deca}- follows.
He stated that the deep fissures in the grinding
surfaces of the teeth often extended to the dentine,
and that the dentine was generally defective with-
in, the defect consisting of an interglobular for-
mation at this point. This interglobular structure
is more rapidly acted upon by the infection than
is the normal tissue everywhere about it. This
condition he considered largely hereditary. Ex-
posure of the dentine is frequently caused b}^
cracks in proximal surfaces near the neck, these
being a source of infection equally with the pits
and fissures of the grinding surfaces. Early in-
fection was shown to fill the exposed tubuli with
gas bubbles and granules. The gas bubbles are
caused, probably, by the action of an acid on the
lime cells of the dentine. This acid is given off
as a waste product of the organisms. The bub-
bles may easily be mistaken for the organisms
themselves.

The lectures were profusely illustrated b\' pho-
tomicrographs thrown upon the screen by the aid
of the new and improved lantern of the Mcintosh
Battery and Optical Co. The lantern was oper-
ated by Dr. Mcintosh, of Chicago.

The Committee on Resolutions on the death of
Dr. F. H. Rehwinkel then reported the following
resolution, which was carried :

Resolved, That the members of the Section on Dental
and Oral Surgerv in the American Medical Association
desire to express their sorrow on the loss by death of the
Chairman of this Section, Dr. F. H. Rehwinkel, of Chil-
licothe, O. And thev would place on record their high
appreciation of his character as a learned scientist and a
skilfnl practitioner for many years, and as an honorable
man in every walk of life.

On motion the Secretary- was instructed to send
a copy of the resolution to the family of the de-
ceased, and that copies be sent for publication to
the various dental journals of the country-.

A cablegram, was received from Prof Bu.sch,
M.D., announcing the fact that a Section of
Odontology has been organized for the Tenth In-
ternational Medical Congress to be held in Berlin
in iSqo.

The following cablegram was ordered sent to
Dr. Busch: "The Section on Dental and Oral
Surgery sends congratulations for the establish-
ment of the Dental Section, and pledges its hearty
cooperation."

1889.]

SOCIETY PROCEEDINGS.

209

The Chairman's Address did not arrive as ex-
pected ; it was therefore read bj' title and ordered
printed in The Journal at the proper time.

On motion the Section adjourned.

Americau Oplitlialniological Society,

Twenty- Fifth Annual Meeting, held at Peguot

House, New London, Conn., July ij

and 18, iS8g.

Wednesday, Morning Session.

The Society was called to order b^- the Presi-
dent, Dr. Wm. F. Norris, of Philadelphia.

Dr. Charles Steadman Bull, of New York,
read a paper on

AN analyses of 90 CASES OF SIMPLE

chronic gl.aucoma,

with special reference to the effects of iridectomj'
upon the acuity of vision and the visual field.
Detailed histories of the 90 cases were presented,
and the following conclusions formulated :

In endeavoring to draw some rational conclu-
sions from the study of 90 cases, it seems wise to
begin with a quotation from Priestly Smith, to
whom ophthalmologists owe so much of their
knowledge of the pathogeny and pathology of
glaucoma.

1. In considering the expediency of an opera-
tion in chronic glaucoma, he says, " In every case
of chronic glaucoma the responsibility of advising
an operation is a hea\'j' one and should on no ac-
count be undertaken without a full explanation to
the patient or his friends of the almost positive
certaint}^ of blindness on the one hand, and of the
uncertainties which beset ihe operation on the
other. Having regard to the age of the patient,
the impossibilit)^ of great benefit and the possi-
bility of a painful and accelerated progress, the
prudent surgeon will onlj' operate on the express
desire of the patient to receive the only chance of
benefit, however small it maj' be." Armed with
the preceding precaution, it seems to be our duty
to operate in cases of chronic progressive glau-
coma, and the earlier the better.

2. If the disease in a given case seems to be
stationary- and is still in the primary- stage, and if
it be po.ssible to test the vision and the visual
field at short intervals, delay in operating is per-
missible, but a weak solution of eserine or pilo-
carpine should be used daily, merely as an aid in
controlling the course of the di.sease. The exam-
ination of these patients should be at short inter-
vals and should invariably include tests for visual
acuitv and the careful examination of the visual
field."

3. If the di-sease exists in both eyes, but with
useful vision in both eyes, the eye in which the

disease is the more advanced should be operated
on without delay, and the surgeon will be guided
in his treatment of the fellow eye by the result of
the operation on the first eye.

4. To insure the best result the incision should
be made well into the sclerotic with a narrow
cataract knife or a broad lance knife, and the en-
tire iris from one end of the incision to the other
should be carefully torn or excised from its inser-
tion.

5. The most carefully performed iridectomy by
skillful hands is sometimes followed by rapid
loss of what sight still remains, sometimes partial,
but, unfortunately, sometimes total.

6. A successful result is, in the majority of
cases, more likely to follow the operation if it is
performed early in the course of the disease, but
the maintenance of the existing degree of vision
even in these cases is not invariable.

7. As regards the question of symmetry, it is
probable that in the large majority of cases, prob-
ably as much as So per cent. , the disease is sooner
or later present in both eyes, and a careful study
of the cases seems to establish the fact that there
can be no specific interval of time which insures
the second eye against an attack.

8. If the patient is old and feeble and one eye
still free from disease for a year or more after the
other eye has become affected, it may be consid-
ered prudent to avoid an operation on the aff"ected
eye, as it is probable that the unafi"ected eye may
remain free during the remainder of the patient's
life.

9. The condition of the field of vision is no
constant guide either in forming a prognosis as to
the progress of the disease or in deciding as to the
time of operation.

10. The acuity of vision bears no constant re-
lation to either the success or failure of the oper-
ation.

11. The anterior chamber is usually shallow, is
occasionally entirely absent, but is often appar-
ently normal in depth. The condition of the
chamber gives no reliable hint as to the state of
the vision or the visual field, nor any indication
as to prognosis.

12. The appearance and motility of the iris
appears to have some bearing upon the prognosis,
though perhaps not to the extent believed by
Nettleship. The latter states that in the cases in
which the iris reacts rapidly to eserine the opera-
tion proves successful. This has not always been
the experience of the reporter, but in the majority
of the cases in which eserine caused rapid con-
traction of the pupil, the visual acuity was
fairly good and the field was not seriously lim-
ited.

13. The depth of the excavation in and the
color of the optic disc seem to have no close con-
nection with the defective vision or with the limi-
tation of the visual field, nor did they offer any

2IO

FOREIGN CORRESPONDENCE.

[August io,

constant guide as to prognosis or to the effect of
operation upon the progress of the disease.

14. The condition of the intra-ocular tension is
a ver>' uncertain guide in deciding the time for
operating. It may be normal or increased, or
even diminished. It does not even seem to bear
any constant relation to the degree of visual
acuity, or to the state of the visual field. The
steady maintenance of the increased tension,
however, without any diminution, almost invari-
ably indicates the necessity for an immediate
operation, and this necessity is especially indi-
cated if the tension is continually on the in-
crease.

15. The health and age of the patient exert a
decided influence upon the effect of the operation.
Any marked evidence of senilitj^ is distinctly un-
favorable to operation.

Dr. H. Knapp, of New York : During the past
nineteen years I have operated on 670 cases of
glaucoma, 226 of which were cases of chronic
glaucoma. I think that the prognosis may be a
little more favorable than has been indicated by
Dr. Bull. I have had four cases in which ma-
lignant disease followed operation for chronic
glaucoma. I do not agree with the author as to
the advisability of the continued use of pilocar-
pine or eserine in those chronic cases where oper-
ation seems doubtful. I advise its use when
there are recurrent symptoms. In prognosis I am
guided a great deal by the condition of the iris.
My operations have been done with the lance-
shaped knife. I consider it of great importance
to carefully reduce the edges of the coloboma, not
only by external pressure, but also by the use of
the blunt probe. I am also careful not to make
the operation too peripheric. Peripheric wounds
are more liable to cystoid scars.

Dr. Emil Gruening, of New York, read a
paper on

IRIDECTOMY IN GI,.\UCOMA.

The speaker classified the different forms of
glaucoma under the following heads : i . Acute
inflammatory' ; 2. Chronic inflammatory without
visible degenerative changes in the iris; 3.
Chronic inflammatory glaucoma with visible de-
generative changes in the iris ; 4. Simple glau-
coma ; 5. Intermittent glaucoma, and described
cases illustrative of these different varieties.

Dr. S. O. Richey, of Wa.shington : I do not
believe that simple chronic glaucoma is to be en-
tirely a local affection. I think that it is a local
expression of a cause to be looked for in the nen--
ous system. I have used eserine with satisfaction
in the early stages, but I support it by galvanism
applied to the cervical ganglia. In some cases
this will enable us to avoid operation.

Dr. Samuel Theobold, of Baltimore : I have
met with one case in which an attack of pro-
nounced acute glaucoma was cut short by the use
of eserine.

Dr. C. S. Bull, of New York : Eserine is fre-
quently used in too strong solution. A solution
of half a grain to the ounce maj' cause iritis after
a single instillation. I never u.se a stronger solu-
tion than this. I often use one as weak as one-
tenth of a grain to the ounce.

Dr. B. Alex. Randall, of Philadelphia : I
can confirm the remarks in regard to the value of
weak solutions. In one case of severe absolute
glaucoma a solution of 'a grain to the ounce was
entirel}' successful in relieving the pain. It has
been used steadily for three years with no recur-
rence of the severe symptoms, and without the
intervention of any inflammatory' trouble.

Dr. S. p. Risley, of Philadelphia: In experi-
menting with weak solutions of eserine, I have
found that a distinct effect was experienced from a
solution as weak as one-thirtieth of a grain to the
ounce. If this was applied three times a day, it
would in two days cause distinct browache. I
have seen benefit from weak solutions where
stronger solutions failed to give relief.

Dr. Henry D. Noyes, of New York : One
point to which m)' attention was called many
years ago is that in certain instances of evident
glaucoma with a large amount of refractive error,
it has seemed that the aggravation of the glauco-
matous disease have been dependent upon the ac-
commodativestrain. In operating I have graduallj-
withdrawn from the external peripheral place of
incision. I prefer to come closer to the border of
the cornea than some do. This involves less risk
and is easier of performance.

Dr. Samuel Theobald, of Baltimore : My
experience tends to convince one that astigmatism,
and particular astigmatism against the rule, is
frequently the cause of glaucoma.

Dr. Arthur M.\Thewson, of Brooklyn : In
one case of glaucoma in which iridectomy had
been done without a.s.serting the progress of the
disease, a large injection of strychnia caused a
decided improvement of vision which continued.
I have used it in other ca,ses with good effect.
iTo be conclude J. \

FOREIGN CORRESPONDENCE.

LETTER FROM PARIS.

(FROM OUR REGULAR CORRESPONDENT.)

Prof. Bouchard' s Mixed Method of Treating
Typhoid Fever — The Pernicious Injtuenee of Arti-
ficial Feeding on Young Children — Dr. Dn Castel
on the Antiseptic Treatment of Blenorrhagia — In-
jections of Carbolic Acid in the Treatment of Car-
buncle— Soap as an Antidote for Carbolic Acid.

Professor Bouchard has a mixed method of
treating typhoid which consists in the application,
within certain limits, of antithermic and general
antiseps}-. General anti.sepsy is obtained by

1889.]

FOREIGN CORRESPONDENCE.

211

mercurial preparations. At the onset only of the
fever, during four days, the patient takes 20 pills of
2 centigrams of calomel per day. Balneotherapy is
prescribed as follows : As soon as the rectal
temperature pas.ses 40° C, cold baths, to the
number of eight in the twenty-four hours, should
be given. These baths should maintain the body
at a temperature of from 37° C. to 37.5° C. If
these baths do not sufficiently lower the tempera-
ture, the sulphate of quinine should be prescribed.
This medicament, according to the experiments
of Chantemesse and Widal, is an excellent micro-
bicide. The dose at the commencement should
be pushed to 2 grams in the twenty-four hours.
This will be gradually diminished, until a tem-
perature of 37° C. in the morning, and 38° C. in
the evening is obtained. As regards intestinal
antiseps}-, M. Bouchard gives the preference to
naphthol A, the antiseptic power of which acts
more especially on diatases or leucomaines, pro-
ducts of microbian excretions, and the toxicity of
which is altogether nil, even at 5 grams per day.
The following is M. Bouchard's favorite prescrip-
tion : Naphthol, salicylate of bismuth, of each,
5 grams to be divided in to ten powders, one of
which is to be taken every hour. According to
the author, the results of this mixed treatment
are most .satisfactorj-. It responds to all the in-
dications.

Professor Bouchard vaunts the application of
naphthol in the treatment of that loathsome affec-
tion called bromhydrosis. He prescribes it in the
form of a solution composed of i gram, 50 centi-
grams of naphthol, and 100 grams of alcohol.
He affirms that the foetidity of the sweating of
the feet disappeared after a few applications of,
this solution.

The pernicious influence of artificial feeding on
the health of young children, is well known. A
statistical report, published in Berlin bj- M.
Richard Bceckh, and which formed the subject of
a report by M. J. Bertillon to the Society of Pub-
lic Medicine, shows that the mortality of infants
brought up by the bottle is six or seven times
higher (all things being otherwise equal) than
that of those nourished by their mother's breast.

This statistic proves that neither the age of the
children, nor their legitimate or illegitimate con-
nection, nor the easy circumstances of their par-
ents could explain the difference between the
mortality of infants brought up by their mother's
breast, and that of those brought up by the bot-
tle. The considerable difference between the two
categories of infants (7 and 45 per 1,000 living of
each categorjO. is entirely due to the difference of
alimentation. It proves also that if the mortality
of illegitimate children, at Berlin, is in general
double that of legitimate children, it is owing to
the fact that the illegitimate children are, more
often than the legitimate children, brought up
by the bottle.

The opinions of Dr. Du Castel as expressed in
a note read before the Societe de Medecine
Pratique on the antiseptic treatment of blenor-
rhagia may be resumed as follows : Antisepsy
has always for result the maintenance of the
urethra in this state of asepsy, which modern medi-
cine seeks to obtain in everj' cavity which suppur-
ates, as favorable to the cure of suppuration. In
a certain number of cases, the antiseptic treat-
ment produces a cure remarkably rapid. It is
only in exceptional cases that antisepsy well con-
ducted does not produce a prompt improvement
of the inflammatory accidents, and a shorter dur-
ation of the acute stage. Antisepsy, practiced
early, diminishes the chances of the propagation
of the blenorrhagia to the posterior part of the
urethra, and renders vesical, prostatic and testicu-
lar complications more rare. The following are
the antiseptic agents employed in these cases : i.
The sulphate of quinine at i per cent., the per-
manganate of potash at .yii'iio, the bichloride of
mercury at jji-nuir, and the biniodide of mercury
at joTiTTu may be utilized, in the form of injec-
tions, in the treatment of acute blennorhagic
urethritis, and applied at the coijimencement of
the malady. Momentary contraindications may
be met with only in cases of local complications.
2. These agents, which, of themselves, constitute
the whole treatment, are superior to balsamic
remedies and to all of the procedures of the class-
ical method, as regards rapidity and innocuous-
ness of effects. 3. The preference should be ac-
corded to the bichloride, and perhaps to the
biniodide of mercun,% the value of which can
only be settled by experience.

MM. Arnozan and Lande have cited in the
Journal dc Mcdccitie de Bordeaux, two cases in
which injections of carbolic acid had given them
verj' remarkable results in the treatment of car-
buncle. In one case in particular, in a woman
aet. 65 years, affected with an enormous carbuncle
in the back, and the patient appearing to be in a
hopeless condition, the authors injected into the
cellular tissue of the peripherj' of the zone in-
flamed 5 grams of a solution composed as follows;
Glycerine, distilled water, of each 15 grams, crys-
tallized carbolic acid 3 grams. These injections
were made iu five points circumscribing the in-
flamed region. They represented a total dose of
50 centigrams of pure carbolic acid. The pain
caused by the first injection was very violent, but
in the evening this subsided, and an evident
amelioration was produced. On the evening of
the next daj', a fresh injection of 30 centigrams
only, on three points was made. On the third
day, 20 centigrams were injected. On the fourth,
fifth and si.Kth day 10 centigrams were injected.
From this moment convalescence commenced and
progressed regularly. This case is interesting in
more than one point of view. The patient was
in a hopeless state when the subcutaneous injec-

212

DOMESTIC CORRESPONDENCE.

[August io,

tions of carbolic acid were practiced, and it was
remarkable to see the rapidity with which the ac-
cidents had disappeared. Twenty-four hours after
the first injections, the amelioration was notable,
twenty-four hours later, the cure of the patient
was ensured. The dose at which the carbolic
acid was employed equally deserves attention, for,
notwithstanding the high dose of 50 centigrams,
the phenomena of intoxication which followed,
were almost nil. The authors conclude that this
case is suflBciently encouraging to render surgeons
less timid in the therapeutic applications of car-
bolic acid, and authorizes, in case of urgencj', an
energetic inten^ention.

The Moniteur Therapeutiqiie relates that ordi-
narj' soap, or indeed, any soap, is the best anti-
dote for carbolic acid. It must be administered
immediately after intoxication, and frequently re-
peated, until the disappearance of all the toxic
phenomena. " A. b.

DOMESTIC CORRESPONDENCE.

LETTER FROM XEW YORK.

(from our own correspondent.)

Dr. Roger S. Tracy' s Report to the Board of
Health on the Mortality of the City — The Board
disse»ii)!ating among the People a knowledge of the
Contagiousness of Tuberculosis.

A preliminaiA- report in relation to the mortal-
ity in this city for the year 1888, recently present-
ed to the Board of Health by Dr. Roger S. Tracy,
Assistant Sanitary Superintendent, has attracted
considerable attention on account of the somewhat
surprising deductions which he makes from the
results of his investigations. These are as follows:
" The death- rate in tenement houses is less than
the general death-rate of the city. The death-rate
in the large tenement houses is less than in the
smaller ones. That while diarrhceal diseases and
diphtheria show a greater death-rate in the larger
houses (leaving out the suburban districts, where
the conditions are xoxy different), phthisis and
pneumonia show comparatively little difference ;
that difference, however, being in favor of the
larger houses. The greatest general death-rate
among persons over 5 years of age, the next to
the highest death-rate from diarrhceal di.seases
and pneumonia, and markedly the highest from
phthisis, are in the district south of Fourteenth
Street and we.st of Broadway. The excessive
mortality in this part of the city is probably con-
nected with the great number of old houses and
the dampness of the .soil. These results are much
at variance with what was expected. It seems to
be sufficiently established that people do not live
under such extremely bad sanitary conditions in
the tenements as they have been supposed to."
The figures which he presents show that while in

1869 the general death-rate was 28. 13 and the tene-
ment death-rate 28.35, in 1888 the general death-
rate was 26.33 si^d the tenement death-rate only
22.71.

The way in which Dr. Tracy reaches his con-
clusions is somewhat as follows : Last j-ear the
sanitary police took a census of the tenement
house population of the city. The general death-
rate, in the estimated population, as just stated,
was 26.33, ^nd the fact that the highest death-
rate in the tenement house population is only 26,
and the general tenement house death-rate being
22.71, would at first seem to indicate that the pop-
ulation of the city has been underestimated and
the quoted death-rate is too high, or that all the
deaths belonging in tenement houses had not been
credited to them ; or else that the death-rate is
actually lower for the tenement house population
than for the rest of the city. It might be that
deaths which should have been credited to these
tenement houses have not been so credited. The
total number of deaths in institutions was 7,774;
of this number the former place of residence was
ascertained in 3,444 instances, and these deaths
have all been credited to the houses in which they
had lived. It is evident that the remaining deaths,
4,330, ought not to be credited solely to the ten-
ement houses, as man5' of them are from out of
town, many from boarding-houses and private
dwellings, many are immigrants just arrived, and
many are old people in homes and alm.shouses, or
infants in foundling or lying-in asjdums. It is a
fair conclusion, therefore, that the death-rate of
the tenement house population is lower than that
of the remaining population.

It would seem, then, according to Dr. Tracy,
that, so far as the risk of death in New York is
concerned, it is better to live in a crowded tene-
ment house than in a brown-stone mansion on
Fifth Avenue. It is probable, however, that the
greater part of the tenement population, if offered
the opportunity, would prefer to take their chances
in the Fifth Avenue mansion. There can be little
doubt that some mistake has been made in esti-
mating the existing conditions, and that the con-
clusion mentioned is not justified by the real facts
of the case. In commenting on Dr. Tracy's sta-
tistics the Ne-d' York Medical fournal says the
tenement house death-rate is perhaps given so low
because of the inordinately high estimated tene-
ment population ; and, of course, the higher the
error in an estimated population, the lower must
the rate of mortality fall. In the statistics given
the total population of the city is placed at 1,526,-
081, and the tenement population at 1,093,701 in
1888, while in 1869 the total population is placed
at 894,419, and the tenement population at 468,-
493 ; showing an increa.se of 625,209 in the tene-
ment population in twenty years. "In other
words, if Dr. Tracy's figures are correct," says
\.\\Q fournal, " the increase has been almost wholly .

1889.]

DOMESTIC CORRESPONDENCE.

213

in the tenements ; the private house classes have
grown only 6,453 i'^ twenty years, or onlj' 323 per
annum. This is incredible ; there have been
thousands of houses put up in that time, to say
nothing of the great number of beings that fill
them. The better, or well-to-do, class, has not
been stationarj'. Stated proportionally, accord-
ing to Dr. Tracy's data, the rate of increase has
been over 133 per cent, in the one class and less
than 1.5 per cent, in the other. If our point is
well taken, it must be seen that a good deal of
what Dr. Tracy says goes for nothing."

It is a fact that when there has been continuous
hot weather for a number of days the mortality in
New York often mounts up from 600 or 800 to
over 1,000 deaths a week, and this increase is al-
most entirely in the tenement house population,
being due to diarrhoeal disease in infants and
3'oung children. A reporter of one of our most
reliable papers recently accompanied one of the
summer corps of the Board of Health's visiting
physicians in his house to house inspection in a
down-town tenement district ; and this is what he
saw: "The street was filthy, a fact that the
housewives along the thoroughfare attributed to \
itinerant peddlers of fish and fruit, whom thej'
charged with hiding their refuse stuff in ash bar-
rels. But whatever was the cause, there was en-
gendered a nauseating stench that came up in
volumes under the scorching heat of the sun.
But filthy and foul-smelling as the streets are, the
habitations are more intolerable in both respects.
The floors of the dark hallwa\-s are covered with
dirt, while the walls are grimj' with dust and [
smoke. In these pig-pen alleys half naked chil- 1
dren that look as though they had never had a I
bath in all their lives play together in a half-
hearted way, without laughter and almost with-
out smiles. They do not seem to have enough
life in their pale little bodies to get up a health}^
romp, if such a thing were possible in such an
atmosphere. Each of these tenements has a
housekeeper, who is generally unclean, unkempt j
and slovenly. The other women in these houses
are usuallj- of the same description as the house-
keeper. They seem to have an antipathy to water
in any form, and spend much of their time hang-
ing about the doors and gossiping. The rooms in
which many of these people sleep beggar descrip-
tion. They are small, badly ventilated, and filled
with stifling, foul odors; and what makes it worse
is that the apartments are overcrowded to an ex-
tent that indicates a great mortality in the event
of a contagious disease breaking out." Any one
at all familiar with New York tenement house life
will acknowledge the correctness of this picture
as applied to many districts of the city.

It is a fact, however, that during the last few
3'ears much has been done to ameliorate the con-
dition of the poor, and especially to sav'e the lives
of the children ; and there can be little doubt that

I the death-rate among the tenement population has
been materially diminished. Each year the Chil-
dren's Aid Society and the St. John's Guild care
for many thousand children, and numerous sum-
mer homes among the churches provide fresh air
and countrj' pleasures for the poor ; while many
lives are saved by the summer visiting corps of

I the Board of Health.

' The Board of Health has been doing a verj'
good work in disseminating among the people a
knowledge of the contagiousness of tuberculosis
and the simplest and most eflicient means for the
prevention of its spread. In June an able report
on this subject was submitted to the Board by the
pathologists, Drs. T. M. Prudden, H. M. Briggs
and H. P. Loomis, and more recently ten thousand
copies of a set of rules to be observed for the pre-
vention of the spread of consumption have been
printed for distribution. As this is probably the
first instance in which any regulations regarding
this disease have been promulgated b}- the public
sanitary authorities, it may be of interest to ap-
pend them.

1. Do not permit persons suspected to have con-
sumption to spit on the floor or On cloths unless
the latter be immediately burned. The spittle of
such persons should be caught in earthen or glass
dishes containing the following solution : Corro-
sive sublimate i part, water 1,000 parts.

2. Do not sleep in a room occupied by a person
suspected of having consumption. The living
rooms of a consumptive patient should have as
little furniture as practicable. Hangings should
be especially avoided. The use of carpets, rugs,
etc, ought always to be avoided.

3. Do not fail to wash thoroughly the eating
utensils of a person suspected of having consump-
tion as soon after eating as possible, using boiling
water for the purpose.

4. Do not mingle the unwashed clothing of
consumptive patients with similar clothing of
other persons.

5. Do not fail to catch the bowel discharges of
consumptive patients with diarrhoea in a vessel
containing corrosive sublimate i part, water 1,000
parts.

6. Do not fail to consult the family physician
regarding the social relations of persons suffering
from suspected consumption.

7. Do not permit mothers suspected of having
consumption to nurse their offspring.

8. Household pets (animals or birds) are quite
susceptible to tuberculosis ; therefore do not ex-
pose them to persons afflicted with consumption ;
also do not keep, but destroy at once, all house-
hold pets suspected of having consumption ; oth-
erwi.se they may give it to human beings.

9. Do not fail to thoroughly cleanse the floors,
walls and ceilings of the living and sleeping rooms
of persons suffering from consumption at least
once in two weeks. p. b. p.

214

BOOK REVIEWS.

[August io,

Expenses of Officers of Sections.

Mr. Editor: — The following letter is one of
several, of similar import, that I have received
during the last six weeks :

"N. S. Davis, M.D.

Dear Doctor : — How are the uecessary expenses of the
various Sections — expenses for stationery, etc. — to be
met ? I hope arrangements will be made for meeting
them out of The Journai. fund of the Association. The
Secretaries of Sections have already been put to a large
expense for printing, correspondence, etc.
Yours truly,

A. B., Secretary of Section."

Some of these letters came to hand a little be-
fore the meeting at Newport, when I was too
much occupied to take time to examine closely
the Constitution and By-laws relating to the sub-
ject, and gave for answer, that if no provision
already existed for meeting the necessarj- expenses
of the Secretaries of the Sections in executing
their ofiBcial correspondence, the defect could be
remedied by proper action of the Association
while in session at Newport.

As no action was taken upon the subject at the
recent meeting, and the above letter has reached
me since, I think it proper to call attention to the
following clause of the Constitution [Section vi.
Funds and Appropriations], " The funds may be
appropriated for defraying the expenses of the
Annual Meetings, including the necessarj' expenses
of the Permanent Secretary' in maintaining the ne-
cessary' correspondence of the Association ; for pub-
lication ; for enabling the Standing Committees to
fulfil their respective duties, re ;/a'?/r/ their correspon-
dence, and procure the materials necessar3' for the
completion of their stated annual reports," etc.

This has constituted a part of the Constitution
since the adoption of that instrument, in 1847,
and for the first thirteen years all the scientific
and professional work of the Association was done
by Standing Committees on Medical Education,
Medical Literature, Practical Medicine, Surgen,-,
Obstetrics, Epidemics and Hygiene, etc., and it
plainly provided for defraying the expenses in-
curred by such committees in conducting their
necessarj' correspondence. When, in i860, all the
work of these committees was transferred to the
several Sections, this provision of the Constitution
certainly became as applicable for the payment of
the necessary expenses of the Secretaries in con-
ducting the proper correspondence of the Sections,
as it had previously been to that of the Standing
Committees.

It would be necessary for the Secretary of the
Section to keep an accurate account of such ex-
penses and to render a bill of items to the Treas-
urer of the Association, which when paid would
remain as a proper voucher in his hands.
Yours truly,

N. S. Davis.

Chicago, 111., July 29, 1889.

BOOK REVIEWS.

Materia Medicv and Ther.^peutics, for Phy-
sicians AND Students. By John B. Biddle,
M.D., late Professor of Materia Medica and
General Therapeutics in the Jefferson iledical
College, Philadelphia. Eleventh Edition, Re-
vised and Enlarged, with Special Reference to
Therapeutics and to the Physiological Action
of Medicines. By Clement Biddle, M.D.,
U. S. N., and Henry Morris, M.D., Fellow
College of Physicians of Philadelphia, etc.
Philadelphia: P. Blakiston, Son & Co , 1889-
Pp. xix-607. Price, $4.25.

The changes which are constantly being made
in Materia Medica by the introduction of new
remedies and the abandonment, partial or entire,
of others, necessitates frequent revisions of the
standard works of this class of books. When
these are of a voluminous and exhaustive charac-
ter the purchase of revised editions is often a mat-
ter of very considerable expense; but there are,
fortunately, less pretentious works which ser\-e
an admirable purpose while recommending them-
selves to the physician, by reason of their com-
parative inexpensiveness. The present edition
of Biddle's well-known treatise is of such a char-
acter. It is a well balanced book and is thor-
oughly modern. Shorn of all that is redundant
in the way of botanical descriptions and explana-
tions of pharmaceutical and chemical prepara-
tions, and presenting concise accounts of the
principal physiological actions of the remedies
described, it affords one most valuable and enter-
taining reading. It does not, of course, take the
place of the cyclopaedic treatises on materia med-
ica which aim at giving complete accounts of the
multitudinous experiments which have been con-
ducted with painstaking care in the various coun-
tries of the world ; it does not even tell us much
of what can not be accomplished by remedies ;
but it does give, in concise form, the principal
physiological actions and therapeutical applica-
tions of the more valuable remedies at our com-
mand. Among the newer remedies introduced
in this edition we find hypuone, urethan, papaya,
adonidine, strophanthus, sparteine, morrhuol, io-
dol, lanolin and saccharin ; while a new chapter
has been added on the subject of antipyretics, in
which the phenyl derivatives, such as acetanilide,
resorcin, hydroquinine, pyrocatechin, salol, naph-
thaline, pyridine, kairine, thalline, antipyrin, etc.,
have been well treated.

Papers Read before the Medico-Legal So-
ciety OF New York. Third Edition (^First
Series). New York : Medico- Legal Journal
Association. 1889.
Casper's great work on forensic medicine is to

be found in the libraries of most of those who-

1889.]

BOOK REVIEWS.

215

profess any extensive knowledge of this depart-
ment. Notwithstanding its author has been dead
for more than twenty-five 3'ears, age appears not
to have made it the less valuable. But it is not
given to all branches of science to grow old so
slowly, and the wisdom of the Medico-I^egal So-
ciety, of New York, in reprinting all the papers
which have been read before it, is apparent. The
present volume,. or first series, includes papers read
in the years 1 868-' 69-' 70 and '71. In Dr. Jas.
J. O'Dea's essa}- regarding "The Sphere, Rights
and Obligations of Medical Experts," he says:
"Next to slander, unreasonable expectation is
the greatest foe to character." If physicians
acted wisel}' they would insist upon drawing a
sharp line of distinction between the medical wit-
ness and the medical-expert witness. Expert
testimony begins where ordinary testimony ends.
The expert witne.ss does more than bear testi-
mony to facts, he delivers opinions not only on
what he himself has observed, but also on what
ordinary witne.sses have stated under oath.

The observ^ation of facts, listening to their re-
cital, weighing and classifj-ing them after due ex-
amination, and so finall)^ rising to a conception of
the general principle of which they are the ex-
pression, constitutes the task of an expert wit-
ness. Stating this conception in appropriate
language is the deliver}- of an opinion. Accord-
ing to Plato, an opinion is at best but a mean
between knowledge and ignorance ; and the more
generally it is understood in this light, the better
it would seem to be for all.

To prevent experts from usurping a power
which they might be tempted to use for the ben-
efit solely of the party calling them, it is sug-
gested as the proper remedy that the court alone
should call and examine medical experts. The
author's view in this respect is supported bj' Prof.
Ordronaux. Under the usual methods the expert
is practically pledged to support the side that
calls him, or if not, the council will lead or force
from him an opinion in the desired direction,
using all his skill to bend it to the cause for
which he contends, or failing, will beat down or
belittle it in the estimation of the jury. Would
it be possible to reach a rational or honest opin-
ion under such circumstances, when an opinion is
at most but an approximation to the truth, often
not far removed from ignorance, and should never
be ventured except the opportunity be given to
arrive at it in a way that is intellectually honest.

A Guide to Therapeutics and Materia Med-
iCA. By Robert Farouharson, M.P., M.D.,
Edinb. Fourth American, from the Fourth
English, Edition. Enlarged so as to include
all preparations ofScinal in the U. S. Pharma-
copoeia, by Frank Woodbury, A.M., M.D.
Philadelphia: Lea Brothers & Co. 1889.
This work, well known to students and prac-

titioners, preserves the same form which has
characterized it in its former editions, although it
has been practically rewritten and very consider-
ably enlarged. In the hands of its author it has
been made to accord with the British Pharmaco-
poeia of 1885. There have been seventeen omis-
sions, and the author would gladly have excluded
a greater number of_ useless articles which still
receive official sanction. There have been 113
primary articles and their preparations added.
The terminations of the names of alkaloids has
been made uniform by adopting the English -hu-
and Latin -ina, i. e., codeine and codeina. Both
the metric and apothecaries' systems are used
side by side throughout the book.

The American editor has added some sixty
pages at the end of the volume, including a few
new non-officinal preparations and an Epitome of
the National Formulary issued by the Committee
of the American Pharmaceutical Association. The
reader will look in vain for such substances as
antifebrin, strophanthus, peroxide of hydrogen,
salol, lanolin, naphthol, sulphonal, saccharin, and
others. However, this work has made its repu-
tation, and will hold it. It may have been pru-
dent to leave out many of the drugs now under
investigation, but we usually look for new light
• upon them when a new book or a new edition of
an old one appears.

Synopsis of Human Anatomy. Physicians'
and Students' Ready Reference Series. By
Jas. K. Young, M.D. Philadelphia and Lon-
don. F. A. Davis, publisher. 1889.
This volume is one of a series, future volumes
of which are to appear from time to time. The
author states in the preface the object of the work,
which it would seem is intended to fill a want
rather more extensive than its title and character
justify.

We hope that students will not depend for
their knowledge of anatomy upon any synopsis
of the subject ; it would be a retrogressive step
anything but desirable. Anatomy is a science,
1 and the presentation of its bare outlines ser\'es
j only to detract from it as such. A student who
has a true scientific spirit would never be .satis-
fied with any short or condensed presentation of
this most important subject. It is unfortunate
indeed for the science of anatomy that it tempts
1 men to present it in this way. As a Synopsis of
' Anatom}- the book is accurate and excellent, but
I as a substitute in the schools for other and larger
works, we cannot recommend it ; as a short-cut
for the acquirement of a broad science we depre-
cate it. It may facilitate the already too rapid
mode of acquiring a knowledge sufficient to pass
an examination, and there are many who, not
being in hearty sympathy with the scientific spirit
of the profession they study, are glad to avail
themselves of abridged volumes, even though

2l6

MISCELLANY.

[August io, 1889.

they lack the life and inspiration which no true
science ever wants, and which its devotees must
and always will find in it. As a work of ready
reference its value depends upon its accuracj',
completeness and the e.xcellence of its arrange-
ment ; we do not hesitate to commend these.

MISCELLANY.

PAMPHLETS RECEIVED.

A Year's Record of Seventy-five vSuccessful Cases of
-Abdominal Section. By B. Curtis Miller, M.D., Charles-
ton, W.Va. (Reprint. 1

Phvsiological Basis of Objective Teaching. Bv Mar-
shaH'Calkins, A.M., M.D., Springfield, Mass.

Two Suggestions for Improving the Operation of Ex-
cision of the Knee-joint for Strumous Disease. By A. G.
Miller, M.D., F.R.C.S., Ed., Edinburgh, Scotland. (Re-
print. )

Twelfth Report of the State Board of Health of Wis-
consin for 1 888.

Medicai, Society of the State of Pennsylvania.
— At a meeting of the Committee, held at Pittsburgh,
July 15, the following resolutions were adopted :

Whereas, The annual meeting of the Medical Society
of the State of Pennsylvania, which convened at Pitts-
burgh, June 4, 1S89. was adjourned until the first Tuesday
of the following September, by reason of the distress
and confusion caused by the flood in the Conemaugh
Valley ; and ]

WHERE-A.S, It is the opinion of many prominent mem-
bers of the Society that a successful meeting of the Soci-
ety cannot belield during the present calendar year, for
many reasons, the chief of which is, that the sorrow and 1
suffering caused by the recent great calamity still op-
presses the entire connnunity to such an extent as to in-
fere with an early meeting ; therefore, be it

Resolved, That the meeting of the Medical Society of
the State of Pennsylvania, which was adjourned to meet
September 3, 1SS9, be still further adjourned until the
second Tuesda}- of June, 1890.

An Important Decision. — In the case of the People
vs. Blue Mountain Joe, the Supreme Court of Illinois
held that section 1 1 of the Medical Practice Act, which
prohibits itinerant venders of medicines, nostrums, etc.,
from operating in the State, to be valid. The point was
raised in the present case that this section was not cov-
ered by the title of the Act, and therefore invalid. The
last General Assembly attempted to repeal the Act, it
being thought invalid, but this decision sustains the .\ct
in every particular.

The Brainard District JIedical Society, of Cen-
tral Illinois, met at Delavan, 111., July 25. An interesting
meeting was held. The leading paper presented was on
the "Etiology of Tubercular and Scrofulous Disease,"
by the President, Dr. S. T. Hurst, of Greenview. Drs.
N. Holmes and .\. G. Ser\'Oss were appointed essayists
for the October meeting, with the topics "Hysteria"
and " Intermittent Fever " respectively.

Encouraging Science. — The Vermont Microscopical
Association has just announced that a prize of $250, given
by the Wells & Richardson Co., the well-known chem-
ists, will be paid to the first discoverer of a new disease
germ. The wonderful discovery by Prof Koch of the
cholera germ, the cause of cholera, stimulated great re-
search throughout the world, and it is believed this lib-
eral prize, offered by a house of such standing, will great-
ly assist in the detection of microorganisms that are the
direct cause of disease and death. All who are interested
in the subject and the conditions of this prize, should
write to C. Smith Boynton, M.D., Secretary of the .Asso-
ciation, Burlington, Vt.

LETTERS RECEIVED.

Dr. N. O Lane, North St. Paul, Minn.; Dr. S. N. Sims,
St. Joseph, JIo. ; Gladstone Lamp Co., New York ; G. &
C. Merriam & Co., Springfield, Mass.; Dr. D. B. Wise,
Mt. Eaton, O.; I. Halderstein, New York; Dr. A. L.
Hummell, Philadelphia ; Druggisfs Circular.New York;
Dr. J. B. Roberts, Philadelphia ; Dr. Herbert Judd, Gales-
burg. 111.; Dr. T. D. Crothers, Hartford, Conu.; Dr. J. A.
Blanchard, Umatilla, Fla. ; Dr. J. Barton Hopkins, Phila-
delphia; Dr. Robt. Newman, New York ; Dr.W. B. Atkin-
son, Philadelphia; The Levitvpe Co., Chicago; Dr. L.
Elliot, Washington; Dr. S. M. Horton, Fort .\dams, R.I.;
Dr. W. B. Hopkins, Philadelphia ; Dr. Walter Channing,
Brookline, Mass.; Battle & Co., St. Louis ; Dr. K. Meller,
Lincoln, Neb.; Dr. A. F. Brock, St. Louis; Dr.C. S.Wood,
New York ; Dr. McPheron, New York ; The Analyst
Publishing Co., New York ; Dr. J. F. Jenkins, Tecumseh,
Mich.; Dr. Dewees. Salina, Kan.; Dr. J. V. Shoemaker,
Philadelphia ; Dr. J. B. Ingals, Meriden, la.; Dr. Harold
N. Mover, Chicago; Dr. Henry O. Marcy, Boston; Witt-
hoff, Marsilly & Co., New York; Dr. Tho'mas L. Bennett,
Kansas City, Mo.; Dr. William Carroll, New York; Gus-
tave E. Stechert. New York; Dr. Henry Smith, Philadel-
phia ; Dr. J. L. Bland, Houma, La.; Dr. E. S. Elder, In-
dianapolis, Ind.; The Provident Chemical Works, St.
Louis ; Dauchv & Co., New York ; Rees Printing Co.,
Omaha, Neb., Dr. H. H. Powell, Cleveland, O.; Dr. L. S.
Trowbridge, Detroit, Mich.; Fred. C. Van Horen, New-
York ; Dr. N. S Watson, Matteawan, N. Y.; Dr. J. M.
Emniert, Atlantic, la.; Dr. C. W. Richards, Washington;
Dr. A. F. .\. King, Washington ; Dr. Joseph E. Root,
Harford, Conn.

BOOKS RECEIVED.

Book on The Physician Himself, and things that con-
cern his Reputation and Success. By D. W. Cathell,
M.D., Baltimore, Md. Philadelphia : F. .\. Davis. i,SS9.

Transactions of the Southern Surgical and Gynecolog-
ical Association. Vol. i. Session of 1888. Birmingham,
Ala.: Caldwell Printing Co.

Official List of Changes in the Stations and Duties of
Officers Serving in the Medical Department, U. S.
Army, from July zj, iSSg, to August 2. /SSg.

Capt. William R. Hall, Asst. Surgeon, is granted leave
of absence for ten days. Par. 5, S. O. 80, Hdqrs. Dept.
of Dak.. July 27, 1SS9.

Capt. Samuel Q. Robinson, .\sst. Surgeon U. S. Army,
leave of absence for two weeks granted by par. 11, S.
O. 165, from these hdqrs., is hereby extended ten days.
Par. S, S. O. 172, Hdqrs. Div. Atlantic, July 30, 1,^89!

By direction of the Secretary of War, so much of par. i,
S. O. 159, .-v. G. O., July 12, i.S.Sg, as directs Capt. Louis
Brechcmin, .\sst. Surgeon, to return to his station at
the close of the encampment of the Illinois National
Guards, is amended to direct him to report in person
not later than .\ugust 20, 18S9, at F't. Robinson, Neb.,
for duty at that place. S. O. 174. Hdqrs. of the .\rmy,
Adjutant General's Oflice, Washington, July 30, 1889.

First Lieut. Robert R. Ball, Asst. Surgeon, extension of
leave of absence granted in S. O. 167, July 22, 1889,
from this oflice, is further extended ten davs. Par. 23,
S. O. 169, A. G. O., Washington, July 24, 1889.

First Lieut. H. S. T. Harris, leave of absence granted in
S. O. 140, A. G. O., June 18, is further extended two
months. Par. 9, S. O. 176, A. G. O., August i, 18S9.

^n

THE

J ournal of the American Medical Association

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.
PUBLISHED WEEKLY.

Vol,. XIII.

CHICAGO, AUGUST 17, 1889.

No. 7.

ADDRESSES.

THE NEED OF DISCUSSING OPHTHAL-
MIC SUBJECTS.

An Addiess deliz'cnd before the Seciion of Ophthalmology of the
American Medical Association. June 25, 1889.

BY GEO. E. FROTHINGHAM, M.D.,

OF ANN ARBOR, MICH., CH.-VIRM.1N OF THE SECTION.

It is my pleasant duty, respected colleagues, to
welcome you as you commence the second decade
of work in this Section. Believing that those of
like tastes and pursuits can develop best by oc-
casional reunions and interchange of views, the
ophthalmologists of the American Medical As-
sociation met and organized this Section at the
meeting in Buffalo, in 1878. Drs. X. C. Scott,
of Cleveland, Eugene Smith, of Detroit, and
Dudley S. Reynolds, of Uouisville, were the orig-
inators of the movement. Dr. H. Knapp, of
New York, was elected Chairman, and Dr. X. C.
Scott, of Cleveland, was made Secretary'. The
first meeting of the Section for actual work was
at Atlanta, Ga., May, 1879.

The late Dr. E. Williams, of Cincinnati, was
among those who contributed papers for this
meeting, and he was made Honoran,' President of
the Section. He has been called the father of
specialism in this countrj'. He \vas the first man
ever appointed to this special chair in any college
this side of the Atlantic. He saw the need of
specialism at a time when only the strong man
dared to profess it, and against the advice of the
majority of his friends, visited the great European
cities where ophthalmology was then cultivated.
After nearly three years of study with such great
teachers as Graefe, Helmholz, Arlt, Jaeger, Des-
marres. Bowman, Critchet and others, he returned
to this countrj' to become the pioneer in this
specialty. Of this great and good man we have
been bereaved since our last meeting. He died
Oct. 5, 1888, at Pittsburgh, Pa., at the age of 66.
He was engaged in ophthalmic practice in Cincin-
nati, for more than a third of a centur\'.

A memorial of his life and work will be pre-
sented bj' the proper committee to the Association
at some one of the general sessions, but as his
labors in this department of medicine, and in

establishing this Section of the Association,
causes us to feel his loss more perhaps, than
others do, it seems proper in this connection, to
give this brief notice of his life, and pay this
tribute to his memorj-.

At first it was found necessary to include with
ophthalmology, otologj' and larj-ngology, and the
resolution by which the Section was established,
called for a change in the organization of the so-
ciety, b}' which there was added to the five then
existing Sections, a Section for Ophthalmologj',
Otology and Lar>-ngologj% which should be known
and designated as Section 6.

For ten years the laborers in these last named
specialties met with this Section, and contributed
to its success. It was with much regret that we
yielded to the necessity of providing more time
for the reading and discussion of papers, and
parted company with these esteemed co-laborers,
who last j-ear established a new Section, in which
they will work for the first time during the pres-
ent meeting of this Association.

During this meeting the work of our Section,
will, for the first time in its histor}', be confined
wholly to the consideration of ophthalmic sub-
jects. From the programme placed before us, it
will be shown that there is an abundance of
work, and if our time is not fullj- occupied in
profitable debate it will be our own fault. We
have as many papers to be read and considered at
this meeting of the Section as we have usually
had before, and upon subjects of as great interest,
and requiring as much attention as when our
work embraced a wider range. This illustrates
the fact that science grows deeper as its boundaries
extend, and that a still further subdivision of
labor becomes necessary- in order to cany- its work
forward with the greatest success.

Fear has, ocasionally, been expressed, that
w-ith such limited fields of labor in the different
Sections, the subjects introduced will become
hackneyed, and lose their interest, and that dis-
cussion of them will cease to be either profitable
or pleasing. But discussion was never more
called for in ophthalmic subjects than at the pres-
ent time. No subject should be abandoned until
the ultimate truth is reached, and uniformity of
views are established, however hacknej-ed it may
seem to be. We should eschew no scientific sub-

2l8

OPHTHALMIC SUBJECTS.

[August 17,

ject as trite while anj' of its principles are vague
and unsettled.

We shall see, as we continue the work of these
meetings, that there are enough mooted ques-
tions to engage all our attention, and that how-
ever extensive our wisdom or experience, it will
be suflBcienth' taxed in attempts made to recon-
cile the conflicting views that may be presented.

Dr. Hotz, in his address last year, verj- cogently
called attention to the fact that we were chal-
lenged to defend many of the doctrines that we
had supposed to be ver}- firmly established. The
record of the past year has not been such as to
change the state of affairs then existing. Even
the value of specialism, itself, and the right of its
followers to exist as a separate and independent
class of practitioners, is still called in question.
The qualifications that should entitle one to the
right of being regarded as a specialist is also still a
mooted subject. Much of value has been written
upon these subjects during the past year, and the
relation that should exist between the specialist
and general practitioner, and also the kind of train-
ing and the qualifications that each should have,
have been discussed. This is labor in the right
direction. There are no more important subjects
that can engage our attention than these, and
upon their correct solution depends the future
progress of ophthalmic science and art more, per-
haps, than upon any others. There is no dis-
guising the fact that the lack of sufiiciently ex-
tensive mutual sympathy, and of cooperation
between the familj' physician and the specialist
is not only one of the great drawbacks to the
practical usefulness of specialism, but one of the
greatest obstacles to its scientific progress.

I need not enter upon a defense of specialism
before this audience, composed, as it is, of those
who devote themselves to the cultivation of one
of the most successful of them all. You, who
have limited, to a great extent, your investiga-
tions to this one small organ, know how neces-
sary it is, to limit judiciously the field of obser\-a-
tion in order to interrogate nature successfully,
and leam from her, her secrets.

In every other department of human knowledge
the necessity- of such a division of labor has long
been recognized. In medicine, however, it is
even now grudgingly admitted, though it has
furnished such abundant proof as to its value and
necessity. Notwithstanding the victories won,
and honors achieved by specialism, they are too
recent, and too grudgingly admitted to warrant
its friends in ceasing their efforts to secure for it a
just recognition.

It is now more than a hundred years (1773)
since Joseph Barth was appointed lecturer on
ophthalmic surgerj- in the University of \'ienna,
and from this we may justly date the beginning
of modem .scientific ophthalmology'.

Getting his first inspiration, as Fusch tells us,'

from a few lectures delivered by Wenzel, who had
been called from Paris to Vienna, to settle a dis-
pute between some phj-sicians as to the nature of
an eye affection, in the case of one of the great
ladies connected with the Court of Maria Theresa,
he entered upon this new field with so much en-
thusiasm that he soon became the most dis-
tinguished of its cultivators. He selected Beer
as his assistant, and, having imparted to him his
enthusiasm, he left him to continue the work he
began, and Vienna soon became the centre of
modern ophthalmology. Students flocked to this
school from all parts of Europe. Yet so slow was
the medical world to comprehend the advantage
to be derived from such special study and teach-
ing, that it was not until 1804 that the L,ondou
Ophthalmic Infirmary was established, and it was
not thrown open to .students until 1810. In
America no special instructor in ophthalmology-
was appointed until i860, while in Paris, from
which the kindling spark went forth, specialism
was so violently opposed b3' the medical facult}"
of the University, that no teacher of this branch
was appointed until 1879.

It is not two score years since in our own
countrj', anj' man who attempted to limit his

I practice to a specialty, was ostracised by the pro-
fession, and often had to drop it and again join

^ the ranks of the general practitioner. Nor is this
spirit of opposition to specialism j'et extinct or
confined in its manifestation to those without in-

j fluence. During the past year one of the best
known medical writers in an editorial article in a
prominent medical journal, revived the old an-
tagonism, and declared that, "The specialist
must become a hand-worker, plying his art

J under the direction of the physician, who calls to
his aid the manual dexterity- which the one has
attained \>y limiting his practice to a single dis-
ease or a single operation." . . . "There is a
necessity'," he declares, ' for an authority superior

\ to the specialist, and the consequent limitation of
the latter to a subordinate place." " Is the gen-
eral practitioner, he asks, "qualified to fulfil this
duty ? If not, he ought to be so qualified. He
must be if he expects to hold his proper place in
the profession.""

This writer would seek to degrade all specialism
to the position surgerj- once occupied — the posi-
tion of a mere handicraft. The surgeon was at
one time allowed to do his work only under the
direction of the physician.

By following the lead of Hunter, however, the
surgeon has achieved for himself a more inde-
pendent, honorable and useful position. He de-
cides now for himself what needs to be done, and
executes it only when his own judgment dic-
tates it. Surgeons have accomplished this by

' History of Ophthalniolog>' in Vienna. See Med. Times nnd
Gazette, 1.S85. page 692.

-Dr. William F. Waugh. in the Philadelphia Medicnl Times.
Dec. 15, 1S8S. page 204, Editorial .Article on Specialism.

1889.]

OPHTHAIvMIC SUBJECTS.

219

laying a proper foundation in the fundamental 1 tion of ophthalmologists as worthy of candid dis-
sciences, and in general medicine also, before ; cussion, and demanding a fixed policy and con-
limiting their practice to surgical cases alone. [ cert of action.

The great surgeon must first have been a good 1 Though no great and brilliant discover}', or op-
general practitioner. By adopting this principle ening of any especially new field of research has
of education, surgery, from occupying an inferior | characterized the history of ophthalmologj- for the
position, its followers being mere " hand-workers" ; past j'ear, 3'et in every direction there has been
under the directions of the general practitioner, i patient, successful and continued labor, and it is
has won the first place in medical rank, and now
surgeons even treat their old masters often as
inferiors.

The most able articles that have been written
within the last j'ear on the subject of specialism,
and its relation to general medicine, have advo-
cated a similar training for all specialists, with a

by such, that the greatest results have always
been accomplished in any department of human
thought. It would take some pages of manu-
script even to ^lanw the great arm}' of workers,
who have contributed their mite to the common
treasury of advancing knowledge, and to do full
justice in the way of reviewing their labors would
view to elevating their position in the profession, occupy an undue proportion of j-our time,
and enabling them to accomplish the most for Not only have the anatomy and physiology of
science.' the ej-e received due consideration, but almost

It is on this principle, it is advocated, that every disease of the eye has been written upon,
ophthalmology must seek to maintain its position : Not only have the special journals devoted to
and advance as it should. Sir Henry Power , ophthalmologj- been filled with interesting matter,

struck the key note of more recent sentiment on
this point, in 1885, when he said: "If the
ophthalmic surgeon of the future is to maintain
the reputation and position of his predecessors in
this branch of the profession, it appears to me
that two things will be necessarj* : first, that he
should possess a sound general knowledge of

but the journals devoted to general medicine have
teemed with -valuable articles on ophthalmic sub-
jects, in which either the investigations and ex-
periences of the writers have been recorded, or
theories of practice have been discussed. Oph-
thalmophotography, refraction and school work,
detachment of the retina, diseases of the optic

medicine and surgery, and second, that he should 1 nerve, cataract, and the whole catalogue of diseases
have a good preliminarj- training in mathematics j have been thus considered. Perhaps more atten-
and physics. ... "I hold," said he, "that no ( tion than usual has been paid to the relation be-
man should commence ophthalmic practice with- ' tween eye symptoms and diseases, and diseases of
out long preliminarj- work in general or dis- the brain and spinal cord. Two papers on our
pensary practice, or in the wards of an hospital, | programme will bring these subjects before you,
and I venture to dwell strongly upon it, because , and open for discussion the value of recent obser-
I think there is a tendency amongst the younger | vations.

members of the profession to regard ophthalmic j There is an old resolution of the Association to
practice as an easy means of obtaining a liveli- j the effect that it shall be the duty of the Chair-

hood, which is at once less troublesome, clean,
and more satisfactory than any other branch of
surger}'."'

His remarks are worthy of consideration, and
they seem to be endorsed by most modern writers,
and we can do very much to advance ophthal-
mology by using our influence to control educa-
tion so that those who come to the stud}' of medi-
cine shall have first received a thorough training
in mathematics, physics and the physical sciences,
and, that those who enter upon ophthalmic prac-
tice, shall first have had an adequate experience
in the practice of general medicine and general
surgery.

The ophthalmologist must answer, in some de-
gree, to the definition some one has given of a
specialist, i.e. "One who knows something
about everything and everything about some-
thing" I commend this subject to the considera-

3 See article " On the Relation between the General Practitioner
and the Consultant, or Specialist." by S. Duncan Bulkley, A.M.,
M.D..in "Jour, of Am. Med. Association," Feb. 2, iSSq. page 155,
also, " The Family Physician." by Andrew H. Smith, M.b.. Harper^s
New Monthly Magazine, April, iSSg. page 726.

■* Med. Times and Gazette, 1SS5, Vol. 3, page 161.

man of each Section to give an address setting
forth the progress for the year in the department
of medicine represented by his vSection.

This resolution was adopted when the number
of Sections was limited to four or five, and the
addresses were delivered at the General Meetings
of the Association, and not, as now, before the
members of the Section only. This resolution
has, I think, been generally disregarded during-
the past few years, perhaps because of the impos-
sibility of fully complying with its requirements.
Saying nothing of the numerous subjects that
would require attention, and to properly discuss
which would extend such an address to an un-
bearable length, we may ask what o>ie man shall
presume to decide for you what is progress and
what is not ? Your Chairman may think certairr
steps are in the line of progress, but this Section
may, after full discussion, think they are retro-
grade.

Even a return to the old methods is advocated
by some as in the line of progress, and this advo-
cacy comes from some who are regarded as among

220

OPHTHALMIC SUBJECTS.

[August 17,

the leaders of thought in our specialty. This is
notably true in regard to the operation and after-
treatment of cataract.

It is now more than a quarter of a centurj^
since Mooren first performed iridectomy as a
preliminary measure to flap extraction. The pro-
cedure was soon adopted by Von Graefe as a step
of his modified linear extraction. The percen-
tage of losses was immediately and greatly less-
ened, and it has continually decreased since the j
general adoption of that method of operating. '
Indeed, it has come to be regarded as one of the
great advances in ophthalmic surgerj\ To-day i
we are urged to return to the old method. We
are assured that .iridectomy is an unnecessarj-
mutilation, adding to the dangers and complica- [
ting the extraction. " That the simple extradio7i \
is not only the best, but also the safest method of re-
moving cataract.- That the iris spread out as a;
velum interfiositum between the corneal section
and ciliarj- body, protect this, the most suscepti-
ble part of the eye, from the deleterious substances
that may enter through the wound." ° Statistics
have been accumulating during the past year in
support of these views that challenge our atten-
tion, and demand of us that we discuss anew this
old and, as once supposed to be, hacknej'ed sub-
ject. With Carter, and the majority of others
who have had experience with both methods of
operating, advising the operators to retain the iri-
dectomy as an important step in the operation,
while Sweigger, Gayet, Galezowski, Wecker,
Knapp and others advise simple extraction, is it
a wonder if the beginner hesitates which method
to tr>', confused and discouraged by conflicting i
opinions regarding the proper operative proce-
dures to be adopted in this old operation, which in
its perfection and marvellous success was consid- \
ered one of the crowning operations of surgery.

But the beginner's perplexity will not end with
the operation alone. One author of extensive ex-
perience'' will tell him to bandage both eyes and
keep his patient reasonably quiet after the opera-
tion. Anotheroperatorof large experience will tell
him he need only to close the lids of the operated
eye with a little plaster and allow the patient to
walk about and use the other eye at pleasure. One
will lead him to think that his patient may walk
five miles immediately after a cataract extraction
•without increasing the danger.' Another of verj-
great experience warns him not to follow such
advice," One will tell him that if any cortical mat-
ter has been left in the eye he should begin the in-
stillation of atropine after four or five days." An-
other warns him, from experience, to avoid such

5H. Knapp in Archives of Oplithal., March, 1889, p. 11,

'Carter, British .Med. Jour. .Vlsosee Am. Jour. Ophthal., Jan.,
i38q, pp. 27 and 28.

7 Prof. \V. Cheatham, Jour. Am. Med. .4ssoeiation, Nov. 17, 1888,
p. 717.

8E. F Drake Brockman. in Ophthalmic Review. Nov., 1888, p.
334.

9Carter. Sec Am, Juur. Ophthal., Jan., 18S9, p. 29.

instillation, as it is likely to excite a glaucomatous
condition under these circumstances.

But we have not time to mention all the con-
flicting directions the anxious inquirer will find
regarding even this one disease and its treatment.
The subject of cataract is, then, not trite — it is
still a live and debatable one.

Nearly as much discord prevails regarding
squint and its treatment.

Although since Dieffenbach made the first oper-
ation for the cure of convergent strabismus, in
1839, the subject has been a prominent one among
ophthalmologists, yet no sufiicient uniformity of
views exist in regard to its pathology and treat-
ment. And when at the meeting of the American
Ophthalmological Society in 1885, the subject of
squint and its treatment came up for discussion,
scarcely any two members had the same opinion
upon the subject. This diversit}- of opinion existed
upon all the important principles connected with
the topic ; whether or not there exists such a thing
as amblyopia ex anoposia : whether it is possible to.
cure converged squint by the use of atropia and
properly-fitting glasses ; whether early operations
should be performed ; and whether the vision of
the squinting eye is improved by an operation.
Some thought the operation for strabismus was
too frequently performed, and that it ought often
to be postponed or not performed at all. Others
thought if there was anything known with cer-
tainty it was how to treat strabismus. Dr. Roosa
and others have added somewhat to the statistics
and discussion of the subject since then, but none
of the questions then the subject of dispute have
been settled as they should be. They are all yet
open to discussion, and onh- by further collection
of statistics and thorough discussion of all the
obser\'ed facts, can the truth in regard to them be
arrived at and accepted.

How shall we treat hypermetropia, and the re-
sulting asthenopia ? This question seemed quite
well settled more than a score of years ago by the
masterly work of Donders, yet to-day no suffi-
ciently definite rules have been agreed upon and
formulated for the guidance of those who are be-
ginners and look to the authorities for light. As
a recent writer truly obser\-ed, " If we ask how
much of the hyperopia should be corrected ? the
answers exhibit a most befogging diversity of
opinion." '" One so high in authoritj' as Landolt,
would allow a patient to use two-thirds or three-
fourths of his dynamic refraction. Others declare
from experience that this cannot be tolerated by
the patient without continued asthenopia. Some
will adv^ise full correction of the Ht. Others
only partially correct the Ht. Here again the
greatest diversity of opinion is experienced as to
how large a portion of the Ht. shall be corrected
and how much left uncorrected. The rules which

">\V. F. Coleman, M.D., Jour. Am. Med. Asso'n., Dec. 29,
page 903.

1889.]

OPHTHALMIC SUBJECTS.

221

this writer"" has culled from the common text-
books show the need of further discussion of even
this hackneyed subject that some standard rules
may be adopted, and the beginner may learn more
nearly the ultimate facts from the authors, and
not have to acquire them after so manj' doubts
and mistakes in his earl)- practice.

About twenty years ago Von Graefe announced
his discover},' of iridectomy as a cure for glau-
coma. This disease had hitherto been regarded
as incurable. For manj- years the profession
thought we had nearly reached the ultimate facts
in our knowledge of the pathology of glaucoma
and the means of cure. But now those of exten-
sive experience declare that " The pathogeny of
this disease is still badly defined, and the therapy
is not less uncertain ; tliat neither iridectomies,
myotics, nor even sclerotomies give any certain
results." " The subject of glaucoma is not worn
out. It needs further obser\-ation and further
earnest discussion to get at the ultimate facts and
establish the scientific principles of its pathogeny
and treatment.

Shall we enucleate an eye during panophthal-
mitis ? How differently are we answered. How
positive are some that we ought to do so. How
severelj- is the practice condemned by others. So
imperative is tlae dictation that a German oculist
once apologized to a medical society' for having
twice so operated during such a condition, though
with the best success, stating that when he per-
formed the enucleations he did not know of von
Graefe's teaching on the subject. Thus while
following the dictates of his reason he had un-
wittingly offended the dictum of authoritj'."
Surely this subject is not only still open to discus-
sion, but needs it very much.

Shall we enucleate or eviscerate ? This is not
j-et settled beyond dispute, though enucleation
still holds its own as not onlj' the safest but the
most speedy cure of those cases in which both
are urged by their advocates for preference.

Through what medium or influence is sympa-
thetic ophthalmia produced ? The question seemed
settled a few years ago, and the ciliarj- ner\'es were
almost universally recognized as the medium
through which the morbid condition was set up
in the sympathizing eye. Recently it is claimed
that the lymph channels carry pathogenic organ-
isms from the diseased to the healthy eye, and
that it is by this agency that sympathetic disease
is induced. Still others believe that both these
agencies are at work in the production of the dis-
ease, and if the question should be called up here
the advocates of each of these theories would
probably be upon their feet, each sure of his
ground and asking for a hearing.

But I might go on to the most tiresome extent,

" Galeszowski. Med. Analectic, Feb. 7, 1889. page 63.
"Manthner, Sympathetic Diseases of the Eye, p. 160. (Webster
& Spalding's Translation. Wra. Wood & Co., 1881.)

and then fail to mention all the subjects of dis-
pute.

What few instances I have brought to notice
might seem to imply that ophthalmology is one
of the most unsettled branches of medicine, in-
stead of being, as it is, the department most nearly
approaching a fixed science.

In general practice we find, in the same way,
the profession is urged to return to old methods,
as for instance the calomel treatment for typhoid
fever,"' which not long ago was abandoned as a
most pernicious treatment.

Not long since, a reviewer of general therapeu-
tics, regarding this unsettled state of things, was
led to make the following statements concerning
that department of medicine : " To establish the-
rapeutic facts the profession clings as with the
heart and hand of one man ; clings with a desper-
ation and unanimity whose intensity is the meas-
ure of the unsatisfied desire for something fixed.
Yet with what a Babel of discordant voices does
it celebrate its two thousand 3-ears of experience.

" This is so well known that it seems superflu-
ous to cite examples of the therapeutic discord ;
and one only shall be mentioned, namely, rheu-
matism. In this di.sease bleeding, nitrate of potas-
sium, quinine, mercurials, flying blisters, purga-
tion, opium, the bromides, veratria, and a host of
other remedies, all have had their advocates, clam-
orous for a hearing : and above all the tumult are
to be heard the trumpet- tones of a Chambers,
'Wrap you patients in blankets and let them
alone.'

"Experience is said to be the mother of wis-
dom. Verily she has been in medicine a blind
leader of the blind, and the historj' of medical
progress is a history of men groping in the dark-
ness, finding seeming gems of tnith one after an-
other, onl)- in a few minutes to cast each back to
the vast heap of forgotten baubles that in their day
had also been mistaken for verities. In the past
there is scarcely a conceivable absurdit}- that men
have not tested bj' experience and for a time found
to be the thing desired. In the present homoe-
opath}' and other similar delusions are eagerly
embraced and honestly believed in by men who
rest their faith upon experience." "

The truth of some of these remarks cannot be
gainsaid, but while it is granted that those who
"rest their faith" upon their individual experiences
alone, may be led into an}' conceivable absurdity
it should be remembered that these experiences
taken collectively furnish the material from which
to glean scientific truths. It is by discussing
them, and submitting them to the intellectual
process of combination and comparison that those
principles are deduced which constitute scientific
progress.

'3Urged by Tnibe, Wuiiderlich, Liebermeister and others.
'4H. C. Wood, in Preface to Therapeutics and Mat. Med., first
edition.

222

THERAPEUTIC USES OF ELECTRICITY.

[August 17,

Even the personal experience which this writer
has referred to, as furnishing to the homoeopathist
facts which still further confirmed his delusion as
to the efl&cacy of his remedies and mode of cure,
also furnished the scientific physician with facts
that enabled him, by discussing them and com-
paring them with the results obtained, by other
methods, to discover the natural history of many
diseases, and to realize the disturbing and injuri-
ous effects of many established modes of treat-
ment. He was thus led to realize more fully the
agency of that ris mcdicatrix naiiira: to which the
homoeopathist' s success could only be ascribed,
since, reasoning from known facts, the peculiar
remedies of the homcepathist must be regarded as
without effect. The result of this discussion of
the subject was the more speedy recognition of
the recuperative powers of the system, and the
abandonment of injurious methods of treatment,
and a consequent rapid advance in medical science
and an increased success in medical practice.

In the same waj' a discussion and comparison of
different experiences in the treatment of any form
of ophthalmic disease may lead to the discovery
of the important underlying principles of cure,
from which must be derived that scientific prac-
tice which we aim to establish and perfect.

If this discord was to be interpreted as indi-
cating a lack of progress it would be dishearten-
ing indeed. On the contrary- it seems rather to
be the natural outcome of too earnest seeking
after facts. It seems with the profession as the
poet declared to be true of the individual,

" Who knows most, the more he knows to doubt.
The least discourse is commonly most stout."

At least we can console ourselves that notwith-
standing all this discord and conflict of opinion
on ophthalmic subjects, progress has been steadily
made. When Graefe devised his cataract extrac-
tion with iridectomy he at once increased the per-
centage of cures very greatly. That increase
went steadily on until about 20 per cent, was
added to successful results, making about 95 per
cent, in all. And now one of those who asks us
to return to the simple operation shows us one
table with 96 per cent., and another with 97 per
cent, of perfect results, and in 200 cases only 2
cases (I per cent.) of total failure.'"

Why is it that after so many years we return
again to simple extraction with so much greater
success ? What are the essential elements of this
success ? Is this attainable by the average oper-
ator ? These are themes for di.scussion . So with
the other subjects I have mentioned. We treat
glaucoma, sympathetic ophthalmia, and errors of
refraction and nearly all other ophthalmic affec-
tions with more success than ever before. What

'5 Report of the first series of One Hundred Successive Extrac-
tions of Cataract williout Iridectomy, by H. Knapp. .\rchivcs of
ophthalmology, Vol. xvii, p. 73. Also second series of One Hun-
dred Cases. Archives Ophthalmology, March, 15159, p. 10.

are the elements of progress? Let us debate
them.

We have indulged in a feast of statistics, and
have not digested and assimilated them as we
ought. It is possible that bj' proper discussion
of these mooted subjects we can separate the
truth from error, and deduce more fixed and
definite principles and standard rules for our
guidance in practice, and one of ray objects in
calling your attention to these unsettled questions
is to remind you that there will be ample ground
for debate in these meetings, and some, if not all,
of the questions referred to will be raised for
your consideration. " Trj' all things, hold fast
by that which is good," is a safe injunction to
heed, and I have no doubt that it will be faith-
fully observed by the members of this Section.

ORIGINAL ARTICLES.

THE THERAPEUTIC USES OF ELECTRI-
CITY.
BY JOHN V. SHOEMAKER, A.M., M.D.,

OF PHILADELPHIA, PA.

It begins to dawn upon the medical mind that
the field covered by electricity is larger than that
comprised by any other curative agencj'. That
this should occur long after the whole world was
disposed to accept the discovery of electricity in
a form applicable to medical treatment as one which
was to revolutionize medical practice, is at the first
glance strange, but is nevertheless susceptible of
easy explanation.

Electricity, known even to the ancients, had
yet to wait until a time so modern as the end of
the last centur}' before a machine was devised to
administer it even in the static form. Then, when
men found themselves possessed of a force which
they could for the first titne generate and control,
they naturally fell into confused notions afcout its
being the vital force. Hence, when it is consid-
ered that the static form of electricity has com-
paratively little range in the treatment of disease,
that quacks rushed forward to assert and maintain
its universal curativeness, and that the sounder
observation of skilful physicians discovered the
untenability of the proposition, it is not surprising
that when, in the early part of this century, cur-
rent electricity was first generated, controlled, and
applied to therapeutic purposes, electricity as a
curative agent had been so discredited, that even
thinkers in the medical profession were slow to
believe in its remedial virtues.

On the one hand, electricity had, by those ig-
norant of its limitations, been lauded to the skies
as a panacea ; while, on the other hand, it had,
by those equally ignorant of any of its merits,
been decried as perfectly worthless. Empirics

1889.]

THERAPEUTIC USES OF ELECTRICITY.

223

having absurdly imagined and claimed that elec-
tricit3' would cure everything, and time having
proved that the claim was unfounded, the medical
use of dynamic electricity came in, without trial,
for a share of the obloquy which attached to the
failure of static electricitj- to do what it should
never have been alleged to be capable of perform-
ing. Yet, the therapeutic value of static electri-
city' will stand all reasonable test, and similarly,
so will the therapeutic value of current electricity.
Static electricitj' has never been fairly tested by
physicians, because extraordinary' efficacj' being
at first ascribed to it, and then as generally de-
nied, it lost all standing in court, while current
electricity never had proper standing there, be-
cause it was discredited in advance, by the loss of
faith in static electricity, for which it was no more
responsible than it was for the preceding ascrip-
tion to static electricity of universal virtue.

The proverb truly says that a poor workman !
never had a good tool, and with equal truth we
may add, that a good workman can supplement
a bad tool. But these cases refer to work directly
wrought by the hand of man. No amount of sci-
entific knowledge or of manual skill can supply
the deficiencies of a poor apparatus. No economy
could be more false than to possess and use one. '
To accomplish our purpose in administering elec-
tricity, the apparatus must be not only good, but
in good condition. Otherwise it is worse than
usele.ss; it is a delusion and a snare to both patient
and physician. Whether, therefore, the apparatus '
be galvanic, faradic, combined galvanic and far-
adic, supplied by the incandescent light current
or by storage batteries, or the apparatus be for
static electricity, let it be excellent of its kind,
under penalty otherwise of its not accomplishing '
the purpose professedly nought. Makers of good
electric instruments now abound in the United
States; France excels in them, and even England,
which was slow in having specialists in that de-
partment of labor, is now supplied.

Dr. W. R. D. Blackwood reports that both
static and faradic treatment often have the eflTect
of relieving the chest pains and the debilitating
night sweats of phthisis, through the improve-
ment which they effect in general innervation and
nutrition.

Faradization of the thorax is ver\- beneficial in
spasmodic asthma and chronic bronchitis. The
dyspnoea of the latter is by this treatment much
dimiflished in gravity.

Even more efficacious in the paroxysms of an-
gina pectoris than inhalation of nitrite of amyl
■does prompt galvanization of the sj-mpathetic
seem to be in aborting an attack of this acute
affection.

Sufferers from hay fever are so much addicted
to seeking refuge in a change of climate when the
season approaches when they are liable to an at-
tack, that there has not yet been the fullest op-

portunity to experiment with electricit}- in cases
of this disease. There is, however, reason to be-
lieve from the result of treatment which has been
practiced in that direction, that hay fever can be
much relieved by the employment of galvaniza-
tion, administered as in exophthalmic goitre.

In exophthalmic goitre itself galvanization re-
lieves the glandular swelling and reduces the pro-
trusion of the ej'eball. The method of application
is to place the anode directh' under the angle of
the inferior maxillarj- bone (over the pneumogas-
tric), and the cathode over the solar plexus. The
current should be moderate, ten minutes at a time,
at inter\-als of two days.

Insomnia is frequently successfulh" treated by
general galvanization or faradization, when the
use of drugs is contraindicated. General faradi-
zation just before the patient is intended to sleep
has a calming effect. This is caused by the ca-
pacity of electricity to equalize the circulation
and reduce the pulse without lowering its tone.
The application is so simple that it can be made
by a nurse or a member of the family.

Sciatica can always be relieved during its acute
paroxysms b}- the administration of descending
galvanic currents. Permanent cure of it has been
frequently obtained by electro-puncture, the needle
being thrust down to the ner\-e at one or more
points along the painful portion of the nerv'e.

Xeurasthenia is not always cured b)- electricitj'
alone, although it frequently is. It will generally
yield to electro-massage. This obviates the as-
sumed necessity- of the gorging which has been so
general in the treatment of this complaint. The
method employed is daily combined general gal-
vanization and faradization.

Torpor of the liver is readily overcome bj' the
faradic current.

General faradization of the abdomen ever}'
morning for a while, or if more convenient, every
evening, will always provoke a movement of the
bowels within a moderate time. This treatment
is to be recommended far beyond that of the tak-
ing of drugs to relieve constipation, becau.se, in-
stead of its being followed by constipation, the
effect tends to be permanent. Constant use of
drugs for that prevalent ailment of constipation
can thus be avoided by the employment of method-
ical faradization. Nothing so surely and prompt-
ly tones up the intestinal muscular fibre as does
electricity, and causes the functions of the bowels
to be regular.

In intestinal occlusion Dr. Larat' recommends
galvanic electrization, and he reported nineteen
cases before the French Academj' of Medicine in
which he cited six successes.

Dyspepsia in various forms receives decided re-
lief from galvanization. Defective secretion of
the gastric juice is rectified, glandular action stim-

> The Treatment of Intestinal Occlusion by Electricitj'.
Larat. Paris Letter to The Journal, June 15, 1S89.

By Dr.

224

THERAPEUTIC USES OF EEECTRICITY.

[August 17,

ulated, and the muscular tone of the stomach in-
creased by this treatment.

Gastralgia and stomach-cramp are usually at
once relieved by galvanization, as are also pyrosis
and the vomiting of pregnancy. Currents not
exceeding 15 milliamperes are best suited to the
purpose, the anode being placed on the cervical
spine and the cathode on the epigastrium.

Instances have been from time to time reported
of the dislodgment of impacted gall-stones by the
administration of electricity. As we have no
remedy for this painful malady except dilcarea
villosa, it would be well to give electricity a fair
trial for its relief.

Haemorrhoids, although not a disease of the
digestive tract, so often depend upon the blocking
of the chylo-poetic circulation, as to suggest some
mention in connection with the preceding brief no-
tice of electrical treatment as applied to the bow-
els. The aching attendant upon congested piles
is often dissipated by placing the anode on the
anus and the cathode over the liver, and passing
the galvanic current for fifteen minutes, with the
strength of from 20 to 30 milliamperes.

The value of electrolysis in urethral stricture
of the male has been incontestably proved by Dr.
Newman, of New York, For that matter, contrac-
tion of any duct, such as the lachrymal canal, the
oesophagus, or the Eustachian tube, is amenable
to the electrolytic method. Extended clinical ob-
servation, however, is still needed to perfect these
latter forms of electrolysis. For the relief of or-
dinary enlargement of the prostate gland, a suita-
ble intra-rectal rheophore is required. In cases
of extreme hypertrophy of the gland, the negative
pole may be applied by a well-insulated needle
introduced per anum, and with a current as strong
as can be tolerated, say from 75 to 150 milliam-
peres, for from three to five minutes, at intervals
of three days. The indifferent electrode may be
applied over the abdomen or on the thigh. In
all administration of the current to a mucous
membrane canal the negative pole must be used,
for the positive pole would ruin the passage.

In diseases of children electricity presents ex-
cellent results. Marasmus, or general wasting
and debility without loss of muscle, is readily
overcome by thorough electrical treatment. In
this case general galvanization should be used for
its tonic effect, and faradization of the muscles
employed for giving exercise to them within the
lines of producing fatigue. Undue muscular ex-
ertion effected in a debilitated child would be in-
jurious, instead of beneficial. Therefore the cur-
rent should be mild, and the time of application
short.

Incontinence of urine, an afifection extremely
intractable to treatment by drugs, is usually eas-
ily controlled by galvanization faithfully admin-
istered.

The vomiting of cholera infantum is sometimes

checked by mild faradization of the pneumogas-
tric.

The dyspnoea following scarlet fever, measles,
and whooping-cough, and the aphonia sometimes
existing as the suite of these affections, are ordi-
narily amenable to galvanization; and in the case
of the aphonia, static electricity has proved to be
extremely valuable.

Dropsy, as the suite of scarlatina, is sometimes
quickly reduced by localized electrization, as is
also oedema in either children or adults, provided
always that it is not complicated with Bright's
disease.

Faradization, which tends to relieve the en-
gorged capillaries of the mucous lining of the
bladder, is therefore often instrumental in curing
cystitis in both adults and children. Incidentally
it has been observed in these cases that electri-
zation reduces the mucoid discharges from the
bladder.

Galvanization has been proved to be of value
in some cases of disease of the eye. Dr. C. S.
Bull remarks, in the A^ezc York A/edical Journal
of April 27, 1889, that, "in traumatic anaesthesia
of the optic nerve and retina, uncomplicated by
any laceration of ner^^e tissue or rupture of nerve
fibres, galvanism carefully and persistenth' ap-
plied has been known to produce a rapid and per-
manent improvement of vision when applied di-
rectly to the closed lids, and the current passed
through the eyeball."

The knife-pains of locomotor ataxia are some-
times sensibly relieved by galvanization, and spi-
nal galvanization has in some instances so greatly
ameliorated the condition of the patient as to per-
mit of his leaving his couch, to which he had
previously been almost confined.

In uterine disorders electricity is almost indis-
pensable. Extra-uterine pregnancies have been
cut short by both currents, some operators prefer-
ring one, and some the other. In dysmenorrhoea
intra-uterine galvanization with a strong current
is of great service, while in amenorrhcea, by means
of faradization through the ovaries and uterus the
menstrual flow is soon established, Menorrhagia
arising from relaxed uterine walls is specially' re-
lieved by faradization. When the result of villous
growth of the endothelium, the employment of
cauterant galvanic currents will remove the active
cause of the affection.

Many eminent alienists, especiallj- abroad, are
reporting favorably on the u.se of galvanization
in .some mental disorders. Melancholia, with or
without delusions, has been benefited by prolonged
treatment without recourse to commitment to an
asylum. Some patients, presenting delusional or
monomaniacal features which had resisted routine
asylum treatment, have been thoroughly restored
to .sanity under cerebro-spinal galvanization.

In the methods of electro-cautery we possess
for many cases great advantages over those of

1889.]

THERAPEUTIC USES OF ELECTRICITY.

225

former surgical procedure. The galvanic loop is
rapid in its operation, aseptic, and bloodless.
When a current of strength suflScient to make
chemical resolution is anywhere used, the opera-
tor should know that the acid goes to the positive
pole and the alkali to the negative pole. Hence
it is not a matter of indifference which pole is to
be used for a particular purpose. In the electrol-
ysis of a fibroid we aim at its disintegration.
Hence, in that case, the needles introduced should
represent the negative pole. The result is the
liquefaction of the mass, and the rapidity and
amount of the effect produced are dependent upon
the strength of the current. If, on the contrary,
we purpose arresting the haemorrhage from a
bleeding myoma, we must depend upon the action
of the positive pole, the current from that pole
tending to neutralize the vascularity of the part,
producing coagulation of the blood.

In this connection we would remark that much
inconsiderate animadversion has taken place with
reference to the use of strong currents upon occa-
sions. The question depends simply upon what
is the occasion. As a general rule, currents should
be used very mild, and their duration not be pro-
longed. But when we saj- that, we are speaking
of currents for general practice. There are manj^
occasions when the currents cannot be otherwise
than strong if they are to accomplish their pro-
fessed purpose. Such are the currents used in
galvano-cautery. They are really not so efficient-
1}' strong as they appear to be from the mere
mention of the number of milliamperes empIo3'ed,
the indifferent pole diffusing the current over a
vast space, 'and the working pole being used as a
cauterizing instrument at the point operated upon.

At least brief mention should not be omitted
here of the efficiency of electrical treatment in neu-
rotic skin affections. Some forms of eczema are
remarkably amenable to both galvanization and
faradization, Acne is also sometimes cured by
local galvanization, and at present attention is
drawn to the employment of strong currents in
ulcerative skin diseases. The distressing itching
of prurigo is readily relieved by general galvani-
zation or faradization.

The diagnosis of nervous diseases is greatly fa-
cilitated by electric tests. Then, the very instru-
mentality which has enabled us in paralysis to
diagnose the extent of the disease to the best ad-
vantage, also enables us to the best advantage to
treat it, if it is at all amenable to treatment.

Many nervous girls who are a burden to them-
selves and their families are brought into new en-
joyment of life under proper electrical treatment.
More treatment by electricity and less by abdom-
inal surgery would relieve large numbers of female
hysterical patients.

Epileptiform seizures and epilepsy are some-
times susceptible of amelioration by galvanization.
The best way in these cases is to administer the

descending current from the vertex to the epigas-
trium. If convenient, the current should be ad-
ministered so as to anticipate the spasm. If this
be accomplished, the seizure is generalh- cut short
or aborted. The effect of the bromides is height-
ened by conjoined electrization. When minor
epilepsy is simplj- held in check by bromine, elec-
trization combined with it has sometimes effected
a cure. Chorea and allied tremor are often nota-
bly relieved by general galvanization. Cases oc-
cur in which a single muscle twitches, as, for in-
stance, the levator labii superioris alaeque nasi,
for which local faradization prov^es entirely suc-
cessful. Spasm of one or both eyelids is effectively
treated in the same manner. The ordinary chorea
of .schools is usually cut short by strong- faradiza-
tion of the entire surface of the bod}-.

When paralysis is dependent upon such central
lesion as intracranial haemorrhage, time should
be given for the absorption of the clot. In
from six to twelve weeks after the onset of the
disease, no treatment equals faradization. Gentle
faradization of the brain undoubtedh- hastens
absorption of the effusion on the brain. For
Bell's palsy nothing exceeds in usefulness local-
ized galvanization. The affected muscles should
be picked out separatel}^ and submitted to treat-
ment one at a time. When the galvanic current
proves slow to act favorably upon the disease,
static sparks may be advantageously substituted.
Recovery is sometimes so prompt as to astonish
; even the patient.

! As we remarked at the beginning of this arti-
cle, early in the history of electro-therapeutics
static electricity was extensively used for the cure
of disease, but owing to the causes detailed, fell
into disrepute. But within the last few years
this form of electricity has been revived for the
treatment of disease. It should undoubtedlj' be
allowed a prominent place in peripheral nervous
disorders, as there is reason to believe that deep-
seated lesions are favorably reached bj^ it through
the instrumentalitjf of reflex action.

The use of static machines for general tonic
electrization is verj' advisable in many cases. \'a-
rious hyperfesthesias and anaesthesias of the sur-
face of the body are often amenable to static ap-
plications. Diseases resembling herpes zoster
may in the beginning be amenable to this form
of electrical treatment. Spermatorrhoea and other
conditions of the generative organs evidencing
debility, are frequently benefited by the admin-
istration of static electricity. Amenorrhcea is
sometimes cured by the administration of static
electricity, after other means, even including dy-
namic electricity, have failed. As a counter-irri-
tant in affections of the joints, such as gout and
articular rheumatism, static electrization is fre-
quently preferable to faradization.

There is nothing concerning the medical em-
ployment of electricity in which we personally

226

NEEDLESS RESTRAINTS IN EYE SURGERY.

[August 17,

feel more interest at the present moment than in
its alleged efficacy in palliating the treatment of
canter of the breast and various other tumors."
Dr. Parsons,' of the Chelsea Hospital for Women,
lately reports that he has been able to check can-
cer by means of electrolization, M. Darin also re-
ports lately excellent results obtained from elec-
trical treatment in the case of cancer and other
tumors. If one does but for a moment reflect
upon the sum of his observations of fungoid
growths, whether vegetable or animal, he will
perceive that their vitality seems to be of the
most precarious sort, all the more precarious
when the growth is morbid, when it is condi-
tioned upon the most undisturbed circumstances
to ensure continued cell proliferation and growth.
It would seem, then, that as nothing is so capa-
ble as electrolysis of shattering the fundamental
integrity of any tumor, it would be well to pursue
the investigations referred to still further in the
direction necessary to settle the question whether
it is equal to the palliation or the cure of cancer.

NEEDLESS AND ANNOYING RE-
STRAINTS IN EYE SURGERY.

Read in the Section of Ophthalmology , at the Fortieth A nnnal Meeting
of the American Medical Association , June 26, iSSq.

BY JULIAN J. CHISOLM, M.D.,

PROFESSOR OF EYE .\ND EAR DISEASES IN THE UNIVERSITY OF
MARYLAND, AND SURGEON-IN-CHIEF OF THE PRESBYTE-
RIAN EY'E, E.\R AND THRO.-^T CHARITY" HOSPITAL
OF BALTIMORE.

The successful surgers- of the day depends
largely upon the care bestowed in the carr>-ing
out of details. Many things, little in appearance
but really essential, make up the summarj- of suc-
cessful treatment. While this applies to all surgerj',
it embraces ej'e surgery as well. The successes of
to-day, which make operations upon the eye the
niost perfect of all surgical practice, is brought
about by the great care bestowed in the prepara-
tions for the operation, the manual for its per-
formance, and the after-treatment.

In ej'e surgerj' smooth operations cover at least
75 per cent, towards successes, so that the bad
results can be partly laid to traumatism, or de-
fective operative procedures. When an eye oper-
ation is well done the surgeon may confidently
expect good results. To ensure this there are
certain points upon which all agree. Clfaiiliness
holds the first place. Clean instruments, clean
hands, clean dressings, clean surroundings, are
all of paramount importance, and should be of
universal adoption. To obtain the largest per
cent, of .successes in eye surgerN- no one of these
can be omitted. The necessity for asepsis and
antisepsis are recognized and adopted more or

= " On the Treatment of Uterine Tumors by Electricity." by
Thomas Keith, M.D.. LI.. 1). The British Med. Jour., June S, 1S.99.

1 " The Arrest of Growth in Cancer l>y a Powerful Interrupted
Voltaic Current (Electro- Necrosis)." by J. Inglis Parsons, M.D. The
British Medical Journal, June 8, 1889.

less generally and thoroughly. Our instruments
must be kept sharp, as well as clean, or they will
not do the nice work required of them. Putting
them in boiling water before as well as after op-
erations ensures this cleanliness, and is a good
precaution which man}- use. The mercurial and
boric acid solutions I find detrimental to delicate
instruments, and hence I do not immerse cataract
instruments in them. The same might be said
of passing the blade of a knife rapidly across a
flame. If left I6ng enough to destroy bacteria
the edge of the blade is ven, apt to suffer. Boil-
ing water ensures all that is desired, with no risk
to the instruments.

The washing of the eye with weak solution of
mercury bi-chloride, i to 4000, or mercurj- bin-
iodide I to 20,000, or boric acid i to 40, are in
very general use for cleansing the conjunctival
surfaces both before, during and after eye opera-
tions. Water which has been boiled is found
quite as good as the medicated lotions. The eye
operated upon is usually in an aseptic condition.
As we desire to keep it in the same, we do
not wish to impregnate the newly made wound
with offending material conveyed in the water
used for cleansing purposes, hence the medicated
liquids in which the sponges or wiping pledgets
of cotton are kept immersed while the operation
is going on. This seems to be the chief protec-
tion against infection. The momentarj^ applica-
tion of these lotions to the conjunctiva can be of
little ser\-ice iu destroying bacteria. We all do
it, some going so far as to wash the face, includ-
ing the e3-elids, with the lotion. It is a harmless
procedure, and I believe as useless as it is in-
nocent.

Some surgeons carry antiseptic precautions to
an excessive and even annoying degree. They
seem to be suffering from bacterial fright, and are
suspicious of the most innocent organisms. To
them it is as if every man, woman and child met
with on the streets of a crowded city are assassins
bent upon mischief and hence enemies. All bac-
teria are treated as if malignant, and are to be
killed in sponges or dressings at least, by the long
continued application of heat. Absorbent cotton
used for dressings is baked at high temperature
for hours, and then kept in air-tight jars which
have been equally sterilized by long exposure in
hot ovens. This seems to me a useless precau-
tion from over- zeal, the more especially when I
see unwashed hands manipulate the excessively
prepared dressings. That bacteria exist and are
omnipresent no one now questions ; but that they
are always bent on mischief only the over-zealous
believe. Experience proves this to be the ca.se,
as no better results are obtained in treatment by
those who over-do in their excessive preparations
for an operation.

Confinement to bed for eye operations is another
practice often annoyingly pressed to the discom-

1889.]

NEEDLESS RESTRAINTS IN EYE SURGERY.

227

fort of the patient. The ej^e is an isolated organ
not easily influenced by the movements of the
body, and therefore to a great extent independent
of them. To restrict the movements of the arms
id legs, and even of the jaws, because the eye
has received a wound at the hands of a skilful
surgeon, when such restraints are not practiced
should the eye have been accidentally wounded
by some crude cutting material, is inconsistent, to
say the least of it. It is about as rational to stop
the eye from moving because the arm is broken,
as to restrain the legs because the eye is cut. The
confinement exacted by some surgeons with pa-
tients who have submitted to eye operations at
their hands, is cruel, the more especially as the
experience of others has shown these restraints to
be useless, always anno5'ing, and in some cases
injurious. I have seen a patient confined to bed
because an e5-e muscle had been advanced. Con-
finement to the house in such cases is bad enough.
My advancement cases walk the streets unband-
aged from the moment of operation, and I secure
excellent results. Why should I therefore con-
fine them ? Up to within a few years nearly all eye
operations were considered proper ca.ses for bed
treatment. At the present time I am glad to
know that the list of such is being freely cut, with
the promise of making it eventually very small.
In my own work I use bed treatment to a very
limited extent, and never make it compulsory.
For the day of operation, especially if chloroform
has been used, patients find the bed the most
comfortable place, but after the first night they
niaj' follow their own inclinations as to its con-
tinuance. I presume it is generally conceded
that lid operations, neurotomies, enucleations and
muscle sections need not be cases for bed treat-
ment. In this list I put iridectomies and cataract
extractions. For the past three years m}' cataract
patients have not been put to bed, and I have
yet to see any injury from the enjoyment of this
liberty. From the operating chair they walk to
their chambers, and use the bed or not, as they
feel inclined.

Another annoying restraint which is gradually
giving way to a more enlightened experience is
the use of the dark room in the after-treatment of
eye operations. When an eye has sustained in-
jury either by accident or at the hands of the sur-
geon, the common habit is to confine the patient
to a dark room while undergoing treatment.
With the people this is an all-pervading desire,
and it is acquiesced in by the majority of physi-
cians. Notwithstanding all of which it is a bad
practice. A simple rule, and in my experience a
ver>' safe one, is to allow the patient to enjoy any
degree of light which is not offensive to the eye.
// light is not a7i7ioying it will not be injurious. By
accepting this law of nature for our guidance the
use of a dark room will be found very limited in
eye surgery. Before I knew better, I also thought

it my duty to do as I saw others do, shut out the
light of day and use candle light for all inspec-
tions. I could not find curtains dark enough to
exclude all the light that I desired to shut out.
In furnishing my hospital some years since every
window in the building, wards, private rooms
and passages, was completely covered with the
darkest shades that I could find ; and when in
iridectomy and cataract cases the bandages were
removed I had additional black curtains which
were hung over the already too dark shades, so
that the rooms were black enough to satisfy the
wants of any eye surgeon. Now these funereal
window dressings have all disappeared, and with
them the dark shades. Experience has slowly
taught me that the theory was wrong and the
practice bad. My desire now is to exclude harsh
light onl}^ and especially to avoid all sudden
transitions. My patients are treated in moder-
ately lighted rooms and are allowed to take all
the light that they can bear with comfort, only
the eye operated upon being closed. To those
who will try the experiment it is surprising to
find how much light can be comfortably borne
by the majority of eye patients, for their own ad-
vantage and that of the attendants.

I have startled some of my specialist friends
who use the candle much too freely, when I took
them into an ordinarily lighted room to examine
a cataract case five days after an extraction, espe-
cially when I drew aside the window shade so
that under the full light of day the examination
of the eye could be made more thoroughly. After
watching these cases for a few days, and finding
much stronger eyes than they were accustomed
to see under the dark room treatment, they have
left me with the intention of becoming, as they
say, more venturesome in the future.

Another annoying I'estraint much too freely used
is the eye bandage. To tie up an eye for disease
or an accident, however trivial to the organ, is a
popular device of universal adoption, and one
might equally add of universal misapplication.
By this I do not mean to infer that the eye band-
age is to be discarded from surgical practice, for
we often find it an essential factor for successful
treatment. I refer to its indiscriminate use, and
consequent abuse. For pressure effects we need
it, and must ever use it. When it is desired
simply to exclude light a better device can be
found. In many cases it is applied to keep an
eye quiet, which is a physiological impossibility.
This delusion is carried out when an attempt is
made to dress an eye recently operated upon for
cataract or iridectomy by surrounding it with
small discs of lint systematically and beautifully
piled up until all the irregularities of the orbital
surface are brought to a level. These are then
secured in place by a roll of bandage for what is
called equable pressure. Many years since I used
to extol an elastic pad of raw cotton for filling

228

NEEDLESS RESTRAINTS IN EYE SURGERY.

[August 17,

these indications. When pressed b}- a bandage ically demonstrated, the movements of the jaws
the soft compress would sink down, filling up any excites corresponding movements in the ej^e, and
excavatory spaces, and give as I then thought, an therefore induces bad results upon the lips of the
excellent support to the cut organ. I found , wound recently made in the cornea. How this
these theories not sustained and I abandoned that ! notion, of the jolting of the eye by the mastica-
practice. i tor>' movements of the jaws, ever secured pro-

Now the only dressing I use after iridectomies ■ fessional recognition is very surprising, but it
and cataract extractions is a piece of isinglass ' nevertheless shows its influence in the practice of
plaster. It is designed simply to keep the lids some who feed their patients on slops for days
closed over the eye ball. I avoid all artificial ■ after cataract extractions. They believe that
compresses. I find the lids with their tarsal they are following out a wise course in so doing,
cartilages a sufficiently thick and heav}- compress. Their patients survive and get well. But so do
a perfectedly adapted splint, moulded by nature also the patients of those who are not subject to
to support every part of the anterior surface of 1 this soft diet. , It is said that we all eat too much,
the eye ball. When the eye is closed the orbicu- 1 and from this standpoint a few meals the less can
lar palpebral muscle automatically makes just the , do no great harm. But there is another law even
degree of pressure needed, and retains the lips of greater in force, which reads: "to secure the
the corneal wound in perfect apposition. After ready healing of a wound with the least degree of
operations on the front of the eye ball, a strip of irritation, disturb the system of the individual as
adhesive plaster fills every indication for lid re- little as possible, and allow the dictates of nature
straint, and it should become the universal eye ' to reign unmolested." Take for instance, our
dressing. It is light, simple, easily applied, ] cataract cases. They occur usually in old people,
comfortably worn and not easily displaced. By 1 in whom habits are strongly established. They
the action of the lid muscle it keeps up equable i have been accustomed to daily exercise and regu-
support. It is also transparent, so that any dis- lar eating. To suddenly suppress in an old per-
charges from the eye, or any changes which the , son these natural functions, by putting him on
lids may take on, can be seen at the daily inspec- his back in bed, with both eyes bandaged, and on

tion, and the condition of the eye known without
disturbing the dressing. When the object is only
to close the eye, the tying up of the head by
bandages, however skilfully constructed, is an
annoying restraint, which patients will gladly
avoid. Those who have submitted to the band-
age and compresses in former cataract operations,
and to the adhesiv^e isinglass strap in subsequent
ones, are loud in their praises of this simple eye
dressing

rigid diet, is not the best way to keep him
healthy while the corneal wound is healing.

The following case, exirssivefy untrammelled
during the treatment, occurred in my practice dur-
ing the month of December, 1888 : Mr. M.,.
set. 90, a wealthj' old gentleman, sent me an ur-
gent appeal to come to his home, 600 miles from
Baltimore, and operate upon him for cataract.
Against my established custom, I, in his indi-
vidual case, yielded to his entreaty and went to

As to the tying of the hands of patients for fear i him. I arrived at bis home in South Carolina at
they may injure the eye recently operated upon, : 2 o'clock in the day, and found him sitting by an

I am glad to say that I have never practiced it
I deem it a needless and very annoying restraint.
My cataract operations now exceed 1,800, and
are being added to at the rate of over 100 ex-
tractions per year — 116 for the 3'ear just closed,
with only two lost eyes. To have the cut eye
touched \)y the finger during sleep, is not an ex-
tremely rare occurrence, and that the patient

open fire. He could see me dimly with the left
eye. With the right eye in which he had been
blind with senile cataract for nearly twenty years,
he had good light perception. Within a half
hour after my arrival, and with no preparation
whatever, I made a smooth extraction under co-
caine. The eye operated upon was dres.sed by
the isinglass strip, and the other eye with limited

should be awakened with a twinge of pain is not sight was left open. With this eye he could still

surprising, but I have never seen any trouble come
from it in these cases in which my attention was
called to the accident at the time of its occurrence.
Why tie up the hands of everj' patient as recom-
mended by some eye surgeons, in order to avoid
this imaginary danger. The very restraint, with
the loss of sleep and the restlessness which it en-
genders, may bring about troubles much more
serious to the eye than the accidental touching
of it with the finger.

Another annoying and injurious restraint is the.
rigid diet enforced after eye operations. There is
an idea that in some mysterious way, not anatom-

see to get about, and after the operation he re-
sumed his accustomed seat by the chimney. The
only change made in this room was closing the
outer slatted blinds to keep out sunlight and
drawing down the shades. It was now his din-
ner time. After the operation he asked for his
usual meal, and with my permi-ssion he had it.
When 8 I'.M. came he went to bed in a contigu-
ous room, undressing himself. In the morning
he was up for breakfast. I found him in his
usual seat in the parlor alongside of the fire
place, a screen having been placed between him
and the blaze to keep the direct rays from shin-

1889.

FACIAL NEURALGIA.

229

ing into his face. He had suffered no inconveni-
ence from the operation, had slept well, had en-
joyed his breakfast, and was in everj- way
comfortable. I left him that day at 2 o'clock,
having spent twenty-four hours with him. My
instructions to his family physician, in whose
care I left him, were to allow him all the latitude
which I had established, and onl}' keep his move-
ments restricted to the darkened parlor and con-
tiguous darkened bed-room, to let him have his
usual meals, to look at the face and closed eye-
lids daily, but to leave the dressings undisturbed
for six days ; also to telegraph me for instruc-
tions should any unsatisfactory changes appear.
I knew that the carefully applied isinglass plaster
would hold on for a week, and therefore the
doctor could not indulge a curiosity for a too
early examination of the e3-e, which he might
have done had the compress and bandage been
used. The programme was carried ont. In due
time the strap was removed: no troubles had been
discovered at the daily visits. The vision of the
new eye rapidly strengthened. Such good sight
was restored that at the end of four weeks by the
use of a two and a half- inch glass, the old gentle-
man himself wrote me a long letter of thanks,
and as he said to give me an evidence of his
handwriting, and of his complete restoration to
sight. Better results could not have been ob-
tained had he been made to go through the most
orthodox course of restraining and abstaining
treatment.

FACIAL NEURALGIA CONSEQUENT
UPON PREGNANCY.

Read before the Section of Dental and Oral Snrgerv, at the Fortieth
Annual Meeting of the American Medical Association, at New-
port,June, 1889.

BY W. W. ALLPORT, M.D., D.D.S.,

OF CHICAGO.

In the paper that I am about to present to this
Section I propose, very briefly, to discuss the na-
ture and causes of facial neuralgia consequent
upon pregnancy.

For the term neuralgia, I have never seen a
definition that exactly suited me, nor am I satis-
fied with any definition that I myself can make.
But in a general way, it ma^^ be said that neural-
gia is an acute, intermittent pain carried in irreg-
ular, and often in divergent currents through the
nerves and their branches, the result of an unnat-
ural disturbance of molecular vital forces ; or, it
may be said to be a nerves expression of some
pathological condition, which may be contiguous
to, or far removed from, the point of expression.
Pain is a nerve's expression of disease, as words
are expressions of thought. It is a symptom, or
an informer of disease, imploring help.

The causes of neuralgia are manifold. Among
the most prominent may be mentioned sudden

changes of temperature, pressure upon any por-
tion of a nerve trunk or its branches. This may
be from a local deposit or growth of any kind ; or
from arterial tension by an increased volume of
blood ; or it may be produced by an opposite, an
anaemic condition, a deficiency of blood ; an im-
poverished condition of blood, indigestion ; or, in
fact, anything that produces such a disproportion
of the standard constituents of the blood as will
disturb nutrition, or by an impairment, or decay
of tissues. Upon this latter point Anstie says :
" Amongst the neuralgias that are the most abso-
hitclv agonizing, are those which occur under cir-
cumstances of impaired nutrition incident to bodily
decay," and especially is this so, when it occurs
at parts at the peripheral end of the nerve.

These are by no means all of the causes of neu-
ralgia, but I have named enough for the object I
have in view, namely : to show that facial neural-
gia due to pregnancy, is not due, as is generally
supposed, from reflex pain, caused by disturbances
in the uterus, or from pressure upon nerve trunks
in its immediate localitj', by the increased weight
of this organ during the period of gestation.

It is a fact, I believe, that women while in this
condition, suffer more from neuralgia in the upper
than in the lower extremity. If this be so, there
must be a reason for it; and it can hardly be from
weight pressure, of the uterus, for were this the
cause of neuralgic pain, we should naturally look
for its prevalence in the lower rather than the up-
per extremities, while in fact, it is in the face,
cranium and teeth that it is most frequentl}' man-
ifest. Then, too, it is a long way and a very cir-
cuitous route from the uterus to the branches of
the fifth pair of nerves in the face and its sur-
roundings, and it is difficult to see why these,
rather than other nerves of the body, should be
most frequently selected for reflex pain from uter-
ine irritation, or pressure.

Although there are exceptions to the rule, I
think it is an admitted fact that, while there is
usually an increased volume of blood in women
in this condition, the increase is in its white,
rather than its red corpuscles, its life-giving prop-
erties. At the ver}' period in a woman's life when
it would seem to be most important that the pro-
portion of life-giving properties of her blood should
be the richest, it generally seems to be the poorest.
When her system is called upon to sustain, in ad-
dition to her own, a new life, her blood is deficient
in the life-giving properties to properly nourish
j her own bod}^ to saj' nothing of the child she is
I to bear. The superabundance of serum in her
blood may make her plump and full, yet she is
usually pale, evincing a lack of vitality, or proper
tissue nourishment.

Another important fact, bearing on the point

in question, is that all below the diaphragm is in

a constant state of venous hyperaemia, while that

I above is in a constant state of arterial hyperemia,

230

INSANITY PROCEEDING FROM THE COI.ON.

[August 17,

and arterial tension with its muscular expansion
and contraction is always a fruitful source of
nerve irritation and pain. This is doubl}- true
when the arterial hyperasmia occurs in organs like
the mouth, where among the teeth there is almost
always some pathological condition present.

Then, too, it is a well known fact that during
the period of gravidity, most women are troubled
with irritability of the nerves of the mucous mem-
brane of the stomach ; so much so that, at times,
it is difficult for them to retain a sufficient amount
of food for proper nourishment. It is much easier,
as well as more rational, to conclude that facial
neuralgia in pregnancy is reflected from the nerve
irritation of the stomach, rather than from the
uterus, for irritation of the stomach, or indiges-
tion, is a well-known cause of this symptom.
Neuralgia in the lower part of the abdomen, the
inguinal regions, etc., is not uncommon in non-
pregnant women. In pregnant women, however,
these neuralgias are said to be seldom seen. If
the neuralgia of pregnane}' were a uterine reflex,
its locale would naturally seem to be near to the
uterus rather than distant from it, as in the prev-
alent facial neuralgia of this condition. In fact,
the entire upper portion of the alimentary' canal,
including the mouth, is usualh- in an irritable,
condition, while the lower part is apt to be in a
sluggish and torpid condition.

In a majority of cases the sweat glands of preg-
nant women are found to be in an abnormal state
of functional activity : of course the face does not
escape this condition, and no one need be told that
with its almost constant exposure to atmospheric
influences, the nen'es of the face are particularly
liable to those atmospheric impressions that are
always productive of those molecular changes pe-
culiar, or essential, to nerve pain.

Gingivitis is another source of irritation to which
these subjects are peculiarly liable, the majority
not escaping it. Such is the nervous and vascu-
lar connection of the gums with the pericemental
membrane, that the disease usually extends to the
latter organ, and it not infrequently happens that
the entire denture becomes not only loose, but the
pressure on the teeth produces acute pain conse-
quent upon severe inflammation in the pericemen-
tal membrane. This membrane, in every way,
presents the hypersemic condition that we would
expect to be productive of reflex nerve pain. Be-
sides this, the swollen condition of the membranes
surrounding the apical foramen of the tooth so
strangles the vascular and nerve supply of the
tooth as to .seriously interfere with their functions,
and must, therefore, produce irritation at the uer\'e
peripheries. Con.sequent upon this, as well as
from other causes, proper nourishment of the
tooth structure is cut off", and the tooth is not
only rendered more liable to irritation and decay .
from the action of external agents, but such
starved condition and retrograde metamorphosis

of the ner\'e fibrils of the tooth structure is estab-
lished, as to be prolific of the agonizing neuralgia
spoken of by Anstie, which occurs under circum-
stances of impaired nutrition incident to a wasting
of tissue or bodilv decav.

INSANITY PROCEEDING FROM THE
COLON.

Read before the Chicago Medical Society, July 75, iSBg.
BY HAROLD N. MOVER, M.D.,

LECTURER OX PHYSIOLOGY. RUSH MEDICAL COLLEGE, CHICAGO.

The term ' ' reflex ' ' as applied to certain pa-
thological conditions has been so often misused,
and such erroneous conceptions have been formed
under this all-embracing title, that we confess to
a dislike of the term and only consent to use it in
its most restricted sense. One has onh- to refer
to the vast number of surgical procedures relegated
to oblivion, to emphasize the erroneous conceptions
formed regarding the reflex nature of some ner\'ous
disorders ; clitoridectomy, circumcision, even cas-
tration, and lastl)- oophorectomy, which we be-
lieve to be still somewhat in fashion. Scarcely a
portion of the body, or organ has escaped, and
the recent literature from the pens of those who
devote special attention to the diseases of a single
organ, is filled with cases illustrating the potency
and power of the particular organ, which they
treat, to cause reflex ner\'ous disorders. The oph-
thalmologist, not content with his reflex headache,
neuralgia, etc., has recently added epilepsy to the
list, the rhinologist has appended asthma to the
phar3'ngeal tonsil, and a homoeopathic surgeon
has recently begun to dilate the anal sphincter
and scrape out the rectum for almost ever>' disease
from haemorrhoids to alopecia. The colon has
thus far largely' escaped ; not, we think, through
want of importance, but solelj' because no one
seems to have devoted especial consideration to
the diseases of this organ. The " colonologist "
belongs to the future.

So far as my knowledge extends the earliest
writer to call attention to the colon as a reflex
cause of insanity, was Schroeder von der Kolk.'
It formed no mean division of his order of sj'm-
pathetic insanities, only 3'ielding in importance to
the uterus and sexual parts. He regarded the
trouble as a true reflex, an irritation beginning
in the peripheral endings of the sympathetic
ner\'es, propagated to the vaso-motor supply of
the central nervous sy.stem, and there working
disorder principally in the circulation. In these
days of genus and ptomaines, a more acceptable
theory to many, will be that we have, in these
cases, a true auto-infection ; an addition to the
blood of noxious elements which, circulating
through the nervous .system, produce toxic effects.
It is probable that both theories have an element

' Mental Disease.

1889.]

INSANITY PROCEEDING FROM THE COLON.

231

of truth. In some cases there may be a direct
poisoning of the blood, while in others the disor-
ders may be purely reflex in character.

Von der Kolk was himself affected with this
disorder. While suffering from constipation and
fatigue from overwork, hallucinations and phan-
tasms appeared to him and continued for three
days. A large clj'ster was administered, which
was followed by a copious evacuation of foul-
smelling fascal matter; immediately the halluci-
nations disappeared and his mind became tran-
quil. There are no distinguishing symptoms of
this condition, but an intellectual disturbance
which has its origin in this source, is said by
Schroeder to be characterized by a peculiar de-
pression of spirits, by anguish of mind, and bj-
the patient's self-accusations of wretchedness and
baseness. The disease has a verj- slow course,
and generally the mental anguish has existed
some time before the physician is consulted.

Whatever view may be taken of the basic pa-
thology of these conditions, there can be no doubt
of their etiological relations, and additional em-
phasis is laid upon the necessitj- of thoroughly
investigating possible sources of reflex irritation
in all functional nerve disorders. The following
cases illustrate the gravity of the disturbance
which may follow disease of the colon and the i
necessity of a more careful inquin,- into the con-
dition of that organ : [

July 17, 1887, I was summoned to an adjoining ;
city to see Mrs. G. , in consultation. The attend- 1
ing phj'sician furnished me with the following ac-
count : Father of patient living and well, mother
died of cancer of the uterus. No trace of insan-
ity in the family, or neurotic heredity of any kind.
Her health previous to the present difficulty had
been fair, an occasional cough with inflammation
of the pharynx being her only illness. Menstru-
ation appeared at 14 and was alwaj-s normally
performed. Married at 23, and at 25 had a pre-
mature labor, this accident not being followed by
any disturbance of the general health. Present
illness began about eighteen months ago and was
marked by an increasing general debilit}-, loss of
appetite, decrease in weight and obstinate consti-
pation. The symptoms did not point to a change
in any particular organ. Six months later had
sudden attacks of faintness occurring at irregular
intervals. These attacks would begin with pain
in the left hypochondrium and a sense of suffoca-
tion. • Within the last six months tenderness on
pressure has appeared in this region, and the at-
tacks have become more frequent and are accom-
panied by vomiting. During this time she had
no febrile reaction, but was nervous, excitable,
and afi"ected with morbid fears. This was sub-
stantially her condition until three months before
she came under my observ'ation, when she began
to show positive signs of insanity ; was restless,
sleepless, and incoherent, with confusional hallu-

cinations and non-systematic delusions of a de-
pressed and melancholy character.

Examination of the patient shows the muscles
and fatty tissues wasted to the last degree. The
flexor tendons of the thighs are contracted, so
that the legs cannot be extended. The skin is of
a dirt}- brown color, and covered with branny
scales. Eyeballs prominent, pupils react normal-
Ij'. Ophthalmoscopic appearance of fundus nor-
mal. The heart, lungs, kidneys and sexual organs
were carefully investigated and nothing abnormal
noted. A line of superficial dulness could be
made out extending transversely across the abdo-
men, on a level with the umbilicus, and a lobu-
lated mass could be felt in the left inguinal region,
but it could not be distinctlj- outlined. The tem-
perature was normal. Pulse weak and variable
from 120 to 140 per minute. The mental symp-
toms were substantialh- those which were de-
scribed as existing for the past three months.

A diagnosis of an exhaustional-confusional form
of insanity proceeding from a dilated and over-
filled colon, was made. Large rectal injections
were ordered, containing in each pint of water 2
ozs. of listerine and i drachm of common salt.
Tonics were also ordered, with cod-liver oil inunc-
tions, massage and general faradization.

The subsequent historj- was furnished by the
attending physician.

July 19. Condition unchanged, absolutely re-
fused food. Insisted that her brother had been
recently killed.

July 20. First injection given, consisting of
about 2 pints. The tube was passed well beyond
the sigmoid flexure. In about an hour the injec-
tion came away and with it a considerable amount
of fsecal matter. Upon withdrawing the tube,
its distal end was found to be coated with dark,
waxy, adhesive faecal matter entirely unlike that
which came away. After the injection the patient
passed into a quiet sleep, from which she awak-
ened after about two hours, and called for food
for the first time in many weeks.

July 21. Marked improvement, pulse 100. No
faecal masses came away with to-day's injection,
but the tube is still coated as at first, showing that
a mass is still retained. Mind perfectly clear and
tranquil.

July 30. Continued improvement. Since be-
ginning the treatment ten rectal injections hav-e
been given. Occasionallj' a dark, hardened faecal
mass comes awaj-.

August 14. Able to be out of bed but walks
with great difficulty, owing to the muscular wast-
ing. Mind perfectly clear, but retains only an
indistinct recollection of the time of her illness.
For the past two weeks her bowels have acted
without cathartics, and her appetite is excellent.

November 20. No longer suffers from consti-
pation, and her health is better than it was before
her illness.

232

MEDICAL PROGRESS. [August 17,

An account of a striking case of this kind was In ordinar>- constipation where there is simple
sent me by my friend Dr. H. M. Bannister, senior atony of the bowels, laxatives may be indicated ;
assistant physician to the Illinois Eastern Hospi- but where we have a true overfilling with disten-
tal for the Insane. The patient, a panophobic sion of the pouches of the colon, cathartics are
melancholic with suicidal tendencies, had refused of little use, and may be positively injurious,
food for months and had been fed artificially. He 434 W. .\dams St.

seemed too weak to walk and was sent to the in-

firmar>' ward, where the attendant noticed that he i MCnirAI PROrRPQQ

had no free passage from his bowels. A large in- i IVlhUlUAL rKUUKcoo.

jection was ordered, which freed him of an im-

mense quantity of fseces, which he had been keep- Should we take Prophylactic Measures
ing in store and letting oS' by driblets. Within FOR THE Prevention of Pneumonia from a
an hour or two, during the momentarj' absence of Point of View of Contagion ?— By Dr. Cro-
the attendant, he got up, dressed himself, broke nigneau (Societede Med. Pratique, Paris),
through a window and made his escape. He About a year ago I was called to a lady whom I
eluded a very thorough search, and was only heard found suffering from pneumonia affecting the
from some time later, when he wrote a perfectly lower third of the right lung. In spite of classi-
straight letter for his clothing. cal treatment rigorously carried out ( antimonials,

Case third was that of a young man 30 years alcohol, tonics, revulsives), nearly the entire lung
of age, having a marked neurotic heredity. His became hepatized, and although the fever did not
mother is now insane. Of ner\-ous temperament, run verj' high, there was soon paralysis of the
but of previous good health and strength. He bladder with retention of urine necessitating cath-
consulted me for what he termed a marked change eterization, and paralysis of the bronchi, phenom-
in his character and habits. From being cheer- ena which, in the light of existing theories, one
ful and contented he had lately become nervous, would ascribe to an intoxication of the entire or-
suspicious of his fellow- workmen, fretful, and in- ganism by the leucomaines of Frankel's diplo-
clined to quarrels and to take offense. These cocci. The patient died. Eight days afterward,
mental symptoms had been accompanied by de- her brother-in-law took to bed with pneumonia
creasing weight, failure of strength, general de- of the apex of the right lung. There was no
bility, loss of appetite and a disinclination to suspicion of tuberculosis, although the patient,
exertion. An account was given of irregular ac- aged 54 years, had long sufiered from catarrh, for
tion of the bowels extending over one year ; at which reason there was a locus iiihioris resistentia
times constipation and again several water>- dis- offered to all infectious germs. The disease ran
charges, to be succeeded by a period of inaction, a normal course up to the eighth day, when the
A copious rectal injection relieved him of a large patient, who was very much cyanosed, died sud-
mass of dark, consistent, foul-smelling faeces, i denly of pulmonarj- haemorrhage. I have re-
With this came a complete restoration of the nor- , ported these cases because I wish to propase the
mal mental tone. 1 following questions : In view of the prevailing

Regarding the treatment of this condition we | opinions relative to the etiology of pneumonia, do
incline to the view expressed by von der Kolk, ' we see in these two cases, separated by an inter-
who says (p. 134, ibid.): "All remedies which val of eight days, afiecting two members of the
act as violent irritants of the colon, the so-called same family living in the same house, an example
drastics, only increase the tendency to stricture, of contagion or simply one of coincidence? If
they add to the sensibility of the colon, and the the former, or if we are in doubt, should we direct
accumulation of blood in it, and cause waterj- the family to take the precautions of disinfection
stools, while the hard masses in the upper portion which hygiene demands as safeguards against all
of the large intestine still remain. The disquie- bacteriological affections?

tude, the excitement, and the uneasy feeling of M. Brocq : There is more than one variety of
the patient are thereby increased, but the strength pneumonia and all pneumonias are not contagious,
is diminished, if these medicines are continued The pneumonia a frig ore of the countrj' does not
for any length of time ; the circulation becomes make victims of those about the patient; the pneu-
more and more irregular, the radial pulse becomes monia of the city, on the contrary-, is often conta-
small, and the limbs cool." The first case is in- gious. The different varieties of pneumonia pre-
structive in this regard. The consulting physi- sent clinical characteristics which are sharply
cian in that case said the diagnosis was an absur- defined and, although I do not deny the existence
dity because the patient had been given cathartics, ' of the pneumococcus, we are not yet sufficiently
causing repeated movements of the bowels, and well informed of its nature and the conditions
they always made her worse, increasing the weak- j requisite for its pathogenic development.

ness and mental aberration. He incontinently
withdrew from the case upon learning that the
attending physician agreed with us.

M. Guelpa : I dispute the assertion of M.
Brocq, that there are non-contagious pneumonias;
for the existence of the pathogenic microbe, be it

I889.J

MEDICAL PROGRESS.

233

that of Friedlander, Frankel or others, may al-
-ways be demonstrated. In this connection I may
cite the case of the ser^'ant, in M. Chantemesse's
laboratorj-, whose saliva injected into guinea pigs
always produced pneumonia.

M. Weber : Of course the contagiousness of
pneumonia is associated with a microbe ; but the
microbe does not develop unless the soil is favor-
able. In animals infectious pneumonia is frequent
and taking cold favors its development. There
is a pneumonia of animals to which the term
" pneumonia of the stables " is applied. This is
always grave and difEcult to cure ; it attacks ani-
mals enfeebled bj' previous disease.

M. DUBOUSOUET : I agree entirely with M.
■Guelpa, so far as contagion by the intervention
of various microbes is concerned. But aside from
the microbe there is the question of soil, as M.
Weber has so well said. During the epidemic of
1886, I attended an old man with pneumonia.
His wife in turn was seized, and then the concierge
of the house and his wife. The old man and the
concierge were both addicted to liquor ; the former
died, the latter was dangerously ill. The two
women, who were of sober habit, were only mildly
attacked.

M. Lavaux : Duiing the epidemic in question,
I myself contracted pneumonia. My comrades,
the internes, cared for me with the greatest devo-
tion, but not one of them had the disease. I
doubt the contagious nature of pneumonia.

M. Petit : Clinicalh' and microbiologically it
is difficult to distinguish the various forms of
pneumonia, and though numberless cases of its
non-contagiousness are observed, the deduction
that it is never contagious does not follow. This
being established it seems to me proper to always
use prophylactic measures, just as it is prudent to
■do so in the case of tuberculosis.

M. Balzer : It is especially important to dis-
infect the sputum and all objects which have been
soiled, for the pneumococcus may preserve its ex-
istence after the pneumonia has been cured.

M. Lecerf : Not merelj' do pneumococci exist
in the saliva of people who have been attacked
by pneumonia, but they are very often found in
the saliva of health}' people who have never had
the disease.

M. TolEdano : Is it not true that the entire
course of pneumonia indicates a disease of infec-
tious nature? The fever, the duration, the incu-
bation, the cyclical evolution are the character-
istics of all contagious diseases.

M. Cronigneau : As we cannot be sure that
the case of pneumonia in hand is not contagious,
would it not be prudent to seek in everj- case to
protect those who surround the patient? This
was the question which I asked, and the discus-
cussion which has followed seems to me to have
given an affirmative answer. — Journal de Medicine
de Paris, June 30, 1889.

On Condurangine. — Kobert {Les Nojiveaux
Remtdes obtained this glucoside from the bark of
the condurango. It possesses two remarkable
qualities: i. If a water solution of it is heated
to 40°, it coagulates ; 2. If sea-salt is added to
the water solution the condurangine forms a pre-
cipitate at the bottom (in these respects it resem-
bles albumen). It has a well-defined toxic effect
upon the central nervous system. When given
in small doses it imparts to the walk of an animal
an ataxic character which has some resemblance
to that of tabes dorsalis. Besides this poison
seems also to have an effect upon the peripheral
ner%-es and the muscles. Electric irritabilitj- is.at
first increased, but diminishes afterwards. In
large doses condurangine always causes a diminu-
tion of the appetite or complete anorexia ; during
the beginning of the period vomiting and a great
deal of salivation was noticed in the carnivora.
The fatal dose is 0.02 gr. per kilo of animals in car-
nivora and about 0.06 gr. in herbivorous animals.
Does condurangine have a specific action on can-
cer cells ? It is well known that of late the condur-
ango bark has been much praised as a cure of
cancer of the stomach. But this remains to be
proven. It is administered either through the
mouth or by injection of a sterilized solution. —
Journal de Medicine de Paris, No. 21, 1889.

The Toxic Action of Cocaine. — Cases ot
poisoning have been collected by Dr. A. Wolfler
from the various Austrian, German, British,
French and American journals, as follows :

1. Instillation in the connective tissue sac of
15 drops of a 5 per cent, solution. Moderate
symptoms of intoxication.

2. Twenty per cent, solution. Penciling of the
nasal cavitj'.

3. Penciling of the larynx with a 20 per cent,
solution (about 5 grm.).

4. Injection of 0.06 grm. of cocaine in the
gums. Very severe symptoms of poisoning.

5. Injection of 6 drops of a 20 per cent, solu-
tion in the gums. Moderate degree of intoxica-
tion, without secondary effects.

6. Injection of 0.2 (!) in a case of facial neu-
ralgia. Severe symptoms.

7. Injection of 0.021 grm. in front of the ear.
Collapse ; cold sweat ; improvement in fifteen
minutes.

8. An injection, by mistake, of 1.25 grm. in a
case of sciatica. Congestion about the head,
rapid pulse, quickened respiration, nervous symp-
toms.

9. Injection in the nasal cavity. Aphasia and
agraphia.

10. Injection of a 5 per cent, solution under
the periosteum of the jaw. Severe collapse in 5
cases.

11. Four centigrams in the eyelid. A doubt-
ful case of intoxication.

234

MEDICAI, PROGRESS.

[August 17,

12. Three-fourths of a syringeful of a 15 per
cent, solution in the gums. Severe poisoning.

13. Injection of 0.75 grm. (!) in the urethra.
Epileptiform convulsions, irregular heart's action,
C3'anosis, death twenty minutes after the injec-
tion.

14. Injection of about 0.2 in the urethra.
Clonic cramps, cyanosis, rapid pulse. Patient
revived in an hour. Patient suffered from epi-
lepsy.

To these cases the author adds five others
which occurred under his own observation, and
from his analysis of the sum total concludes that
cocaine, when employed about the head and face,
is capable of producing much more serious results
than when used in other parts of the body more
remote from the brain. This corresponds some-
what with the observation that other agents, such
for example as chloride of iron; when injected in
the extremities hardlj' ever produce injurious
effects, while injected in the face dangerous em-
boli of the brain not infrequently result. In all
small operations on the extremities or trunk a
gram of a 5 per cent, solution may be safely in-
jected ; whereas in the face, with the exception
of the mouth and throat, and the hairy scalp,
more than 2 centigrams should never be used. — .
Wiener Med. Woch., No. 18, 1889.

Extraction of Nerves. — At the Congress of
the German Surgical Society in Berlin, 1889,
Thiersch, of Leipsic, read a paper on the extrac-
tion of nerves. In order to tear out nerves, espe-
cially the trigeminus, with as little manipulation
as possible and as close as can be to the base of
the brain, it has been customary to grasp the
nerve in its continuity in the direction of its
length. In this procedure the ner\-es which are
really grasped are drawn out, but not the branch-
ing twigs. It occurred to Thiersch to twist the
entire bundle of ner\-es, and after a number ofi
fruitless experiments he succeeded in constructing
an instrument which is fairly well adapted to this
purpose. It consists of a forceps which holds
fast without cutting or slipping. One branch is
concave, the other convex ; these fit closely to-
gether and both are serrated, the serrations being
smoothed off. In the five or six years since the
writer began his experiments he has operated
twenty-eight times, on seventeen patients. In
five cases the supraorbital nerve was involved, in
eleven cases the infraorbital, in three the lingual,
in four the infraraaxillar\-, and in one each the
mental, the auricularis major, intercostalis, etc.

Horsley has operated fifteen times in cases of
trigeminal neuralgia, with complete cures in
about one-third of the cases. In obstinate, re-
curring cases he has opened the middle cranial
fossa and cut through the branches of the trigemi-.
nus to the inner side of the foramen ovale. Hors-
ley was obliged to abandon an attempt to extir-

pate the ganglion gasseri on account of haemor-
rhage. He regards the diseases in question as
mostlj' of peripheral origin.

Thiersch has repeatedly performed the operation
at the foramen volurdum and foramen ovale, some-
times with trephining, but regards the operation
as a difficult and dangerous one, calculated to
produce functional disturbances. He has consid-
ered the extirpation of the ganglion gasseri, but
has never attempted it because a portion of it is
firmly attached to the dura mater. He believes
that these neuroses depend generally upon peri-
pheral changes, although he has seen cases of
undoubted cerebral origin. — Wiener Med. U'oe/i.,
No, 19, 1889.

Experiments regarding Death by Hvper-

THERMY, and THE COMBINED EFFECT OF CHLO-
RAL AND Heat. — On the ground of experiments
made on dogs, Ralliere (Paris) arrived at the
following conclusions : The body temperature
maj^ be increased to 5 or even 6 degrees Celsius
above the normal if this increase is temporary and
immediately followed by a cooling-off; the danger
of hypertherm}- lies in the duration only. Ani-
mals which have stood an overheating quite well
maj^ die within the next twenty-four hours ; after
the expiration of this period unfavorable occur-
rences are not apt to take place. If the animal
has previously been given chloral the danger is
incomparably greater ; death often occurs sooner,
at lower temperatures and with shorter duration
of the effect. Often general convulsions will
occur immediately after the increase of tempera-
ture, or later, within thirty-six hours ; in this
case the animals die with a subnormal tempera-
ture (as low as 26°), or with temperature nearly
normal. Sometimes death ensues without previ-
ous convulsions. The author concludes that high
temperatures or continued increase of body temper-
ature are a contra-indication to the use of chloral.
He also thinks that in administering medicine the
degree of fever should be taken into consideration
more than has been done so far. — Centralblatt fiir
Klitiisehe .Mediein, No. 26, 18S9.

On Syphilitic Arthritis. — In a resume of
a clinical lecture on this subject, M. Kirmisson,
of Paris, says : From a diagnostic standpoint the
exact location of the pains and of the tumefaction
at one or at several places about the. joint are of
vital importance. Another factor equally signifi-
cant is the contrast between the oftentimes an-
atomical lesions and the lack of functional
troubles. A patient with a tumefaction of enor-
mous size on his knee still moves his joint with
great facility-. In other varieties of chronic
arthritis, and especially in tubercular arthritis,
such innnunity is but rarely observed in the move-
ments.— Le Bulletin .Medical, No. 43, 1889.

[889.]

EDITORIAL.

235

Journal of the American Medical Association

PUBLISHED WEEKLY.

StTBSCRiPTiON Price. Including Postage.

Per Annum, in Advance $5-oo

SixGLE Copies 10 cents.

Subscription may begin at any time. The salest mode of remit-
tance is by bank check or postal money order, dra-mi to the order
of The Journal. When neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
letters.
Address
JOURN.\I. OF THE AMERICAN MEDICAL ASSOCIATION,
No. 6S Wabash Ave..

Chicago, Illinois.
All members of the Association should send their Annual Dues
to the Treasurer, Richard J. Dunglison, M.D., Lock Box 1274, Phila
delphia, Pa.

London Office, 57 and 59 Ludgate Hill.
SATURDAY, AUGUST 17, 1889.

REFLEX NASAL NEUROSES.

Five years have elapsed since Dr. Wilhelm
Hack's monograph; " Ueber eine Operative Rad-
ical-Behand!ung BestimmterFormen von Migjane,
Asthma, Heufieber," etc., aroused, in those not
intimately familiar with the possibilities in the
case, a sense of skepticism by reason of the mul-
tiplicity and diversity of the pathological reflexes
which were described as emanating from the nose.
Certain forms of asthma, spasm of the glottis,
cough, migraine, supra-orbital neuralgia, swell-
ing and redness of the external nose, syncope,
and epileptoid seizures, were attributed to nasal
irritation, occasioned bj- hypertrophy of the tur-
binated bodies, polypus, and intra- nasal deformity.
His observations were, in part, corroborative of
those previously published by Dr. Daly, Dr. J.
M. Mackenzie, and Dr. Friinkel, while the re-
maining ones have since been confirmed and sup-
plemented by other writers.

Two essays reiterating these conditions, entitled
respectively, " Cough in its Relations to Morbid
States of the Nasal Cavities," and "Epilepsy
Caused by Intra-Nasal Disease," were read at
Newport before the Section of Larj-ngologj' and
Otologj' of the American Medical Association,
and Dr. J. M. Mackenzie, at the recent Congress
of the American Laryngological Association, de-
scribed similar phenomena which were excited by
adenoid hypertrophy in the naso-pharynx.

The term " reflex" is, doubtless, often misap-
propriated, yet it has a definite significance, and
the pathological reflexes which originate in nasal
or naso-phar>'ngeal irritation and terminate in

cough, larj'ngeal spasm, or asthma, follow much,
the same pathwa)- as the physiological reflex
known as sneezing. The nasal branches of the
ophthalmic division of the fifth ner\-e and the
nasal branches of the anterior palatine descend-
ing from Meckel's ganglion which is in connec-
tion with the superior maxillary division of the
fifth nerve, conduct the sensory impressions to
the medulla. It is there reflected to the respira-
tory, pneumogastric, and other centres, whence
the deep inspiration, the forced expiration, and
the coincident spasm of the pharj'ngeal and lar-
3'ngeal muscles, termed a sneeze.

This mechanism, of course, varies somewhat with
the difierent pathological reflex acts, and in the
group constituted by reflex pareses, considerable
complexity may enter by implication of the vaso-
dilators through the superior cervical sympathetic
ganglion.

But nasal irritation does not in every case re-
sult in reflex phenomena. Evidently still other
conditions are essential.

Certain cases are in part determined bj^ involve-
ment, especially of the " sensitive areas " described
by Mackenzie, of Baltimore, as limited to the na-
sal erectile tissue and particularly to the posterior
ends of the inferior turbinals, but even then the
tendency to evolution of reflex phenomena varies
in different individuals. Functional derangement
tending toward special susceptibility of certain
ner\-e centres, including those wrought upon by
peripheral nasal irritation, doubtless determines
other ca-ses ; and chronic inflammation or a pre-
disposition to acute congestive states of particular
organs, unquestionably favors the development,
at that point, of the ultimate link in the reflex
chain. Thus, one affected with bronchitis would
suffer the more readily from asthma excited re-
flexly by nasal irritation, laryngitis predisposes
under like conditions to spasm of the glottis, and
digestive derangements to migraine. So, in the
completed cycle three factors obtain : nasal irrita-
tion, super-excitable nerve centres, and a suscep-
tive peripheral organ. But the nasal irritation is
the initial link without which the peculiar reflex
is not excited and to which the other factors are
subservient. It is the element most easily demon-
strated, most readily removed, and eradication of
which will accomplish a cure.

It is, perhaps, not as specifically stated as it
should be by writers, that only a considerable

236

ILEUS.

[August 17,

■number of such neuroses have a nasal origin, i men opinion extant among surgeons as expressed
Identical symptoms can proceed from distal irri- 1 by Greig Smith, quoted by Jacobson, viz.: "To
tation elsewhere than in the nose or from imme- ] acute cases there can be but one termination
diate disease of the organ of manifestation, and death. . . . Certainly 95 per cent, of such cases
nasal irregularities, being general, may confuse | die, hence the indication is clear enough (as clear
the diagnosis by incidentally coexisting. Emphy- ; as the indication to tie a bleeding) carotid ar-
sema and nasal polypi are not uncommonlj' asso- artery."
ciated, but it would be unwise to expect the mere , Not that we may ever hope to discover a

removal of the polypi to afford complete relief of
the dyspnoea consequent upon the emph^'sema.

panacea for an ill posessing, a symptom-complex
that may be evoked by the most varied of ana-

Nevertheless the polypi should be removed, as in tomico-pathological conditions ; from intestinal

this and analogous states, benefit is thereby se-

concretions to cancer, mesenteric embolism to in-

cured to nasal function and any possible reflex vagination ; but because by so doing we may
nasal element is eliminated. ' possibly disabuse ourselves of the notion that

Occasionally the relation of cause and effect ' there is but one proper course to pursue in every
between nasal disease and its reflex manifestation : case, as well as reap the benefit of the new truths
becomes apparent from the general history and always elicited on such occasions. Among the

symptomatology. Again, the- diagnosis can be
made by exclusion, and more rarely, an explosion
of the reflex may be induced through artificial ir-
ritation by a probe to the sensitive area. But

latter then the above quoted opinion is not wholly
true.

' ' Success in this department will only come
when a diagnosis has first been made, at least

commonly only the subsidence of the reflex act i with reasonable surety. The practice of explora

following the removal of an associated nasal le-
sion will amount to a demonstration.

It is certainly ' ' unnecessary where no incon-
venience is felt to restore geometrical symmetry-
to the turbinated bodies or to invest the lining
membrane of the nose with artistic merit," but
the mere coexistence of a decided pathological
condition or deformity in the nose with any one
of the reflex acts known, at times, to proceed
therefrom, should prompt the immediate correc-
tion of the nasal fault.

tive laparotomy for everj- case is as j-et to be con-
demned. Our statistics can onh- then be made
more favorable than the expectant treatment,
when we have selected those cases in which there
is a rea.sonable hope." (Jacobson).

Ju!;t here it seems fitting to emphasize the fact
that 30 per cent, of all cases recovered under such
palliative treatment as full physiological doses of
opium may be considered to be, when combined
with rigid attention to diet. Also that the post-
mortem examination of those dying under said
treatment were as follows, 20 per cent, cancerous,
10 per cent, old cicatricial adhesions, 14 per cent.
ILEUS. invaginations, 6 per cent, old or new perimetritis,

The perennial effort of the medical world to 1 2 per cent, old strictures from cicatrices, and 4
secure some definite mode of treatment for in- per cent, tubercular peritonitis, extensive ad-
testinal obstruction (an indefinite ailment) praise- hesions,

worthy as it is futile, has again made its appear- If we regard as incurable by any treatment the
ance. This time at a recent meeting of the Berlin j cases of cancer, the cases of tuberculosis with ad-
Medical Society, through the presentation by Dr. hesions, and half the cases of invagination — such
GoLTDAMMER of a Series of fifty cases, occurring | are the statistics for the latter — he is to be cred-
in his own practice which he had treated without ited with results that " must give us pause " —
selection and consecutively, bj' large doses of over 50 per cent, recovery !

opium. The results obtained by such treatment, 1 In concluding he presented the following de-
(30 per cent recovery), compare very favorably ductions. which are thoughtful if not to be com-

with those of laparotomy — out of 328 cases of
laparotomy collected by B. F. Curtis, 68.9 per
cent, mortality — and invite our mature delibera-
tion, especially when we bear in mind the com-

mended in every case.

I. To be operated are: Cases in which an in-
vagination is clearly to be diagnosticated as shown,
by the youthful age ; sudden onset ; bloody stool;

1889.]

ILEUS.

237

absence of meteorism, possibly tenesmus ; but
above all a tumor.

2. In such cases of verj' acute inception as fail
to receive benefit from the bold use of opium —
7 grains in twenty-four hours — and in whom the
symptoms of collapse continue after such treat-
ment to increase. And,

3. Finally in those cases in which the opium
has, for a time seemed to benefit only to have the
symptoms reappear. If to these we add those
which the surgical authorities are now almost
unanimously agreed never to operate, (a) when an
approximatelj' correct diagnosis cannot be made ;
(b) when the patient is already moribund ; (the
statistics in the past have been spoiled by such
surgery) or (c) when there is great cachexia with
distention ; we will not go far astray in our treat-
ment.

As to diagnosis there is this to say : Bearing in
mind that we may have all the symptoms as
secondary to acute inflammatory processes ;
peritonitis, perityphlitis, etc., or likewise (and
this without actual occlusion of the gut) in
paralysis, embolus of the art. mesar. or external
adhesions ; that it is essentially differential, and
must be made by exclusion. To do this some
aid may be furnished by an effort on the part of
the physician to answer the following five ques-
tions ;

1. Is it mechanical or inflammatory, acute or
chronic ?

2. Is there a tumor palpable?

3. What is the location ?

4. Is it a new growth ?

5. Where was the initial pain?

I. The inflammatory ileus, {ileus injiammatorius
of old writers) will differentiate itself from that
which is of mechanical origin, by the historj^ of
fever with its concomitant symptoms of pain and
tenderness, the former of a colicky, the latter of
a localized character, the other sj'stemic excita-
tion rather than a depression. If constipation
exist in the inflammatory obstruction, it is not so
complete that some faeces cannot be reached by
enemata. Having ruled out the inflammatory
form, then decide as to the acuteness of the at-
tack. Among the acute obstructions are to be
classed volvulus ; invagination ; incarceration ;
almost always affecting the small intestine, and
requiring operative interference for cure. Pain in
the incarceration abrupt in its onset and continu-

ous ; while paroxysmal in intussusception and
volvulus. The two quickly fatal, meteoric as
well as meteorism, the last slow ; no meteorism.

If chronic then we have to deal with the large
intestine and carcinoma in by far the largest num-
ber of cases, though stenosis from syphilitic and
tubercular origin are also factors here. How ex-
ceedingly essential however it is to differentiate
between the sudden failure of compensation after
a gradual!}' occurring stenosis, and an acute ob-
struction, Rosenbach has recently demonstrated,
making at the same time a taking parallel between
this and the similar failures in other organs, like
the heart, bladder, stomach, etc., where a time
comes when the work becomes greater than the
compensator}- hypertrophy, and sudden absolute
failure results.

Study the initial symptoms and prodromata !

2. Almost every case of invagination is accom-
panied by a characteristic sausage-shaped tumor,
so much so that 70 per cent, are to be diagnosed ;
when we take into consideration the absence of
meteorism, blood in stool, etc., with the tenesmus
so characteristic. The rectum should be explored
in every case, with the whole hand if necessar}-,
when the tumor can usually be felt, as well as the
answer to the fourth question elicited, for over 60
per cent, of the large intestine occlusions are
located in the rectum and sigmoidea.

3. Location. Every case will be treated to a
number of enemata before a positive diagnosis
has been made. Knowing that the average rectum
holds a pint, that i J^, 2 and 3 pints are required
to fill the three segments of the sigmoidea, and
never more than 9 pints the colon, we can ap-
proximate the location of the obstruction if we
measure the quantity of fluids injected. This
should be done gradually, gentle massage of the
abdomen being employed, and an elevation of syr-
inge 6 feet (which gives 2.6 pounds pressure).
Vomiting of formed fasces is the only absolutely
sure stercoraceous vomiting, and indicates that the
location is at least below the valve. It is admit-
ted that illy-smelling digesta come sometimes from
the lower portions of the ileum.

The nearer to the p54orus the greater the sup-
pression of urine. The signe de Dance is a de-
pression in the right iliac fossa, due to the trac-
tion of an ileo-caecal invagination, as it mounts

I upward and toward the mesial line.

1 The last question both aids in locating, as well

238

EDITORIAL NOTES.

[August 17,

as from its nature determining the character of
the obstruction.

A fitting couclusion to this will be the observa-
tions of R. H. Fitz, . . . "The diagnosis
must be made in the first two days ; the capacity
of the colon determined before tympany develops.
Make diagnosis by exclusion, seat by injection,
variet}' by seat, age and antecedents. Treatment
is surgical on the third day." To which we will
only add, if the diagnosis cawiot be made, use
opium. In medias tutissimus ibis.

EDITORIAL NOTES.
HOME.
Dr. W. p. Manton, of Detroit, has received
the appointment as consulting gynecologist to the
Eastern Michigan Asylum.

Faculty Changes. — The College of Physi-
cians and Surgeons at St. Louis have added to
the facult}- Dr. Y. H. Bond, as Professor of Gyne-
cology ; Dr. Wm. Porter, Professor of Diseases of
the Chest ; and Dr. I. N. Love, Professor of Dis-
eases of Children.

The New York Board of Health. — The
Sanitarj' Superintendent of the Cit}' Board of
Health, Dr. Walter DeF. Day, has been compelled
to resign on account of ill-health, after sixteen
3'ears of ser\nce. Dr. William A. Ewing has been
appointed in his stead. Dr. Ewing has formerly
had a long term of service in the Board, as Sani-
tary Inspector, going back after an absence of
three years.

The Hospital at Burlington. — The Mary
Fletcher Hospital at Burlington, Vermont, has
added an ophthalmological service, with Dr. J. H.
Woodward in charge. Dr. Richardson of the
Visiting Medical Staff has resigned and Dr. J. C.
Rutherford has been appointed in his stead. Dr.
Walter Carpenter has been reelected President of
the Board of Trustees.

University of Michigan. — It is reported
that the Professorship of Surgery in the Medical
Department of the University of Michigan has
been offered to Dr. Charles B. Nancrede, of Phila-
delphia. He is the Senior Surgeon at the Epis-
copal Hospital in that city.

Improvements at the Protestant Hospi-

tal.— The Weekly Medical Review says: The
Protestant Hospital Association (St. Louis) has
recently been the recipient of some generous do-
nations, amongst which we note the following :
By Mr. and Mrs. Thos. B. Dyer, a strip of ground
running along the south line of the hospital
propert}^ and which is equivalent to at least $1000.
Mr. Alex. Largue, before his decease, expressed
a determination to make a bequest to the hospital
of $500. He diefl before he had completed his-
will, but his widow and son, Mr. Alex. Largue, Jr.,
have voluntarily paid over to the Hospital Asso-
ciation their proportion of this $500. Mr. Wm.
R. Pj^e has shown his liberality by donating $5000.
That the hospital is in a flourishing condition is
shown by the fact that the want of room compels
the erection of an addition and the making of
alterations to the extent of $10,000 ; this work is
now in progress. Twentj'-four new private rooms
will be added.

Ice in the Sick-room. — The Sa?iitarian says;-
A saucerful of shaved ice may be preserved for
twenty-four hours with the thermometer in the
room at 90° F., if the following precautions are
observed : Put the saucer containing the ice in
a soup plate and cover it with another. Place
the soup plates thus arranged on a good, hea\^
pillow, and cover it with another pillow, pressings
the pillov^s so that the plates are completely em-
bedded in them. An old jack-plane set deep is a
most excellent thing with which to shave ice. it
should be turned bottom upward, and the ice
shoved backward and forward over the cutter."

A Medical Index. — The Times and Register
has commenced the publication in its columns of
a Medical Index which will contain a list of orig-
inal articles published in exchanges, especially
those of interest to the practitioner.

All Honor to Him. — The Albany Medical
.Annals relates the following : One of the bright
spots in the Johnstown disaster is furnished by a
member of our profession. Among the mass of
.shattered humanity was Dr. Matthews. He had
himself sustained the fracture of several ribs ;
but with the loyal instinct of the right-hearted
physician he devoted himself to those about him
who, with broken limbs and otherwise gravely
hurt, were in need of some surgical help, besides
cheering them with encouraging words. In the
scattered and disjointed reports we have had but

1889.]

KDITORIAL NOTES.

239

a glimpse of this scene, but when the history of
the great event is connectedly written, it is to be
hoped that this episode will be found true and
due honor given to the hero of it.

Birth Returns, — The Medical Record quotes
the following from \.\i^ New York Herald : Massa-
chusetts has a new statute, which has just gone
into effect, for securing a more perfect record of
vital statistics. All doctors are required to report
births, and for each birth reported the doctor gets
a fee of twenty-five cents. No penalty is fixed
for failure to report. This little fee is no great
object, yet it is proper as recognizing that the
State has no right to exact a gratuitous service
from medical men — which it does when it calls
for a whole series of certificates that must be given
under penalties for failure, as with doctors in this
city. The language of the Massachusetts statute
is odd. It requires the doctor to report all births
" at which he is present." Suppose the baby is
born before the doctor gets there.

The New York County Medical Association has
a special committee for the purpose of considering
the certificate-grievance, with the view of securing
as well more complete returns. A professional
friend solemnly assures us that half his life is
spent in writing certificates for life insurance,
schools, judges, societies, and all kinds of health
organizations. Great Britain and, we think, Ger-
many wisely throw the responsibility of returning
births upon the parents themselves. At all events,
the legal opinion is that the State has no power
to impose any service without providing a com-
pensation.

FOREIGN.

A New Use for Flags. — The medical de-
partment of the Paris University will use a flag
whenever a confinement is in progress in the
lying-in wards. A blue flag indicates a simple
confinement, a yellow flag a difficult labor, and a
green flag that an operation may be necessary.

French Congress of Surgery. — The fourth
meeting of the French Congress of Surgery will
be held in the large amphitheatre of the School
of Medicine, Paris, from October 14 to 20. The
following questions will be taken in the order of
the day of meeting : i. Results, direct and remote,
of practical operation for local tuberculosis. 2.
Surgical treatment of peritonitis. 3. Treatment
of aneurism of limbs. Baron Larrey will preside.

Dr. S. Pozzi, 10 Place Vendome, Paris, is
Secretary-General of the Congress.

the

Low MORT.\LITY among THE FrENCH TrOOPS.

— The health of the French army is constantly
improving. The death-rate has fallen to 7.58 per
1000. This is the lowest point yet reached in this
arm}', and it is lower than has been reported con-
cerning any other of the European forces. The
troops in Tunis exhibit the highest rate of mor-
tality, about 19.4 per 1000. The disease which
figures most prominently among the causes of
death has been typhoid fever, which gives about
one-tenth of the admissions to the hospitals, but
even in this respect the conditions show a mani-
fest improvement.

The Health of the Pope, — The age of Leo
XIII is said to be 82 j-ears, but his health is firmer
and better than it was twelve years ago when he
became Pontiff'. He is described as active, robust
and heartj' for one of even a less advanced age,
and he speaks of himself in far more promising
terms than he did twelve j'ears ago, when he told
his friends that it would be useless to make him
Pope, for he had only a few months to live, and
his appearance then did not belie his words.

Hydrophobia in Brazil. — The Lancet con-
tains an abstract of the first annual report of the
Pasteurian Institute at Rio de Janeiro. It com-
prises the data of the work performed during the
first eleven months of its existence. The first
patient was received February 9, 1888, between
which date and January 8, 1889, one hundred
and six persons were treated for hydrophobia,
with only one death. Sixty-two of the patients
were undoubted cases of biting b^' dogs having
rabies. The death is reported to have been the
case of a young child who was not long enough
under treatment to allow of the full Pasteurian
method.

In India the Indian Medical Gazette has a vig-
orous article dealing with the need of an Imperial
Sanitary Board, A new Women's Hospital is to
be erected at Kurrachee at a cost of 40,000 rupees.
Calcutta will soon be provided with an Ophthal-
mic Hospital through the liberality of a native
gentleman. Baboo Churn Lahaa. Dr. Lall Madhull
Mookerjee is the President of the Calcutta Medi-
cal Society. Typhus fever is epidemic in the
Rawal Pindi districts.

240

TOPICS OF THE WEEK.

[August 17,

TOPICS OF THE WEEK.

OCEAN CLIMATIC THERAPEUTICS.

The following are some of the things well said by Dr.
.Albert L. Gihon, Medical Director U. S. Navy, in his
Address before the American Cliniatological Association,
in June last.

First, if season, course, and destination be judiciously
chosen, the invalid will obtain, on a long voyage, in a
comfortable sailing vessel, lesi—oi mind and body— a
condition of absolute insouciance, and relief from the
cares and distractions, the daily worries and anxieties of
life, the interruptions and noise and turmoil and excite-
ments which railroads, telegraphs, and newspapers bring
into the very sick-room on land.

If not so completely bed-ridden (in which case he
probably ought not to go to sea at all) but that he can lie
in aa easy chair on deck, he will be able to breathe and
bathe in an air -that is barren of every impurity, and with
everj- inspiration experience a sense of pleasurable in-
vigoration.

If sea-sickness is not an indomitable idiosyncrasy, as I
have known it to be even in captains of the navy, he will,
after a few days, when he " gets his sea-legs," as sailors
term it, find inexpressible delight in pacing the narrow
bounds of the quarter-deck, and lengthen the hours of
this gentle exercise until they become whole watches
long.

Once accustomed to the motion of the vessel and of the
sea, nausea will give place to appetite, which is sharpened
as well for old salts as land-lubbers, and the plainest food
will be taken with unwonted relish, betokening improved
assimilation. If care be had to overcome the usual
tendency to constipation, ingestion may go on without
restraint. The eagerly anticipated meal-hours become
the eventful marks of the passage of time. The whilom
patient eats and sleeps, and wakes to find new zest in the
simple employments of the day. Rocked in the cradle of
the deep, the ocean's lullaby soothes the sufferer into for-
getfulness of his ills. . . .

Next to the transitory exposure to ocean climate in the
course of a sea-voyage is the residence on some small
mid-ocean island where there are few \'icissitudes of
weather, short range of temperature, and none of the
physical befoulments from masses of men and animals or
decaying vegetable matter. Here, even better than on
shipboard, is to be found the opportunity for making
ocean climatic influences available as curative meas-
ures. . . .

The therapeutic agencies which operate upon the broad
ocean — rest, pure air, equable temperature and moisture,
and the minimum of disturbing causes, are to be found in
almost as great degree on the ocean islets, where the
sound of rippling springs, the sight of fresh verdure, and
the scent of earth replace the monotony of the horizon-
bound disk of water.

These islets are dotted over the sea — numerous in
Oceanica, where distance and rare opportunities of com-
munication place them beyond convenient and frequent
access — less numerous but easily reached in the .\tlantic.

where midway between the continents the\- invite the
wearj- broken down sufferers in mind and body to find
rest and sweet oblivious antidote for all their ills. The
Azores, Madeiras, and Canaries are the chief among these
"isles of the blest." The former, especially Fayal,
about two thousand miles, ordinarily a pleasant fort-
night's run from Boston, offer a climate so mild, that one
need hardly look for a better, were it not that the better
is to be found at Madeira, and a best of all at Orotava on
the Island of Teneriffe, one of the group of the Canaries
— Las Canaris of the Spanish, the Insula Fortiaiata of
Roman geographers, whose mountain peaks stand above
the waters like tombstones in this ocean cemetery, where
a continent and its millions of Atlantean inhabitants are
buried.

The Madeiras are but five hundred miles from the
Azores, and the Canaries two hundred farther south, so
that the wa\- is easy to that delightful spot, which Hum-
boldt thanked God he had lived to behold — the valley of
Orotava, fit garden of another Eden, where he who
would begin life anew may find everything save the vice
and artificialities and malefic agencies of modem civili-
zation.

Is it not time to stop and ask ourselves whether it be
not the better part to place our patients where, amid
Heaven's boundless supplies, the wiser air-cells, and
blood-vessels, and lymphatics may themselves select just
what they most require — where pure air and water, and
good food, cooked to tempt the palate with half the art
in making pretty portions to please both eye and taste,
shall be the tonics to regenerate the blood till it revivify
the worn-out nerves, repair the wasted tissue, and set
once more in healthy play the vital machinery which ani-
mates and gives the body being ? Mere drugs cannot do
this, and drugs needlessly, excessively wrongfully admin-
istered, can only retard it. The pharmacist may often-
time be idle, but the therapeutist's task will be no lighter,
for climato-therapy requires sound judgment, wise and
discriminating adaptation of natural agencies, and the
same watchful observation of the grade of action shown
by the pulse, the condition of the organic fibre, and the
state of the secretions, which are the sum of the physi-
cian's duty, however huge his pharmacopoeia. If he can
preserve tissue from destructive change, keep the emunc-
tories in active play, and control the pulse's fitful beat,
he may patiently bide his time for those forces to exert
their power, which out of the germinal vesicle make the
perfected man — out of the stomach's bole, the blood's
living corpuscles, and out of these the sentient flesh and
conscious brain. — Medical Nezvs.

THE MEDICAL SOCIETY OF DELAWARE.

This organization dates back to 1789, and accordingly
this is its centennial year. The annual address delivered
by W. T. Skinner, M.D., of Glasgow, Del., is replete
with historic as well as medical interest. We would be
pleased to publish the entire ' address as found in The
Afedical Bullelin, but must content ourselves with a few
brief extracts:

"The Medical Society of Delaware is one of the oldest
institutions of the kind in this country, being probably

1889.]

TOPICS OF THE WEEK.

241

antedated only by the Massachusetts and New Jersey
Medical Societies," and, to use a somewhat trite expres-
sion, it had its birth in the " times which tried men's
souls." The colonies had, it is true, gained their inde-
pendence, had adopted the constitution, and had just in-
augurated George Washington, iu New York, as the first
President of the United States. But it was not all smooth
sailing yet. We are told that the nation was confronted
by grave financial embarrassment; its energies as well
as its resources seemed exhausted b^' the prolonged
struggle through which it had just passed. The people,
so long accustomed to war, were now ill fitted for the
pursuits of peace, and, feeling very keenly the pinch of
hard times, soon began to be discontented, and rebellion
threatened even the very existence of the newly organ-
ized Government. ....

Of the medical men whose services were so indispensa-
ble to the existence of our country in its earlier days
none were more distinguished than those of Delaware.
The first President of this Society, Dr. James Tilton, was
a man of broad culture, and his distinguished services
throughout the Revolutionary War very justly entitle
him to be named as one of the trio of great men in the
profession in that day, namely: Rush, Warren, and Til-
ton. He had the honor, as you know, to be elected to a
professorship in the University of Pennsylvania, which
he declined, in order to continue in his comitry's service,
and upon the breaking out of the war of 1S12-15 he was
made Surgeon-General of the United States.

Dr. Joseph Philip Eugene Capelle, another one of the
corporators of this Society, served upon the staff of La-
fayette, and when the great general was wounded at the
battle of Brandywine Dr. Capelle was the first to offer
him surgical aid. Of Dr. Edward Miller, another of the
patriots of the Revolution, and one of the charter mem-
bers of this Societj-, its first Secretary, and the first to
deliver the annual oration before it, the great Rush de-
clared that " he was second to no physician in all this
country."

It does not come within my scope to give an historical
sketch of the members of our Society, the historian of
the day has already attended to this part of the pro-
gramme; but I have cited a few examples only from his
statements, to show you that "our ancient record is an
honorable one." "There were giants in those days,"
men who were further in advance of the times in which
they lived than any we now number in our membership.

For one hundred years the meetings of the Medical
Society have been the Mecca to which the faithful have
journeyed once a year. Yes, journeyed is the term, for
it must have taken at least three days for a man from
Wilmington or Sussex to attend a meeting here in Dover
— one to come, one to attend the meeting, and one to re-
turn home again. But to-day we step aboard of a fast
train, have agreeable companions, and after spending an
hour or so pleasantly chatting and, as the train proceeds,
constantly deriving new pleasures by being joined at every
station by old friends whom we have not seen since our
Jast meeting, we reach our destination and find ourselves
all together, Sussex, Kent, and New Castle. I will not

attempt to describe what follows. It is a grand old re-
union, and yet I doubt that so large a percentage of the
medical fraternity attend its meetings to-day as there did
in those good old days.

EFFECTS OF CORROSIVE SUBLIMATE.

The following symptoms have been observed in cases
of poisoning caused by vaginal or intra-uterine injection
with corrosive sublimate :

The alimentary canal. Thirst, foul breath, metallic
taste, red or bluish color and swelling of the gums ; red-
ness, ulceration and sloughing of different parts of the mu-
cous membrane of the buccal cavity ; deep ulcers in the
tonsils ; soreness and looseness of the teeth, and some-
limes salivation ;vomiting,abdominal pain, tenesmus; pro-
fuse stinking, often bloody, diarrhcea. The faeces contain
mercury. It has been found in numerous cases after va-
ginal or intra-uterine injections of a solution of 1:3000,
followed by the injection of plain water. Even when the
solution was so weak as 1:4000, it was found iu one case,
but in the others not. In the majority of cases it is found
the next day, and it is yet found a long time after discon-
tinuing the use of the bichloride.

The uropoctic system. There is a marked diminution
in the amount of urine, rising to absolute suppression of
the secretion. The urine is dark, grumous, contains
much albumin, mercury epithelial cells from the kidneys,
and hyaline or granular casts.

The skin is often wet with perspiration ; it has been
found hypersesthetic, itching, pale or erythematous.
Sometimes there is considerable swelling of the subcuta-
neous tissue.

The nervous system. In the beginning the patient is
restless, and suffers from insomnia ; later she becomes
drowsj-, sometimes delirious ; and finally she collapses.
In some cases spasmodic twitchings or cataleptic stiffness-
has been found in the extremities. The pupils are some-
times contracted as in opium poisoning. Sometimes-
there is a sensation of being choked.

The /"^^Ac is rapid and weak, the temperature subnor-
mal.

Of these symptoms the most characteristic are the di-
arrhoea, the diminution or suppression of the urinary
secretion, the stomatitis, the low temperature, and the
presence of mercury in the urine and the stools, which
may be found by chemical analysis.

The chief changes found after death are haemorrhagic
infiltration and extensive ulceration, sometimes diphther-
itic patches and sloughs of the large intestine. In some
cases a lower degree of inflammation is found in the
ilium. Exceptionally, the cesophagus has been found
inflamed. In some cases there has been found local
peritonitis.

In the mouth and throat are found the above-mentioned
changes.

Another constant change is parenchymatous nephritis.
Sometimes deposits of phosphate of lime are found in
the convoluted or straight tubules, but these calcareous
deposits are often absent, and may, on the other hand, be
found under different circumstances.

In some cases the substance of the brain was found
dry ; in other there were extravasations of blood in the
meninges. — Garrigues, American Journal of the Med-
ical .Sciences.

242

SOCIETY PROCEEDINGS.

[August 17,

SOCIETY PROCEEDINGS.

American Oplitlialniological Society,

Twenty-Fifth Anmial Meeting, held at Pequot

House, New London, Conn., July ij

and 18, i88g.

{Concluded from page zro.')

Dr. Emil GruEning, of New York, read a

paper on

THE USE OF THE CURETTE IN ANTERIOR
TRACHOMA.

The speaker often referring to the various
measures proposed for the relief of this condition,
described an operation which he had employed in
eleven eyes during the past ten years. A 6 per
cent, solution .of cocaine was first instilled. The
surface of the cornea and the vessels present
were then scraped away with a gouge-shaped
instrument, and the vessels followed well on to
the conjunction. The eye is then washed with
boric acid solution, and warm compresses applied
for four or five days. In three cases new vessels
formed, and the operation was repeated. The
ultimate result in all the cases was highly satis-
factory. In old and protracted pannus, this op-
eration may be recommended for its directness,
simplicitj' and eflScacj'.

Dr. S. D. St. John, of Hartford : I have used
this operation in one case with the highly gratify-
ing result of increasing the vision from ^J^ to
jW. This has since still further improved.

Dr. H. F. Hansell, of Philadelphia, read a
paper on

CORNEAL ABSCESS.

Describing its symptoms and referring to the
differential diagnosis between it and ulcer. He
protested against the use of cocaine in abscess or
other inflammatory conditions of the cornea. A
few drops of a strong solution will often destroy
the epithelium. Instillation of eserine alternat-
ing atropine was recommended. Operative inter-
ference should be limited to evacuation of the
pus.

Dr. Charles J. Kipp, of Newark, read a
paper entitled

FURTHER operations ON MALARIAL KERATITIS.

The author had called attention to this condi-
tion in a paper read before the Society in 1880.
He had seen 120 cases of the disease. In all
there had been paroxysms of malarial fever, and
in 90 per cent, the corneal inflammation followed
a few days after a paroxysm. In 25 per cent, the
patients had suffered from similar trouble in
previous attacks of malaria. The inflammation
of the cornea occurred in the form of respiginous
ulceration, with narrow prolongations. The

trouble began as a line of small grayish eleva-
tions, which soon broke down, forming a furrow
of ulceration. In mild cases the duration is two
or three weeks, while in severe cases it may last
several months. There is a marked tendency to
recurrence in subsequent attacks of malarial fever.
In a few cases he had seen a similar affection in
non-malarial individuals. The treatment con-
sists in remedies directed to the general condition
and in mild cases with warm fermentation. In
severe cases a i per cent, or a 2 per cent, solution
of nitrate of silver applied directly to the furrow
after the use of cocaine answers well. In some
very severe cases the actual cauten,- was employed.
This arrested the progress of the disease and
stopped the pain, provided the malarial trouble
had previously been cured.

Dr. Henry D. Noyes, of New York : During
the past fifteen or 20 years, I have met with cases
of superficial keratitis due to malaria. It is rare
to find the deeper tissues invaded, I am led to
suspect a malarial origin in cases where there is
exaggerated tenderness of the supra-orbital nerve
and distinct anaesthesia of the surface of the cor-
nea. The form of ulcerative keratitis which has
been described I regard as of mycotic origin, and
have cured • it by scraping thoroughly the lines
of infiltration.

Dr. T. Y. Sutphen, of Newark : I have seen
cases similar to those described by Dr. Kipp, in
patients suffering with malaria, and where there
has been no distinct chill, the individuals have
resided in malarious districts.

Dr. John Green, of St. Louis: I have seen
many cases in which malarial fever was followed
by superficial keratitis, or keratitis modified by
neglect or improper treatment. I have not met
with the form described by Dr. Kipp.

Dr. Emil Gruening, of New York : I have
seen this form of ulcerative keratitis, but I have
associated it with the teeth. These patients have
had tartar on the teeth, and have been in the
habit of moistening the lids with saliva. I think
therefore that the source of infection is in the
mouth.

Dr. Samuel Theobald, of Baltimore : I
have also seen for many years this keratitis as-
sociated with malarial trouble. These cases do
not always show ulceration of the cornea. I have
in a general waj' regarded this condition as
analagous to herpes zoster. I have once or
twice seen iritis associated with the keratitis fol-
lowing malaria. In one case of malaria I have
seen this keratitis with herpes zoster of the
temple.

Dr. J. A. LiPPiNCOTT, of Pittsburgh, read a
paper on

IRRIGATION OF THE ANTERIOR CHAMBER.

This procedure is useful for the removal of de-
bris in cataract extraction and of clotted or liquid

1889.]

SOCIETY PROCEEDINGS.

243

Wood. In order to accomplish this successfully
it is necessarj' to have an apparatus which can be
readily made and kept aseptic; which will alwaj-s
be ready for use ; which can be easih- handled and
the movement controlled with one hand ; whose
ejecting force is capable of being easily regulated:
and which is free from liability of forcing air bub-
bles into the anterior chamber. As fulfilling these
requirements he exhibited an apparatus consisting
of a small metal receptacle with which was con-
nected a rubber tube ending in a metal nozzle ;
the flow of liquid being controlled by a short pis-
ton in a rubber handle through which the rubber
tube passed. The ejecting force can be varied b)'
elevating or lowering the receptacle.

Dr. E. Gruening, of New York, exhibited a
small flask devised by von Graefe for the same
purpose.

Dr. David Webster, of New York, exhibited
two specimens of sword fishes' ej-es.

Dr. Hexrv D. Noyes, of New York, exhibited
a spectacle frame in which the nose-piece of the
ej'e glass was combined with the ordinary- specta-
cle frame.

Dr. Henry D. Noves, of New York, read a
paper on

ENUCLE.\TION OF THE EYE IN PANOPHTHALMITIS.

There have been reported b}- observers thirtj'
or forty deaths following enucleation, almost all
from meningitis. About one-half of the fatal
cases have occurred after enucleation during acute
•suppurative panophthalmitis. At the New York
Ej'e and Ear Infirman.- there have been no deaths
from this cause when no additional operations in
the orbit, such as the removal of tumors, etc., |
■have been done. The number of enucleations
from 1868 to 1888 was 1,164; the number of evis--
cerations seventeen. Panophthalmitis existed in
14 per cent, of the cases. It seems fair to con-
clude that whilst a small risk to life is incurred bj'
enucleation of the e3'e, the supposed increased
risk by the existence of suppurative panophthal- ;
mitis is not so far justified by the facts as to bar
its performance in this condition.

Afternoon Session. i

Dr. H. Knapp, of New York, read a paper on ;
The treatment of caries and necrosis of !
the orbit.
The upper wall of the orbit is the most frequent
seat of disease and here its consequences are most
dangerous. In every case of caries and necrosis
of the orbit the condition of the neighboring cav-
ities, and especially the nose, should be carefully
investigated. Foci of suppuration .should be free-
\y opened, the cavitj- thoroughly cleansed and !
drainage established. This can be well accom-
plished by small silver tubes provided with flan-
ges. Rough bone should be scraped awaj' with ,
a sharp spoon. Necrosed portions of bone should j

be removed as soon as thej- become loose or when
the}- can be detached without injury to adjacent
tissues. The eyeball should be protected, and if
there is insufficient closure of the lids, a plastic
operation should not be postponed until the cor-

I nea becomes ulcerated from exposure.

I Dr. H. W. Williams, of Boston, read a paper

jOn

multiple cysts of the iris occurring in

both eyes.
The subject was a girl 9 years of age. In the
right eye there was a projection resembling a
large cyst extending from the upper margin of

I the pupil. A similar growth projected from the

,' temporal border. At the inner margin there were
two small pedunculated growths. All were of the
color of the iris. In the left eye, two somewhat
oval cysts filled the pupillary space. Through the
square opening left in each pupil there was a lit-
tle oblique vision.

Dr. T. Y. Sutphen, of Newark, read a paper on

j S.ARCOM.A OF THE OPTIC NERVE.

I The patient was 10 years of age. The tumor
involved the left orbit and was of two years' du-

1 ration. It was mushroom-shaped and sprang from
the optic nerve. Its size was 6 x 5 '^ inches, and
2 inches thick. It was readily removed with
curved scissors. As much as possible of the nerve
was removed.

Dr. George C. H.\rlan, of Philadelphia, read
a paper on

EXTENSIVE V.\SCUL.\R GROWTH IN THE VITREOUS.

The patient, a woman set. 50, presented herself
November 29, 1888, on account of disturbance of
vision. Examination of the right eye showed
the fundus to be slightly hazy, with small, dull
white spots about the macula, the remains of old
haemorrhages, but no recent exudation. The disc
was obscured bj^ a delicate network of vessels.
Otherwise there was no opacity. There was no
stroma. Up to March 2, 1889, there had been sev-
eral retinal haemorrhages, but there had been no
change in the vascular membrane. Vision had
been reduced to i^.

Dr. O. F. Wadsworth, of Boston, described
two cases of

EXTRACTION FROM THE VITREOUS OF PIECES OF
STEEL BY THE MAGNET,

in which the piece of steel was removed by pass-
ing an electro-magnet into the vitreous through
an opening in the sclera. In the second case, the
operation was followed some weeks later by a
separation of the retina beginning at a point op-
posite that at which the puncture was made.

Dr. J. O. TOMLEY, of New York, read a paper
on

CORNEAL TR.\NSPLANTATION.

The speaker reported a case in which he had
done this operation for opacity of the cornea. At

244

SOCIETY PROCEEDINGS.

[August 17,

the first operation the opacity was not removed to

its full depth, and although the cornea cleared to
a certain extent the result was not satisfactory.
The operation was therefore repeated, but with-
out any improvement in vision. In both opera-
tions there was primary union of the graft and in
neither was there any inflammatorj' reaction.

Dr. L. Webster Fox, of Philadelphia: I
have performed the same operation in a case of
opacity of the cornea where the patient could just
distinguish light from darkness. The graft healed
readily without inflammator\- reaction, and the pa-
tient obtained useful vision and could almost count
fingers.

Dr. Chas. a. Oliver, of Philadelphia, read
a paper entitled

AN ANALYSIS OF SOME OF THE OCULAR SYMPTOMS
OBSERVED IN SO-CALLED GENERAL PARESIS.

These operations were made on twent}^ well-
marked cases of general paralysis of the insane.
The study was limited to subjects in the so-called
second stage of the disease, where the psychical
symptoms had become of such a character as to
necessitate control and where motor and sensor}-
derangement had become more or less manifest.
Care was taken that each subject was seemingly
free from any extraneous general disease or local
disorder, and the entire study was limited to the
male sex, so as to escape au}- conflicting or com-
plicating changes that might appear in connection
with the man}' diseases peculiar to the female sex.
Thirty observations were made, resulting in the
following summary :

1. The sensorj' changes herein described, which
have been limited to unequal optic ner^^e degen-
eration, decrease of retinal circulation, with sub-
normal direct and excentric vision for both form
and color, distinctly show lowered sensory re-
sponse.

2. The motor sj-mptoms, consisting in unequal
and feeble movements of the irides,' causing ine-
quality and irregularity of pupillary areas, the
peculiar form of ataxic nystagmus, the slight loss
of ciliary tone, all express want of proper muscle
action — true paresis.

3. The peculiarly local conditions shown in the
fundus, such as the pigment massings, the cres-
cents of absorption, the disturbed and granular
condition of the choroid, etc., all indicate wear
and tear of an abu-sed and irritated organ.

4. Therefore these observations upon the ocu-
lar apparatus, which were most probably made
during the second stage of the disease known as
general paralysis of the insane, show not only
local changes, but distinctly demonstrate that the
series of sensor)' motor disturbances found, are
but the peripheral expressions of one of the many
indices of gradual loss of neural strength and
power in this disease.

Dr. George C. Harlan, of Philadelphia, re-

ported A Case of Hysterical Blindness of ten years''
duration in a male 22 years of age.

Dr. S.amuel B. St. John, Hartford, described
A Case of Hemianopsia with peculiar cerebral
symptoms.

Dr. B. Alex. Randall read a paper on Sim-
ple Tests of t/ie Ocular Muscle.

Dr. T. Y. Sutphen, of Newark, N. J., reported

a CASE OF double PURULENT CHOROIDITIS RE-
SULTING FROM MENINGITIS.

February' 23, 1887, was called in consultation
to see G. \V. B., a robust farmer, set. 39 years.
He had always been healthy with the exception
of an occasional ' ' bilious headache. ' ' Never had
had any specific trouble. The history was that
on Februarj- q he came in at noon perspiring verj-
freely. That evening he suffered with intense
headache. The next morning he was apparently
well, but at breakfast had a violent chill with
aching of the whole body. This was followed by
high fever. Leaving the breakfast table was the
last that the man remembered for three months.
From this time the patient rolled and tossed in
bed without decided delirium, but being in a
stupid condition and easily restrained. Ques-
tions were answered only after frequent repeti-
tion and the replies ran off" into complete incohe-
rence. On the third day of the illness the body
became quite rigid with the head thrown back
wards. On the fourth daj-, the left hand and
forearm became swollen and the right eye in-
flamed. The left eye became inflamed on the
tenth day. Later the left foot became swollen.
The swelling of the hand and foot lasted about a
week and then subsided. The fever then became
less violent and the general condition improved,
but the mental sluggishness remained. There
was no paralysis, no convulsion, no vomiting. At
the end of the third week he had a slight chill,
and another after he was out of bed.

At present the man is apparenth- in good health.
He has lost none of his functions and the mind is
perfectly clear. When first seen by the writer the
ej'es were in the following condition : No swell-
ing of the lids; moderate pericorneal injection;
cornea clear ; anterior chamber normal in depth ;
irides slighth' discolored. Pupils nioderateh' di-
lated, with a j-ellowish reflex from the anterior
portion of the vitreous. There was no perception
of light. No tenderness on pressure, but a marked
lowering of the tension of the globe. Three days
later, the anterior chamber in each eye was oblit-
erated by pressure from behind the lens, the ej'e-
balls being harder than normal. One week later,
the anterior chamber was again restored and ten-
sion had again fallen much below the normal.
I-'rom that time there was progressive atrophy of
both eyes until now there is left only the greatly
shrunken globes, with, of course, absolute blind-
ness.

1889.]

SOCIETY PROCEEDINGS.

245

In this case there must have been an extension
of the intracranial inflammation along the sheath
of the nerves and not a forcing of the products of
inflammation fom-ards, as sufiicient pressure with-
in the cranium to produce this must evidently have
become apparent b}' more or less paral5'sis.

The case is reported simply as a clinical contri-
bution to this somewhat rare and obscure trouble,
which is certain to be met with in the course of
practice.

Thursday, Second Day.

Dr. O. F. Wadsworth, of Boston, reported a
case of Torticollis Cured by Tenotomy of the Ex-
ternal Rectus.

Dr. Myles Standish, of Boston, read a paper
on

PARTIAL TENOTOMIES IN C.\SES OF NEURASTHE-
NIA WITH INSUFFICIENCY OF THE OCULAR
MUSCLES.

The author reported five cases in which he had
performed this operation on account of constant
headache, inability to use the eyes and neuras-
thenic .symptoms. In all but one there was marked
and prompt relief of the local and general symp-
toms by the operation. Cases requiring operation
are comparatively rare.

Dr. D.wid Coggin, of Salem, read a paper
entitled

notes on some vagaries of accommodation.

A case was of hypermetropic astigmatism pass-
ing into myopia. A case of recurrent spasm of
accommodation was also reported. The third ca.se
was one of temporary anomaly' of sight occurring
daily. In the morning could see well, but in the
afternoon could not distinguish objects across the
street. Double vision also occurred. The dis-
turbance is gradually disappearing.

Dr. E. E. Holt, of Portland, read a paper on
the

EFFECT UPON THE .ACCOMMODATION OF \ PA-
TIENT'S EYE CAUSED BY LOOKING INTO THE
MIRROR SET OBLIQUELY IN THE ROOM
DURING OPHTHALMOSCOPIC EX-
AMIN.\TION.

Directing the patient to look with one eye into
a mirror set obliquely while the other was exam-
ined with the ophthalmoscope, an element of ease 1
was found in making the examination, and of|
comfort and steadiness on the part of the patient '
never experienced before. The eye fatigues
quickly in looking at a single object. Looking
into the oblique mirror gives the impression of'
gazing into the distance. A notable change in
the pupil will be obser\-ed when the patient is
directed to look at an object at the distance of the
mirror, and when he is directed to look at objects
reflected from it. I

Dr. O. F. Wadsworth, of Boston, read a
paper on

paralysis of the SPHINCTER IRIDES.

A case was reported of paralysis of the sphinc-
ter irides, without affection of the accommodation
lasting several months, and following the instilla-
tion of homatropine in both eyes.

Dr. Samuel Theob.\ld, of Baltimore : In all
such cases it is important to exclude malingering.
It would be possible for the patient by the use of
a weak solution, to keep up the mydriasis with-
out affecting the accommodation.

Dr. Samuel D. Risley, of Philadelphia : An-
other protracted explanation of such cases is the
use of pipette previously used for a solution of a
mydriatic, for a solution which contains no my-
driatic.

Dr. John Green, of St. Louis, presented a
series of Geometrical Constructions, illustrating
certain cases of oblique pencils refracted at cylin-
drical and spherical surfaces.

Dr. John Green also read a paper on Some of
the Stereoscopic Alterations Evoked hv Unequal
Glasses placed before the two Eyes.

Dr. Samuel Theobald, of Baltimore, read a
paper on

THE EMPLOY.MENT OF OLEATE OF VERATRIA

TO FACILITATE THE DETERMINATION OP

ERRORS OF REFRACTION.

A mj'driatic affords valuable aid in myopia and
in hypermetropia, but in astigmatism its use is
not so satisfactory. In astigmatism he had found
great help from the use of a 10 per cent, oleate of
veratria to the temple and forehead once a day
for three or four days. This seems to exert a
quieting effect upon the ciliar}- muscle, and
especially of the radiating fibres and lessens the
tendencj' to a symmetrical accommodation. The
following rule was formulated in regard to the
correction of astigmatism : When the astigma-
tism is according to the rule, we need correct
only that which is readily made manifest. On
the other hand in astigmatism against the rule,
we are warranted in arresting fully every part of
the defect which can be rendered manifest.

Dr. E. E. Holt, of Portland, read a paper on

THE INEFFICIENCY OF HYDROBROMATE OF
HOM.\TROPINE IN CONTROLLING THE AC-
COMMODATION FOR THE PURPOSE
OF FITTING GLASSES.

The experience of the writer was that this
drug could not be relied upon. He reported one
case in which the lateral h3''permetropia revealed
by 3 per cent, solution of hydrobromate of homa-
tropine, was just one-half of that revealed by i
per cent, solution of atropia.

Dr. Edward Jackson, of Philadelphia: I
have found homatropine entirely satisfactory

246

SOCIETY PROCEEDINGS.

[August 17,

when used properly. The instillations must be
repeated at short inter\-als five or ten minutes,
and three or four instillations practiced. The
efiect rapidly passes off, and the examination
must be made within one or two hours. I have
followed the use of homatropine b^- another
mj'driatic without alteration in the result.

Dr. Edward Jackson, of Philadelphia, read a
paper on

American Otological Societv.

Tivcnty-second Annual Meeti?ig, held at the Pequot
House, A^ew Londoti, Conn., July 16, iSSg.

The Society was called to order bj- the Presi-
dent, Dr. J. S. Prout, of Brooklyn.

Dr. B. Alexander Randall, of Philadelphia,
read the first paper, entiled

AMETROPIA AS DETERMINED UNDER COMPLETE : INFLAMMATION OF THE TYMPANIC ATTIC AND
MYDRIASIS. 1 PERFORATION IN SHROPNELL'S MEMBRANE.

He had examined 4,000 eyes under complete
paralysis, and presented the following table of his
results. These were compared with results ob-
tained by another observer :

with without

Mydriasis. Mydriasis.

Compound hyperopic astigmatism. . . 40 °o 9,'2 °o

" myopic " ... 9" n

Simple hyperop'ic " . . . 6 " 16^ "

Simple myopic " ... 2 " 24 "

Mixed astigmatism 6>4" 2 "

Hyperopia 31 " 10 "

Myopia 4 " 9,!^ "

Emmetropia ■ . . . I'i" I7'4 "

Dr. Jackson also presented a paper on Ac-
curacy in the Prescription of Prisms.

Dr. W. S. Dennett, of New York, read a
paper in which he suggested a New Unit of
Angular Measurement for Prismatic Glasses.

Dr. George C. Harlan, of Philadelphia,
exhibited Periscopic Cylindrical and Sphero-
Cylindical Lenses.

Dr. W. F. Multendorf, of New York, re-
ported

a case of amblyopi.a due to chlor.\l
hydrates.

The object was to put on record a case of toxic
amblyopia, due to chloral hj'drate. The patient
had for six months been in the habit of taking
40-60 grains of the drug at night to induce sleep.
Suspension of the drug relieved the amblyopia.

executive session.

Officers for ensuing year : President, Dr. Has-
ket Derby, Boston ; Vice-President, Dr. George
C. Harlan, Philadelphia; Secretary- and Treasurer,
Dr. Samuel B. St. John, Hartford ; Correspond-
ing Secretary, Dr. J. S. Prout, Brooklyn ; Dele-
gate to the Executive Committee of the Congress
of American Physicians and Surgeons, Dr. John
Green, St. Louis ; Alternate, Dr. D. B. St. John
Roosa, New York,

The following were elected to membership :
Dr. Carl Koller, New York ; R. A. Reeve,
Toronto, Canada; Dr. David Harrower, Jr.,
Worcester, Massachusetts ; and Dr. George E.
de Schweinit/., Philadelphia.

The Society then adjourned to meet at the
Hotel Katerskill, the third Wednesday of July,
1890.

The author reported twenty cases, fifteen of
which had been seen in the past six months, and
urged that the condition was not a rarity. It
often coexists with one or more perforations of
! the other parts of the drum head. If sought and
recognized early, it is a less tedious and serious
matter than these attic inflammations are gener-
ally considered to be. He cited some 120 cases
reported by several obser\'ers among 10,000 pa-
tients, and while he had seen a still larger propor-
tion, accepted this as the average. Passing over
the treatment as having been already thoroughly
discussed, he turned to the question of causation,
and cited the view of Walb that infection from
without through a "foramen Ravinii " was the
starting-point. Contesting this view as to any
colobomatotis opening in the flaccid membrane as
wholh- negatived by modern embrj-ologists, he
urged that the individual variations in the septa
in the attic predisposed some cases to localized
inflammation and led to perforation at this point ;
and that these cases, neglected or recurrent,
formed the group from which the usual obstinate
cases were derived. He therefore advocated scru-
pulous search in all cases for disease in this local-
ity as promising to nip in the bud what might
later become disease notoriously difficult to con-
trol. The paper was illustrated bj- drawings and
photographs of specimens.

Dr. S. O. Riley, of Philadelphia: I have
frequently seen perforations elsewhere associated
with perforations in Shropnell's membrane. The
presence of perforations in other parts of the drum
membrane does not exclude its presence in Shrop-
nell's membrane.

Dr. J. O. Tanslev, of New York : I have
never met with perforation of the drum to which
the doctor refers, a.ssociated with perforation in
other parts of the drum. A singular thing is
that we so rarely get the perforation whistle.

Dr. S. O. Richev, of Washington : I do not
think that perforations of Shropnell's membrane
are so common as has been stated. My experi-
ence with the absence of perforation whistle cor-
res[ionds with that of others. I have had cases
in which perforations in other parts of the drum
healed but the perforation in Shropnell's mem-
brane persisted. In treating these cases, besides
\ using measures through the external auditory

1889.]

SOCIETY PROCEEDINGS.

247

meatus, I have emplo3'ed injections through the
catheter consisting of nitrate of silver i part, boric
acid ID parts, glycerine 20 parts and water 500
parts.

Dr. Gorh.^ji Bacon, of New York : I have
not obser\-ed this condition so frequently- as Dr.
Randall. It is often difficult to see these perfora-
tions. In treatment I have generally used Blake's
extra-tympanic syringe. By persistent syringing
and the use of astringents, cicatrization is often
produced. These cases are, however, very tedi-
ous.

Dr. J. A. Andrews, of New York: In treat-
ing these cases in which there is purulent inflam-
mation of the attic with a large hole in Shropnell's
membrane, after injecting the cavities. I wash out
the fluid by means of this instrument, consisting
of a delicate metal tube with a curved extremity
to which is attached a rubber tube. I use simply
a boric acid solution. After washing out the fluid
I dry it with cotton wrapped on a probe. I then
blow in a'^ne cloud of boric acid.

Dr. Herm.-vn Kn.\pp, of New York : There
is a capital difference between perforations in the
upper and those in the lower part of the drum j
membrane. Those in the lower part maj' close 1
in a few days, while in the upper part they may
continue for months or years. I think this is due
to difference in anatomical structure. The lower
portion is a specific tissue with little association
with periosteum, while the upper part is a dupli-
cature of periosteum and skin. When the latter
part is affected the process extends to the perios-
teum, leading to caries and necrosis of the bone.

Dr. F. M. Wilson, of Bridgeport, Conn., re-
ported

THREE DEATHS FOLLOWING SUPPUR.'^TIVE OTITIS,
WITH TWO AUTOPSIES.

Cases in which death follows a first attack are
so rare that it was thought of value to report
these cases. The first patient \vas set. 40 years,
who for two weeks before coming under observa-
tion had had pain in both ears. Februarj- 27,
1888, the pain in the left ear became very intense.
March i he became partially unconscious and re-
mained so, with occasional convulsive movement, 1
until March 6, when he died. The mastoid was
drilled ■_■ inch but no pus found. No autopsy
was made.

The second case was a male set. 23 j'ears, who
was attacked with subacute otitis March 1 1 . Symp-
toms of meningitis appeared, with high tempera-
ture, and he died March 27. At the autop.sy one-
third of the base of the cerebrum was involved in
the purulent process, which extended up under
the frontal convolutions. There was about ' j oz.
of turbid fluid between the dura mater and inner
meninges. There was pus in the labyrinth and
in the tympanic cavity.

The third case was that of a boy set, 10 years.

who was attacked with suppurative otitis Sep-
tember 5 and died about ten days later. At the
autopsy the meninges were found normal, but an
abscess containing 2 drachms of fluid was found
in the cerebellum.

Dr. Wilson also presented a Mastoid Drill, pro-
vided with a guard which could be set at any de-
sired point, regulating the distance to which the
drill entered. The edges of the drill are sharp,
so that the opening can be enlarged horizontally
to any desired extent.

Dr. Gorham B.\con, of New York : It seems-
to me that in these cases where we do not find anj^
collection of pus in the mastoid cells, we are jus-
tified in investigating the condition of the brain.

Dr. J. O. Tanslev, of New York ; I have had
several of these cases, and have without success-
sought for some means by which we could differ-
entiate between those cases in which there was
meningitis and those in which there was abscess.
In one case. Dr. Seguin made a diagnosis of ab-
scess based upon conjugate deviation of the eyes.
Subsequent autopsy showed the correctness of
this diagnosis. In another case I suspected ab-
scess. Dr. Weir opened the mastoid but found
no pus. We also exposed the cerebrum, and two
days later the cerebellum, but found no pus. The
patient died of suppurative meningitis.

Dr. S. D. Risley, of Philadelphia : It .seems
to me that in the differential diagnosis attention
to the temperature in connection with symptoms
of pressure is of great importance. In meningitis
the temperature from the outset will be hi<^her
than in abscess, and the symptoms of pressure
come on later.

Dr. J. A. Andrews, of New York : In the
past year I have made a number of autopsies in
cases of brain abscess. Brain abscess maj' con-
tinue for a considerable time without any xqtv
positive symptoms, but where there is meningitis
or phlebitis, there is usually a sudden rise of tem-
perature with chills.

Dr. Oren D. Pomeroy, of New York : In a
case of brain abscess secondary to tympanic dis-
ease the only marked symptom was a sudden rise
of temperature, sometimes going up in half an
hour from normal to 107°. Intelligence was un-
affected until the last. The man gradually im-
proved but died suddenly. The autopsy showed
a large abscess of the brain covering the petrous
portion of the temporal bone.

Dr. Arthur Mathewson, of Brooklyn ; It is
often difficult to make a diagnosis between ab-
scess and meningitis, and in fact many are mixed
cases. In meningitis the pain is more marked
than in abscess. In meningitis there is more
likely to be optic neuritis, while in brain abscess
I have noted a peculiar dark appearance about the
retinal veins.

Dr. Samuel Theobald, of Baltimore : The
treatment of the preliminary stages of these cases

248

SOCIETY PROCEEDINGS.

[August 17,

is important. It seems to me that a great deal
might be done to prevent the occurrence of the
conditions referred to. I have found benefit from
local applications, especially atropia and cocaine
and morphia and cocaine. If the bowels were
constipated I should use a calomel cathartic. If
there should be sj-mptoms of cerebral implication
I should administer mercury in some form to se-
cure its constitutional effect.

Dr. E. Fridenberg, of New York : During
the past eighteen months I have made autopsies
in two patients dead from cerebral absce.ss. In
one case suppuration had lasted a year, but there
had been no symptoms until a week before death,
except irritability of temper. There was some
odor, but very slight discharge from the ear. A
week before death the patient developed pain in
the ear, slight tenderness over the mastoid, fol-
lowed by fever and symptoms of brain pressure. :
A small abscess was found in the temporo-sphe-
noidal lobe. The roof of the tympanum was
carious and the meninges strongly adherent. In
the second case the patient had had suppuration
for years. Two months before death headache
occurred, which was relieved by treatment. It 1
recurred, with fever. There was some pain on
pressure over the mastoid process. The symp- '
toms again disappeared under treatment. Three
weeks later he returned with similar symptoms.
The next morning vomiting occurred, and that
evening he died. An abscess containing two
ounces of pus was found in the temporo-sphenoidal
lobe.

Dr. T. Y. Sutphen, of Newark : These cases
of brain trouble almost invariably follow the ar-
rest of the flow of pus. We should look upon
these cases as instances of local trouble and
should treat the middle-ear by fomentations, and
perhaps by poultice to bring about free discharge
of pus.

Dr. R. a. Reeve, of Toronto, Can. : In one
case of death following acute suppurative otitis,
there was the most profuse purulent discharge
that I have ever seen, and it continued from be-
ginning to end.

Dr. B. Alex.\nder Randall, of Philadelphia:
A case of cerebral abscess occurred in my prac-
tice last year in a boy, the subject of scrofulous
disease of the elbow and other joints. I found
both ears discharging, with caries of the auditory
meatus on both sides. On the left all the mastoid
tissues were involved. Under treatment the right
side rapidly improved and on the left side there
was also improvement. The case was then trans-
ferred to my surgical colleague. Six weeks later
the ears were still in good condition, but the pa-
tient was gradually failing from the constitutional
trouble. An hour before death there was sud-
denly a di.scharge of at least two ounces of fetid
pus from the ear. There was no meningitis, but
a large abscess cavity was found in the spheno-

temporal lobe and '^ inch from the tympanum
and connected with it bj- a sinus. In cases where
it is thought justifiable to perform exploratory
trephining of the brain an admirable and safe
point is I '4 inches behind, and an equal distance
above, the upper posterior margin of the osseous
meatus. This avoids the major blood-vessels,
and it would be favorable to reach the cerebellum
through it.

Dr. E. E. Holt, of Portland, Me,, reported a
case of

complete closure of both extern.\l audi-
tory CAN.\LS BY BOXE IN A PATIENT HAVING
good hearing POWER, WITH A PREVIOUS
HISTORY OF CHRONIC SUPPUR.ATIVE
OTITIS MEDIA.

T. M., age 18 years, was seen in April, 1S89,
for an affection of the eye. It was incidentally
learned that he had had abscesses in both ears
when 7 years old and the ears discharged more
or less for six years, but stopped entirely five
years since. Examination showed the canals of
both ears of about half the usual length and oc-
cupied by a continuation of the skin of the me-
atus, with no appearance of the membrana t3'm-
pani. There was complete closure of the canal
by what appeared to be bone b\- all the tests
employed.

The hearing power for the voice was good.
The stoja-watch was heard only when close to the
ear ; the tuning-fork was heard about ninetj' sec-
onds, both by bone and aerial conduction. Konig's
rod, of thirty thousand vibrations per second, was
heard bj- both ears. He heard less distinctly
when both ears were closed b}- pressure on each
tragus. Shutting the mouth and closing the •
nostrils did not seem to affect the hearing power
much, if at all. Cases of closure of one meatus
with the skin of the canal continuous over the
obstruction have been observed, but the hearing
power is verj- defective. Cases in which there is
a small opening between the exostosis and the
walls of the meatus are not uncommon.

Dr. S.^muel Theob.\ld, of Baltimore : Four
or five years ago I reported a case very similar to
the one described. The newly-formed membrane
was, however, nearer the orifice. The hearing
power was good.

Dr. B. Alexander Randall, of Philadelphia :
I have had one case in which one ear was ob-
structed by a bony mass. There was no evidence
of exostosis. The hearing was, however, defec-
tive.

Dr. E. E. Holt, of Portland, Me,, reported a
case of

OTITIS MEDI.\ C.\TARRHAL ACUT.\

accompanied with facial paralysis and impairment
of accommodation of the eye of the affected side.
Judging from statistics one would be led to believe
that paralysis of the facial nerve in connection

1889.]

SOCIETY PROCEEDINGS.

249

with the acute catarrhal inflammation of the
-middle-ear was not a common complication. In
many cases the pain having been slight and having
passed off and the parah'sis having come on the
patient's attention is directed to this and he seeks
advice for the latter affection and the cause of the
paralj-sis is recorded " a cold," or "rheumatic."

F. , aged 24, seen May 19, 1889. Seven days
before he took cold and right ear began to pain
that night. This pain continued three days,
when it subsided, and on the fourth day he was
unable to use his lips properl)-. Examination
showed all the characteristics of facial paralysis.
Testing the eyes there was found paralysis of ac-
commodation of the right eye. This the author
knew to be a fact, because he had previously had
the patient under his care and recorded the test of
his eyes, and also bj- the fact that since the im-
provement of the paralysis of the face the paral-
j-sis of accommodation has disappeared.

Dr. S. O. Richey, of Washington, D. C, read
a paper on

THE PHYSIOLOGY OF THE INTR.\-TYMPANIC

MUSCLES.

The paper was the elaboration of a suggestion
made bj' the writer in the discussion of a paper
read by him at the Congress of American Physi-
cians and Surgeons in 1888. If the membranum
tympanum in purpose protects the aural tissues
lying interior to it the muscles being appendages
to the membrane are designed to assist the pur-
poses of the membrane, which thej' do in part by
protecting it from injur}' by the impact upon it of
-sound impulses violent enough to rupture an in-
flexible membrane firmly attached and having
such a plane as to expose it to the fullest force of
the concussion. The membrani tympani fulfils
one of these conditions, it is firmly attached. He
quoted Toynbee and Henle as having many years
ago expressed somewhat similar views as to the
action of the tympanic muscles, and states that
he can find no reference to this subject by later
writers. The shape and other peculiarities of the
auditing meatus, the elasticity and capacitj' for
motion of the drum membrane and its oblique
position with relation to the meatus ; the coordin-
ation between the palatal and the intra-tj'mpanic
muscles converting the tympanic cavitj- into an
air-cushion, all indicate a similar purpose on the
part of nature to guard the membrani tympani
immediately and the labyrinth mediately from
violence.

Evening Session.

Dr. Gorham Bacon, of New York, exhibited
photographs of the ear.

CYSTS of the .■VURICLE.

Of late a number of cases of so-called c}'sts of
the auricle have been reported. Not one of these,
iowever, seem to represent a genuine cystic tu-

mor such as is found in other parts of the body.
They all were situated on the anterior surface of
the pinna, and were of rapid development. They
either were the results of traumatism, and con-
tained a sanguinolent fluid, or thej^ developed
without known cause. Mild inflammaton,' S}'mp-
toms were present in all. The development
within two or three weeks in almost all cases dis-
tinguishes them clearly from the slow and non-
inflammatory development of true cj'stic tumors.
All got well either by spontaneous absorption or
by incision. The speaker had seen at least half
a dozen of these cyst-like sub-perichondrial swell-
ings of the auricle. He considered them to be
mild cases of perichondritis, for these mild cases
of circumscribed perichondritis ma}', instead of
getting well, remain in this condition for a time
and then develop into the full picture of a difiiise
perichondritis. He reported such a case.

Dr. Knapp also described a case of genuine
cj'st of the auricle occurring in a girl 19 years of
age. The growth was double the size of a large
filbert, distinctly cystic, and had developed with-
out known cause and without any inflammatory
symptoms. The cyst was removed b}' operation,
without rupture, knd was exhibited. These tu-
mors are not frequent in the auricle, but they can
not be so rare as we might infer from otological
literature.

Dr. Wm. H. Carmalt, of Hew Haven, pre-
sented a case of

epitheliom.\ of the middle ear.

The patient, a robust man aged 47 years, was
first seen in June, 1888. On account of a suppur-
ating ear (left) which had existed 42 3-ears and
had followed measles. The ear had given him
no inconvenience with the exception of the dis-
charge until a few weeks before he came under
observation. He then began to have pain in
and around the ear, and the discharge was ex-
ceeding!)' offensive. The canal was blocked bj'
a ragged but firm excrescence, ver)' sensitive to
touch. There was slight tenderness, but no swell-
ing or pitting over the mastoid. The pain ra-
diated through the side of the head and interfered
with sleeping. At the second visit the left side
of the face was completeh- paralyzed. The case
was regarded as one of epithelioma of the skin of
the canal. The patient was seen by another gen-
tleman, who thought the trouble might be a ca-
rious antrum. An attempt was therefore made
to open the antrum, but the bone around it was
.so sclerosed that the cavity was practically oblit-
erated. There was nothing of the nature of an
abscess in the mastoid. The incision was then
prolonged through the soft parts and into the ex-
ternal auditory canals. What polypoid could be
reached were removed and a drainage tube in-
serted. The mass removed proved to be carcino-
matous. In the course of a few weeks the ear

250

BOOK REVIEWS.

[August 17,

again became blocked up and the skin became
involved. With the object of alleviating some of
the distressing accompaniments of the condition,
another attempt was made to clear it out. By
chiseling awaj' the bone posteriorly, free access to
the ear cavity was obtained and the bone scraped
apparently clean. No auditor^' apparatus was
seen, simply a mass of carcinomatous tissue. The
cavity was washed with a solution of resorcin and
for a time the wound did well, but subsequently
the disease reappeared. The discharges became
again offensive and the patient exhausted, and he
finally bled to death without the condition being
detected, probably from erosion of the lateral si-
nus. No autopsy was permitted.

Dr. B. Alex. R.\xd.\ll exhibited a series of
Photographs, and made some remarks on the use
of photographs and of the lantern in teaching
otology.

Dr. Randall -also reported five cases of Super-
numcraiy Auricle, four of the right ear, one of
the left ear.

Dr. T. Y. Sctphen, of Newark, exhibited a
MiiniDiified Pea which he had removed from the
auditorj' canal, where it had lain for 19 years.
The patient had been deaf in that ear since child-
hood. He heard the watch at one inch. After
removal of the foreign body the hearing was al-
most normal.

Dr. B. Alex. R.\nd.\ll made some remarks
upon the anatomy of the drum membrane.

Dr. Huntington Richards, of New York,
read a paper entitled

TWO NOTEWORTHY CASES OF TRAUMATIC

RUPTURE OF THE MEMBR.\NI

TYMPANI.

Case I. — Seen May 7. A woman aet. 30, two
days before had received a box on the left ear.
The symptoms were vertigo tinnitus and marked
deafness. There had been no bleeding or ether
discharge. There were some evidences of pre-
existing tympanic catarrh, in that it was some-
what depressed and moderately atrophic. Save
for pronounced congestion of the manubrial ves-
sels and a narrow red line along the border of the
opening, it was not congested. The exposed
inner wall of the tympanum was likewise pallid,
secreting only sufficient mucus to give its surface
a glistening appearance. The patient was directed
to let the ear alone and a small, loose cotton
obturator was placed in the auditorj' meatus.

Case 2. — A woman, set. 23. Came under ob-
servation May 22. There was no discharge or
bleeding. There was no congestion of the mem-
brane or of the tympanic wall. The patient had
complained of aural symptoms for several weeks.
On May 21st she consulted a physician, who in-
troduced a cotton-covered probe. This made her
so dizzy that she had to lie down immediately
and within two hours she discovered that she was
very deaf.

The treatment was negative, and up to May
31st no change had occurred. The edges of the
opening were then stimulated with nitrate of
silver solution and a small quantity of boric acid
was insufflated. Examination made a few daj-s
later showed that the opening had healed, with
the exception of a small part. The patient then
passed from observation.

Executive Session.

Officers for ensuing year :

President, Dr. Oren D. Pomeroy,New York.

Vice-President, Dr. Gorhara Bacon, New York.

Secretary and Treasurer, Dr. J. J. B. Vermyne,
New Bedford, :Mass.

Members of Executive Committee of Congress
of American Physicians and Surgeons, Dr. W. H.
Carmalt, New Haven ; Alternate, Dr. F. B. Lor-
ing, Washington, D. C.

Committee on Membership, Drs. Arthur
Mathewson, Samuel Theobald and S. D. Risley.

Committee on Publication, Drs. J. J. B. Ver-
myne, C. J. Blake and J. Orne Green.

A committee consisting of Drs. S. C. Ayres
and Wm. W. Seeley was appointed to prepare a
minute on the death of Honorarj' Member Dr. E.
Williams, of Cincinnati.

The following were elected to membership :
Drs. Harlan P. Allen, Columbus. O.: Ralph W.
Seiss, Philadelphia, Pa.; David Harrower, Jr.,
Worcester, Mass, ; Robert Barclay, St. Louis, Mo. ;
Neil P. Hepburn, New York, N. Y.

BOOK REVIEWS.

A Treatise on Surgery ; its Principles ani>
Practice. By T. Holmes, M.A., Cantab,
Consulting Surgeon to St. George's Hospital,
etc. With 428 illustrations. Fifth Edition.
Edited by T. Pickering Pick, Surgeon at St.
George's Hospital, etc. Philadelphia : L,ea
Bros. & Co. 18S9. Chicago; A. C. McClurg
& Co. Pp. xxiii-1008. Price $7.00.

The fifth edition of this well-known work, al-
though bearing evidence of considerable emen-
dation, represents about the same purposes as did
the earlier editions ; it aims to occupy an honor-
able place among the text-books in use in the
schools, and is intended to be in a sense an intro-
duction to Holmes' System of Surgery. The gen-
eral arrangement of the work has not been dis-
turbed, except as regards the chapter on Di.seases
of the Eye, which has been omitted as requiring
too much of the limited space of the entire treatise
were it emended so as to fairly represent the pres-
ent status of ophthalmic surgery. In other re-
spects the editor has endeavored to bring the work
up to the standard of our present knowledge of

1889.]

BOOK REVIEWS.

2.S1

surgerj' without altering the general character of
the work. j

Among the subjects which have received the
most attention in this revision, are inflammation,
wounds, tumors, diseases of the bones and joints, ;
abdominal surgerj^ and intestinal obstruction, dis- 1
eases of the breast, and operative treatment in
reference to cerebral localization. It has evi- i
dently been the aim of the editor to maintain the
conservatism of the older work by introducing
little of anj'thing too recent to have become in a
measure classical, but one would think that a
little more might have been said of recent ad-
vances made in England and in this country in ,
the direction of the surgery of the brain, intes- 1
tines, thorax, joints, etc., but little reference be-
ing made to the important advancement in these
departments during the last three 3-ears : nor does
it seem necessarj^ to have retained such antiqua-
ted and ambiguous expressions as ' ' scrofula, ' '
where tuberculosis is meant, and "caries," where I
definite diseases are under consideration. !

The work, notwithstanding minor shortcom-
ings, is one of the ver\- best of that class which
aims at being comprehensive in scope and con-
cise in detail.

Wood's Medicai, and Surgical Monographs.
$10 GO a year. Single copies, $1.00. Vol. 2,
No. 3, June, 1889, and Vol. 3, No. i, Julv,
1889. New York : William Wood & Co., pub- 1
lishers. [

The June number of this series is a volume of
350 pages, entirely devoted to "General Ortho- '
pedics, including Surgical Operations," by Dr.
August Schreiber, Surgeon-in- Chief of the Augs-
burg Hospital. This is a work of great interest
and is rendered particularl}- valuable by reason
of the large number of its illustrations descrip-
tive of deformities and deformit}' apparatus. The |
bibliographical references are extremely' numer- !
ous, and much attention has evidently been given '
by the author to the recent works of American •
and English writers. The following chapter
headings will serve to give an idea of the scope
of the work :

Chap. I. General Orthopedics. Surgical Or-
thopedic Operations.

Chap. 2. Rachitis.

Chap. 3. Torticollis.

Chap. 4. Deformities of the Spinal Column.
Deformities of the Thorax.

Chap. 5. Orthopedic Affections of the Ex-
tremities.

Chap. 6. Contractures of the Foot.

Chap. 7. Deformities of the Toes.

Chap. 8. Paralytic Deformities.

Chap. 9. Orthopedic Affections following
Fractures and Luxations.

Chap. 10. Congenital Luxations.

The July number contains the following mono-
graphs and lectures :

"Cancer and Cancerous Diseases." By Sir
Spencer Wells.

"Cardiac Dyspnoea and Cardiac Asthma." By
Dr. S. von Basch.

"The Influence of Menstruation and of the
Pathological Condition of the Uterus on Cuta-
neous Diseases." By Dr. L. Grellet}-.

' ' Torsion as met with in Surgical Practice ; In-
flammation of Bone ; Cranial and Intercrauial
Injuries." By T. Bryant, F.R.C.S.

"Antisepsis and its Relation to Bacteriology."
By D. J. Neudorfer.

Sir S. Wells finds that cancerous diseases are
increasing in proportion greater than that of the
increase of population, this being as true in the
United States as in Great Britain. He believes,
with Virchow, that so long as cancer is a local
disease, it is curable. In cancer of the uterus,
where the disease is limited to the parts near the
OS, he prevents intra- vaginal amputation by means
of galvano-cauterj' ; where the disease has ex-
tended much higher he advises total extirpation
of the organ.

Prof von Basch compares the pathology-, symp-
toms, diagnosis, cause and treatment of cardiac
dyspnoea and cardiac asthma, and gives short re-
ports of a number of interesting cases bj' way of
illustration.

Dr. Grellety considers briefl}- the relation be-
tween uterine and cutaneous pathology, together
with certain considerations regarding etiology and
therapeutics.

Mr. Bryant's article is the most extensive one
in the volume. It is in the form of three lec-
tures. The principal topics considered are as
follows : The causes, efi"ects and treatment of
tension as met with in surgical practice ; diagno-
sis of tension ; tension from new growths'; ten-
sion the result of inflammation ; effects of tension
as illustrated in inflammation of bone ; cranial
and intracranial injuries. Reports of numerous
illustrative cases are included in the monograph.

Dr. Neudorfer gives a short account of the his-
tory and present status of antisepsis with its re-
lation to bacteriolog}'. He also gives an excel-
lent synopsis of the chief antiseptics used before
and since the antiseptic era, including the most
recent members of this group of remedies.

Under the will of the late Dr. Alonzo Clark,
a scholarship was endowed at the College of Phy-
sicians and Surgeons, New York, for the promo-
tion of the discovery of new facts in medical
science. This scholarship has an annual income of
about nine hundred dollars, and the Facultj^ of
the College have worthily bestowed it for a term
of three years upon Dr. T. Mitchell Prudden. —
Medical News, Aug. 10, 1889.

252

MISCELLANY.

[August 17, 1889.

MISCELLANY.

Tenth International Medical Congress at Ber-
lin, 1S90. — We the undersigned, do hereby give notice
that, according to the resolution passed at the Washing-
ton meeting September 9, 1SS7, the Tenth International
Medical Congress will be held in Berlin. '

The Congress will be opened on the 4th and closed on
the 9th day of August, 1890.

Detailed information as to the order of the proceedings
will be issued after the meeting of the delegates of the
German Medical Faculties and Medical Societies at Hei-
delberg on the 17th of September in the current year.

Meanwhile, we should feel sincerely obliged if 3-ou
would kindU' make this communication known among
your medical circles, and add at the same time our cor-
dial invitation to the Congress. VoN Bergmann,

ViRCHOW,

Waldeyer.
Berlin NW., Karlstrasse 19, July 8, iSSq.

Health in Michigan, July, 1SS9. — For the month
of Julj-, 1SS9, compared with the preceding month, the
reports indicate that diarrhoea, cholera morbus, cholera
infantum, dysenter\- and inflammation of the bowels in-
creased in prevalence.

Compared with the preceding month, the temperature
in the month of July, 1889, was higher, the absolute
humidity was more, the relative humidity and the day
and night ozone were less.

Compared with the average for the month of July in
the three years, 18S6-88, bronchitis increased and cholera
infantum, cholera morbus and dysenter\- were less preva-
lent in July, 1 889.

For the month of July, 1889, compared with the
average of corresponding months in the three years 1886-
'88, the temperature was lower, the absolute humidity
was slighth- less, the relative humidity was more, and
the day ozone about the same, and the night ozone was
less.

Including reports by regular obser\'ers and others, diph-
theria was reported present in Michigan in the month of
July, 1889, at 26 places, scarlet fever at 30 places, ty-
phoid fever at iS places, and measles at 13 places.

Reports from all sources show diphtheria reported at
3 place more, scarlet fever at 7 places less, typhoid fever
at 2 places more, measles at 6 places less, than in the
preceding month.

Louis, Mo. ; Dr. George E. Hubbard, W. H. Sheiifelin &
Co., New York: S. R. Xiles, Boston, Mass.; Dr. A. B.
Judsou, New York; Dr. J. H. Kellogg, Battle Creek,
Mich.; Northwestern University, Evanston, 111.; Dr.
Samuel Hart, Marietta, O.; Dr. John S. Marshall, Green
Spring, O.; Thomas Leeming & Co., New York; Dr. R.
S. Sutton. Pittsburg, Pa.; H. Soule, Ann Arbor, Mich.;
Dr. J. H. Breedlove, Ft. Smith, Ark.; H. C. Lewis, Balti-
more, Md.

LETTERS RECEIVED.

Official List of Changes in the Stations and Duties of
Officers Serving in the Medical Department, U. S.
Army, from August s, i88g, to August 9, iSSg.

Col. Andrew K. Smith, Surgeon, is granted leave of ab-
sence for seven days, by direction of the acting Secre-
tarv of War. Par. 12, S. O. 178, A. G. O., August 3,
18S9.

Major Alfred ,\. Woodhull, Surgeon, is granted leave of
absence for two months on account of sickness, with
permission to leave the Div. of the Missouri, by direc-
tion of the acting Secretarv of War. Par. 5, S. O.
1 78, A. G. O., .\ugust 3, 1889.

Major John H. Janeway, Surgeon, is hereby granted leave
of absence for two months, with permission to apply
for an extension of two months. Par. 3, S. O. 52,
Hdqrs. Div. of the Pacific, July 29, 1889.

By direction of the Secretary of War, Capt. John J. Coch-
ran, Asst. Surgeon, now on duty at Ft. Adams, R. I.,
will report in person to the commanding General Dept.
of the Platte for temporary' duty with troops en route
to and at the summer camp at Ft. Robinson. Neb. Up-
on completion of this duty will return to his proper
station. Par. 10, S. O. 180, 'a. G. O., August 6, 1889.

Capt. Louis M. Maus, Asst. Surgeon U. S. Army (Ft.
Porter, N. Y. I, is hereby granted leave of absence for
twentv davs, on surgeon's certificate of disabilitj-. Par.
2, S. 6. 173, Hdqrs. Div. of the Atlantic, August ;, 1S89.

By direction of the acting Secretan,- of War, First Lieut.
William B. Banister, Asst. Surgeon, is relieved from
further duty at Ft. Wingate, N. M., and will report in
person to the commanding officer. Ft. Grant, Ariz., for
duty at that station, relieving Capt. .\rthur H. Taylor,
Asst. Surgeon, who, upon being so relieved, will pro-
ceed to Ft. Wingate, N. M., and report in person to the
commanding officer thereof for dutv at that post. Par.
4, S. O. 17S, A. G. O., August 3, 1889.

Dr. Hiram H. Barney, Philadelphia; K. Rank, Fort
Dodge, la.; Dr. Geo. E. Frothiugham, Ann Arbor, Mich.;
J. A. Sexton, Chicago; Witthoff.Marsily & Co., New York;
Dr. J. D. S. Davis, Birmingham, .\la.; S. K. Brewster,
Creston, la.; Dr. F. Randall, Maiden, Mass.; Dr. A. S.
von Mansfelde, Ashland, Neb.; E. P. Donnell Mfg. Co.,
Chicago; Dr. J. Y. Shoemaker, Philadelphia; Dr. J. G.
McDougal, New Lexington, O.; Dr. C. J. Smith, Derby,
O.; Dr. T. D. Crothers, Hartford, Conn.; Dr. E. L. Shur-
ly, Detroit; J. H. Bates, New York; Dr. Maris Gibson,
Wilkesbarre, Pa.; Mackintosh Battery and Optical Co.,
Chicago; Dr. S. Pozzi, Paris, France; Pappenheim's Zei-
tungs-Verlag, Vienna, Austria; H. Hornfeld, Berlin, Ger-
many; The Bancroft Co., San Francisco, Cal.; Charles
H. Phillips Chemical Co., Lutz & Movius, J. Walter
Thompson, New York; Mrs. J. F. Hopkins, Chicago; Ed-
ward McWhord, New York; Dr. D. J. Giarth, F'rugality,
Pa.; Dr. Wm. McCollora, Brooklyn, N. Y.; Dr. Henry H.
Smith, Philadelphia, Pa.; Ward Bros.. Jacksonville, 111.;
Dr. Wni. Brodie, Detroit, Mich.; Dr. H. Cushman, Oak-
dale, Neb.; Dr. L. L. McArthur, Chicago; Dr. W. C.
Wade, Holly, Mich.; Dr. J. Little, Bloomington, 111.; F.
A. Davis, Philadelphia; Provident Chemical Works, St.

Official List of Changes in the Medical Corps of the U. S.
Navy for the Week Ending August j, /S8g.

Asst. Surgeon P. H. Bryant, ordered to temporary duty
on ironclads, Richmond, Va.

Official List of Changes of Stations and Duties of Medi-
cal Officers of the U. S. Marine-Hospital Service,
for the Two Weeks Ending August s- /SSq.

Surgeon W. H. H. Button, when relieved at Mobile, Ala.,
to assume command of the Service at Baltimore, Md.
July 23, 1889.

Surgeon George Purviance, when relieved at Baltimore,
Md.. to assume command of the Service at Philadel-
phia, Pa. July 24, 18S9.

Surgeon J. M. Gassaway, ordered to New Orleans, La.,
foi temporary duty, .\ugust 2, 18S9.

Surgeon C. B. Goldsborough, granted leave of absence
for thirty days. July 29, 1889.

Asst. Surgeon G. T. Vaughan, orders to Norfolk, Va., re-
voked; to proceed to Cairo, 111., for temporary duty.
August I, 18S9.

Asst. Surgeon J. F. Groenevelt, relieved from duty at
Gulf Quarantine Station; ordered to Mobile, Ala., for
temporary duty. August 3, 18S9.

THE

Journal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.
PUBLISHED WEEKLY.

Vol. XIII.

CHICAGO, AUGUST 24, 1889.

No. 8.

ADDRESSES.

JOHN CLARKE, PHYSICIAN, PHILAN-
THROPIST, PREACHER AND
PATRIOT.

A n Oration delivered before the A merican Medical Association, June
25, rSS9.

BY HON. WM. P. SHEFFIELD,

OF NEWPORT, R. I.. LATE CNITEP STATES SENATE.

No person however equipped for the duty, who
duly appreciates the undertaking, can arise to
address an audience of men trained in any depart-
ment of science without embarrassment.

This embarrassment is increased with the con-
sciousness of the want of the special knowledge
in which the audience before me are adepts, and
by the different schools of professional life in
which we have been trained.

Before me is an audience of men selected from
the most eminent of the devotees of the most ab-
struse of physical sciences, while I have no claim
to their attention, but the having from an un-
fortunate accident, presented a case which has at-
tracted the notice of some very eminent persons
in one of the departments of their humane
profession.

The teachings of experience are that the human
race are prone to violate the laws of life and
health, and all of the analogies of Nature as well
as of the revealed law of God indicate that
penalty falls upon violated law, and that there is
the necessity of a curative or healing process.

Evangelical Christianity as well as civil codes,
are based upon these fundamental ideas. Here
rest the foundations for the necessity of the office,
and from these premises ma}- be drawn the out-
line of the duties of the physician. A profession
sanctioned b}' the example of the Savior of man-
kind in His healing of the sick, and making the
lame to walk.

The limits prescribed to me as well as the
proprieties of this occasion, forbid anj- further ad-
vance in this direction.

I have been asked to speak to you of John
Clarke. Many who hear me will ask, Who was
John Clarke ? I answer, the pioneer physician of
Rhode Island, the first Baptist Clergj-man in

America, the author and procurer of the Charter
for the State of Rhode Island which remained
the fundamental law of the State until May, 1S43,
and up to the time of its repeal was the oldest
and most liberal written constitution of govern-
ment in Christendom.

John Clarke was born in Bedfordshire, Eng-
land, October 8, 1609. I have not ascertained
where he was educated, but it has been said that
he was "a master of his native tongue and
learned in the ancient languages."

The Rev. D. B. Ray, on the authority of " The
Trilemraa," says that "he received his baptism
in Elder Stillwill's Church in London." He
writes, " in the year 1637 I left my native laud,
and in the ninth month of the same (November),
I arrived in Boston." He came while the court
was in session, and after the death sentence of
Mrs. Hutchinson.

On the 17th of May previous, the Massa-
chusetts General Court had enacted a law forbid-
ding towns and persons to receive anj' stranger
who resorted there with intent to reside in that
jurisdiction, or to allow any lot or habitation to
anj- such, or to entertain them above three weeks,
but under allowance of one of the governor's
council or under the hands of two of the magis-
trates. For a violation of this law a heavy
penalty was provided.

Unhappily, Clarke entered Boston while this
law was in force, and during the pendency of a
bitter controversy which had arisen out of the
question whether the internal evidence of the
Spirit, which was called the covenant of grace, or
the works demonstrated in the lives of professors,
was the better evidence of justification before
God.

The Rev. John Wheelwright, who was an
ardent advocate of the covenant of grace, had

been tried for his heresy,
sentence of banishment.
And on the 20th of

and was already under

November, a few day's
after Mr. Clarke's arrival in Boston, many other
persons, including ]\Ir. Clarke, were given liberty
to depart from that Colony, and Clarke went into
banishment with Wheelwright, and thej- spent
the winter in Exeter, New Hampshire. When
Clarke came to Boston, he was 28 j-ears of age.
He was described as being a physician.

254

JOHN CLARKE.

[August 24,

He complained of the coldness of the New |
Hampshire winter, and in Boston early in the
following March, he joined eighteen of the vie- ,
tims of the covenant of grace, and crossed the
Country to Providence, where he arrived within the
first seven days of March, and from there went to
Plymouth with William Coddington, to see about
obtaining a place for a settlement, and then re- ;
turned to Providence, and signed a compact for
the settlement of Rhode Island on the 7th of,
March, and the next day with his co-settlers
came to Rhode Island in Roger Williams' shal-
lop, and on the 24th of March, with Coddington
and Williams, went across the Bay to Canonocus's
city, and there the}' procured the title to this
island. Here they lived in caves until they could
provide better shelters.

Among their earl}' acts in the Spring of 1638,
was to appoint a committee to lay out a site, and
to provide for the erection of a meeting-house.
Clarke was their preacher, as well as their phy-
sician. The men whom he accompanied to Rhode
Island, had among them some who were gentle
born, men of learning and of high characters.

They had no charter from the Crown, but had
agreed upon a form of government based upon
the Bible as their constitution, and the majority
of the masters of families as its final interpreter
only in civil things. They declared their form
of government to be democratic, and for full lib-
erty of conscience so long as conscience was not
sought as a shield for breaking the public peace.

New men came among them who denied the
validity of their government in the absence of a
roj'al charter. Here a question arose which seri-
ously threatened the peace of the Colony. Then
Coddington, Clarke and others, early in 1639, re-
moved to Newport, and there commenced the
.settlement of the town in which we are now as-
-sembled.

In the following December a church had been
organized, and Clarke was its preacher.

John Clarke was now actively engaged with his
co-settlers in establishing the Colony, and in pre-
paring a concordance of the Bible

In July, 1651, the church at Newport received
a request from William Witter, an aged blind
man of its faith and order, that some of the
church would visit him at his residence in L,ynn,
in the Colony of Massachusetts, Clarke, ac-
companied by Obadiah Holmes and John Cran-
dall, responded to Witter's invitation, and went
to Lynn. On Sunday, while at Witter's, with
Witter and his family and four or five other per-
sons, while conversing upon religion, two consta-
bles arrested the three visitors and took them to
the Lynn church and detained them until the
next morning, when they were taken before a
magi.strate when, without evidence being adduced
against them, they were convicted of having been
taken by the con.stable at a private meeting at

Lynn upon the Lord's day exercising among
themselves, to whom diverse of the town repaired
and joined with them, for which Clarke was
sentenced to pay X'20 or to be whipped. He re-
fused to pay the fine or to assent to its payment
by others, yet the fine was secretly paid without
his consent, while Holmes and Crandall both
suffered the infliction of the alternative sentence,
and were severely whipped.

A difficulty had arisen in the Colony, and in
consequence thereof, William Coddington, who
had been governor, had obtained from the ruling
power in England, a commission to be governor
of the Island of Rhode Island for life. The
Colony up to that time had maintained a demo-
cratic form of government, and this change in its
civil polity aroused the people to resist the
change. The attention of the people was at
once turned to Dr. Clarke, and a request signed
by sixty-five, a majority of the freemen at New-
port, and by 41, a majority of the freemen of
Portsmouth, was presented to him to go to Eng-
land and procure a revocation of Coddington's
Commission, and to endeavor to secure a
charter protecting the rights of the Colony. He
accepted this service, and in November, 1651,
with Roger Williams, who represented the Provi-
dence Colony, sailed for England, and here com-
menced Dr. Clarke's career as a Statesman. I
use the term Statesman in its higher and better
sense, for the popular mind overlooking literal
meanings draws a wide distinction between the
terms Statesman and politician. The latter thus
is made to signify the art of obtaining votes by
calculation, and by cunning and adroit methods,
while the former implies the power to wisely or-
ganize, and prudently administer a government
for the people. In this sense it will appear that
I John Clarke, though he was the contemporary of
Sidney, of Cromwell, of Vane and of John
Milton, was endowed with a genius of Statesman-
! ship above, and in advance of that which any
' man of his time was enabled to practically ap-
ply to the government of a civil State.
1 In England Dr. Clarke was kindly received by
I the leaders in the great struggle which was then
being carried on. Coddington's commission was
i at once suspended and ultimately revoked. Clarke
remained in England, the agent of the Colony for
twelve years, during which time he published his
concordance of the Scriptures. (Aug. 3, 1655.)

In the calender of Colonial State Papers, p.
427, is the following entry: "John Clarke, phy-
sician of Rhode Island, in America, having com-
posed and very closely compacted a new concord-
ance to the Holy Scriptures of Truth, which in
regard of its plainne.ss and fulness, and yet sniall-
ness of volume and price may prove singularly
conducive to the help of those who desire to try
all things in these trying times by that touch
stone of tnith. Henn.- Hill is licensed to print

1889.]

JOHN CLARKE.

255

and publish the same to the exclusion of all
others, and the Compan}' of Stationers are re-
quired to enter this order in their Register."

I am not aware that a single copy of this con-
cordance has survived the wastes of the inter\'en-
ing centuries.

Clarke mortgaged his estates in Newport to
Richard Dean, to obtain money in London to sup-
port himself while he was abroad on the business
of the Colony.

His occupations during the twelve j-ears he was
the agent of the Colonj' in London, are largely
left to inference and to the declaration of the
town of Warwick, which in refusing to pay its
proportion of the expenses, he incurred in render-
ing his great service to the Colony while in Eng-
land said : "He was much employed about model-
izing of matters concerning the affairs of Eng-
land, in which no doubt he was encouraged by
men of no small estates." It is known that he
was on intimate terms with, and was often the
guest of Sir Henry Vane, and that he sustained
friendly relations with other leading men in Eng-
land in the time of the Commonwealth.

Both Massachusetts and Connecticut sought,
while Dr. Clarke was the agent of the Rhode
Island Colony, to obtain parts of the territory of
the latter Colony to be annexed to their respective
territory. Clarke, by unwearied exertion, and
with remarkable address, defeated these designs.
In 1662, in behalf of the Colony of Rhode Island,
he presented two addresses to the Crown, asking
for a Royal Charter. If Clarke's fame stood
alone upon these wonderful State papers, he
would have been regarded as having made one of
the boldest and clearest conceptions of the rights
of persons, and of the most advanced theories of
civil government that up to that time had ever
been announced. He closed the second of these
Addresses with the following passage, which was
embodied in the Charter:

" Your petitioners have it much on their hearts,
(if they may be permitted) to hold forth a lively
experiment, that a flourishing civil State may
stand, 5'ea, and be best maintained, and that
among English spirits, with a full liberty in re-
ligious concernments, and that true piety rightly
governed upon gospel principles will give the
best and greatest security to true sovereignty, and
will lay in the heart of men the strongest obliga-
tions to a true loyalty."

The Charter was granted by the King to the
great displeasure of his counsellors of State, and
new principles were thus embodied into civil
government. Mind was emancipated when con-
science was made free. And a people were en-
abled to make their own laws which by the
charter might be pleaded in bar to an Act of
Parliament or of the King. Laws which were
not to be subjected to the risks of a royal veto.
And under that charter, says Calmers, the people

of Rhode Island acted as if they were without
the King's dominions. It is safe to say, that up
to that time, and until after the American Revo-
lution, no fundamental law of any State in
Christendom had embodied absolute freedom in
religious concernments, and so large a measure of
civil liberty, as was embraced in the Charter of
1663.

On the 24th of November, with every possible
demonstration of joy, the assembled freemen of
the Colony adopted the Charter, and it became
the fundamental law of the State, and so it re-
mained until Ma}% 1843.

The expressions of the gratitude of the Colony
to Dr. Clarke and to the King, couched in
language of extreme eulogy, were returned to
them in England. While this charter was yet
the fundamental law of the State, said Bancroft,
the venerated historian of our countrj', "no
where in the world has life, liberty, and property
been better preserved than in Rhode Island under
this royal Charter."

Graham, the Scotch historian, arraigned Dr.
Clarke for the manner in which he obtained
this Charter from the Crown. This attracted the
attention of Mr. Bancroft, who was the first
prominent writer of American history to do
justice to the founders of Rhode Island, and he
demonstrated that the charges of Graham rested
mainly upon what occurred at Westminster be-
tween the King and John Greene and Randall
Holden, who went to England after the decease
of Dr. Clarke, not as the agents of the Colony,
but in behalf of themselves and possiblj^ some
other settlers of the town of Warwick. In this
controversy Mr. Edmund Quincy, and others in
Boston, took the side of Graham, and Mr. Bancroft
was abh- supported by the late Professor Gammell.
Mr. Bancroft has thus recorded his appreciation of
Dr. John Clarke.

' ' Never did a young Commonwealth possess a
more faithful friend than the modest and virtuous
Clarke, the persevering and disinterested envoy,
who during a twelve years' mission had sustained
himself by his own exertions and a mortgage on
his estate ; whose whole life was a continued ex-
ercise of benevolence, and who at his death be-
queathed all his possessions for the relief of the
needj', and the education of the young. Others
have sought office to advance their fortunes ; he,
like Roger Williams, parted with his little means
for the public good. He had powerful enemies in
Massachusetts, and left a name without a spot."

The Rev. John Callender, who was well ac-
quainted with some of the men who in his time
had known and been the associates of Dr. Clarke,
said of him :

"He was a faithful and useful minister, courte-
ous in all the relations of life, and an ornament to
his profession, and to the several offices which he
sustained. To no man is Rhode Island more in-

256

JOHN CLARKE.

[August 24,

debted than to him. No character in New Eng-
land is of purer fame than John Clarke."

The Rev. Isaac Backus, of Massachusetts, the
historian of the New England Baptists, writing
of Dr. Clarke, says :

"Mr. Clarke left as spotless a character as any
man I know of, that ever acted in any public sta- j
tion in this country. The Massachusetts writers
have been so watchful and careful to publish
whatever they could find, which might seem to
countenance the severities thej^ used towards dis- 1
senters from their way, that I expected to find ;
something of that nature against Mr. Clark, but j
I have happil}- been disappointed. Among all 1
their authors or records that I have searched, I
have not met with a single reflection cast upon him
bj- anyone ; which I think is ver}- extraordinan.'. |
Few men ever merited the title of a Patriot more
than he did, for he was a principal procurer of
Rhode Island for sufferers and exiles. And when !
their rights and liberties were invaded, he crossed
the ocean, and exerted all his influence, in twelve
years' watchful and diligent labors for his Colony
at the British Court, till he obtained a new
Charter for them, of great and distinguishing
privileges. ' '

At the time of the arising of the Quaker Con-
trovers}' in 165S, Rhode Island had received an
official letter from the United Colonies, advising
it not to entertain these people, and admonishing
the Colony, "if it did receive and entertain them
notwithstanding the advice of the United Col-
onies, that these Colonies would then see what
God would move them to do to save them-
selves and their families from the influence of
Quakerism."

This occurred while Dr. Clarke was the agent
of the Colony in L,ondon. And the Colony ad-
dressed a letter to Dr. Clarke upon this subject,
in which its appreciation of the doctor's services
is stated as follows : ' ' We have known not only
j'our ability and diligence, but also your love and
care to be such concerning the welfare and pros-
perity of this Colony since you have been en-
trusted with the more public aff'airs thereof, sur-
passing that no small benefit which we formerlj'
had .of your presence at home, and in all straits
and incumbrances are emboldened to repair to
you for your continued counsel care and help,
finding that your .solid Christian demeanor hath
gotten no small interest in the hearts of our
superiors, those worthy and noble senators with
whom you have had to do in our behalf, as it
hath constantly appeared in your addresses made
unto them, which we have by good and comforta-
ble proofs found having plentiful experience
thereof ' '

This letter besought Clarke ' ' to have an eye
and ear open in ca.se our adversaries should seek
to imdermine us in our privileges granted unto
us, and to plead our case in such sort as we may

not be compelled to exercise any civil power over
men's consciences, so long as human orders in
point of civility are not corrupted and violated,
which our neighbors about us do frequently prac-
tice, whereof many of us have large experience, and
do judge it to be no less than absolute cruelty."
Referring to the Quakers, this letter sets out :
"We have found no just cause to charge them
with a breach of the civil peace. The}^ are con-
stantly going forth amongst them about us, and
vex and trouble them in point of their religion
and spiritual state, and return with manj' foul
scars in their bodies for the same. ' '

The situation of Dr. Clarke when in England
was perplexing in the extreme, for Connecticut
claimed the territory of Rhode Island on the west
to Narragansett Bay, and Massachusetts and Plj--
mouth claimed the territory- of the eastern part of
the Colony also to the same Bay. So as the
agent of the Colony he had to contend for the ex-
istence of his constituency. Happily for him,
Connecticut was for a time represented in Eng-
land by Governor John Winthrop, Jr.. who was
like Clarke a physician of eminence, and a de-
voted scientist. Clarke and Winthrop met as
wise and just men should always meet, and
agreed upon a settlement of the Connecticut
boundary, the result of which settlement Clarke
prudently had inserted in the Charter, and though
afterwards long contentions were had between
these Colonies, in which Connecticut sought to
vacate this settlement, yet the boundarj- fixed by
Clarke and Winthrop remains the line which
marks the jurisdiction of the States of Rhode
Island and Connecticut to this hour.

Clarke returned to Rhode Island to receive the
gratitude of its people for the priceless benefac-
tion his genius and Statesmanship had conferred
upon the Colony in June, 1664.

On his return he was at once elected a member
. of the General Assembly, now organized under
I the Charter procured by his exertions, which se-
, cured beyond any lawful interference of Crown or
Parliament the civil and religious liberties of the
people. And upon which a government was to
be framed on principles which had no traditions
in the past history of the world. Clarke entered
the Assembly. The first resolution to be passed
was that thereafter every session of the Assembly
should be opened by the reading of the patent.
A letter of thanks was drawn up and pre.sented
by the presiding officer to Dr. Clarke, and a com-
mittee was appointed to audit his accounts. He
was also made a member of a committee to revise
the laws of the Colony to see that they be made
to conform to the Charter, and was appointed a
commissioner to run the boundary- line between
the Colony and the Colony of Connecticut.

The distinctive principles recognized in the
foundations of the government of Rhode Island
in the Charter procured by Dr. Clarke were :

1889.]

MARKING AN ERA IN LARYNGOLOGY.

257

1. The Indians had a title to the soil of which
they could not be deprived but with their
consent.

2. The right of the people who owned the soil
to establish a civil government for those who
should reside upon it, and to determine who
should be admitted to be freemen with them.

3. The freedom of conscience from the control
of the State, so long as the exercise of that free-
dom did not tend to the disturbance of the civil
peace.

4. By the Charter it was provided that the
legitimate exercise of authoritj- conferred thereby
should be a bar to any prosecution therefore,
against any act or proceeding of the King or of
Parliament.

The credit of the discovery- of these principles
in government Dr. Clarke shares with others, but
the incorporation of the principles of civil and
religious liberty into the Charter, and the protec-
tion of Chartered rights against the invasion of
King and Parliament, bj- anticipating and apply-
ing to this quasi-corporation the principles long
after settled in the Dartmouth College case, was
the work of Dr. Clarke.

To properly appreciate the merit of these pro-
visions we should place ourselves in the situation
in which Dr. Clarke was placed, and surround our-
selves by the state of governmental science, as it
was at the time of the return of Charles II to the
throne, and the granting of this Charter, and then
look forward through the inter\'ening time, and
watch the expansion of these principles in govern-
ment as they, like the dawn of the coming day,
have been spreading over the world. Then we
reflect that principles are stronger than men ;
men die, but principles live forever. The princi-
ples incorporated into the Charter of Rhode Island
are yet expanding and ameliorating the conditions
of mankind, and will continue their work until
they overthrow thrones and every where break
down dynasties and hereditary privileges to
govern. And the dissemination of education and
morality among the masses of the people after the
manner proposed by Dr. Clarke, and for which
he by his will gave his private fortune, will fit
the people to rise above the scrambling hoard of
political pirates who now, like hungry dogs after
prey, strive to obtain places which should be
places of honor and trust, with as little scruple or
regard to consequences as the privateersman dis-
poses of his plunder and prize money.

Dr. Clarke was thrice married, but died child-
less, April 20, 1676, and was buried in what was
the south-east corner of his orchard, near his
dwelling, and his church on the northerly side of
what is now West Broadway, in Newport.

MARKING AN ERA IN LARYNGOLOGY.

The Address of the Chairma/i of the Section of Laryngology and Otol-
ogy, delivered at the Fortieth Annual Meeting of the American
Medical A ssociation , June , jSSg.

BY WILLIAM H. DALY,

OF PITTSBURGH, PA.

M.D.,

Dr. Seguix, of New York, has been presented
to the Paris Academy of Medicine as correspond-
ing member.

Ge7itlemen and Colleagues: — Let us congratulate
ourselves that, at last, we, as larj'ngologists and
otologists, are in position to mark an era in the
progressive histor}^ of the American Medical As-
sociation— an era of good, solid medical sense. I
refer to this, the first meeting of the Section of
Lar\^ngolog>- and Otology, as a separate and indi-
vidual body disassociated from the Section of Oph-
thalmolog3^ in which the two former closely re-
lated specialties have thus far in our history played
a secondary- role

As laryngologists and otologists we have long
agreed that, to be an able practitioner in either
specialty, one must be a well informed and com-
petent practitioner in both these special branches
of medicine ; but so far as ophthalmology is con-
cerned, if we except certain catarrhal ophthalmias
of a chronic character, there is little call for the
constant special skill and daily practice of the
laryngologist in the ordinary treatment of the
eye. But in the interest of otology, we, as lar-
yngologists, feel a pride that grows with experi-
ence (especially those of us who have given more
than the usual attention to intra-nasal diseases),
that we made no mistake in our formulated opin-
ion expressed eight 3'ears ago, at the International
Medical Congress at Copenhagen, viz.: That the
laryngologist of the future must be more the
rhinologist, and the rhinologist more the surgeon
than the physician. For this formulated prog-
nostic expression of opinion, the author was as-
sailed b}' some excellent men and friends in our
specialty, as giving a blow to laryngologj- ; but
when such able minds as Profs. Bosworth and Jar-
vis of New York, Roe of Rochester, Woakes of
London, and others, endorsed the author's views
in their dailj' practice, and publich- in their writ-
ings and di.scussions, and a host of others, such as
Profs. Harrison, Allen, Sajous, etc., endorsed
them by adopting them in their daily practice, it
was enough that I had voiced a prediction that
was being and has been entirely verified by expe-
rience.

But as to the practical application of these
views, they come to us with a redoubled force and
utilit}' in by far the largest number of the inflam-
matory' diseases of the middle ear; hence I desire
to refer to them, and to this end I ask the ques-
tion, " How shall we attack a chronic otitis me-
dia successfully?" How can we do it without
the necessary skill of the laryngologist and rhi-
nologist ? The largest number of these cases have
begun not in the ear, but in the naso-pharj-nx,
and we all know are only arrested (alas ! we say
arrested advisedlj') by the rational treatment.

258

PRESIDENT'S ADDRESS.

[August 24,

Applied through skill in treating these intra-nasal
parts, because too often the original or central
disease has been neglected so long, or ignored,
that the patient has suffered a permanent and ir-
remediable damage to the middle ear, before the
cause of the disability' is suspected. However,
no informed otologist will think of questioning ,
the assertion that the rhinologist, and the surgical
one at that, is the man who will oftenest help him
out of his difficulty in all the cases of inflamma-
tions of the inner and middle ear.

Now, gentlemen, as we have for the first time
in our history come together as laryngologists and
otologists, the two (to us, at least) most enticing
fields of medicine, where there is probably the
largest possible future for good to humanity, in
solid, useful and brilliant work, and hence more
distinction to ourselves than even the most san-
guine suspect, as you see by our programme, we
have a long list of papers from able authors,
about forty- eight in all, and we must strictly ad-
here to our rules limiting discussion ; and since
j-ou have made these rules and I, as your Presi-
dent, simply enforce them, I trust you will aid me
with the same courtes}' j-ou have always shown
me, both personallj' and publicly, while seeking
to perform the not always easy task of a presiding
officer.

AN ABSTRACT OF THE PRESIDENT'S
ADDRESS.

Delivered at the Fifty-Seventh A unual Meeting 0/ the British Medical
Association, Aug. ij, 188^.

BY CLAUDIUS G. WHEELHOUSE, F.R.C.S.,

CONSULTING SDRGEON TO THE LEEDS GENERAL INFIRMARY.

A CURSORY REVIEW OF THE PROGRESS OF
MEDICINE AND OF MEDICAL EDUCATION.

Life, as measured by the standard of the space
of time allotted to each unit of the human family,
is but a little span. Man has not reached his
present condition of intellectual, of moral, or
even of physical greatness in one generation ;
the white cliiTs of Albion, in their formation,
mark not only generations, but aeons in the pro-
gress of creation. Rome was not built in a day !
So medicine, as she stands to-day, strong by the
acquirements of her children of many genera-
tions, did not arise upon the world in the full
glorj' of a heaven-born science ; but, sifting grain
by grain of her faith from the speculations laid at
her feet by her followers through countless ages,
has, little by little, built up the temple of her
fame until it has assumed the proportions in
which we now behold it, and of which we are the
accredited custodians.

THE MEDICINE OF THE EARLY AGES.

Sometimes in the current of events her progress
has been labored and slow ; with halting and un-
certain steps, with Arabian mythologists, as-

trologers, and such like visionaries as her com-
panions, she has picked her way through gloomy
times of mystery, uncertaint}-, and doubt. At
times the light of truth has .shone upon her path
more brightly and has cheered her on her way ;
and with the Harvej's, the Sydenhams, the Jen-
ners, and the Hunters, the Dupuytrens, Laennecs,
and Pasteurs of the world for her companions she
has walked with firmer steps until at last she has
become an acknowledged power, and stands forth
as the companion of even the exact sciences.
Each generation of her votaries as it passes across
the stage of the world's historj-, is henceforward
bound to leave a mark behind it as its contribu-
tion to the sum of existence, and that mark must,
j in the aggregate, be the result of individual
1 efforts.

] To some it is given to do great things, and to

stand revealed by the unmistakable stamp of

! genius. To some, by more prolonged and patient

I effort, to leave an impress which, if it be not so

brilliant, is yet equall}- fruitful and enduring.

And to ever}' one of us, however humble may be

i the current of his life, it is permitted to make his

1 mark, to add his little contribution to the total

! sum of a ceaseless progress, and to advance it or

to hinder its advance.

I I can look upon the broad roll of this great
Association and can see there names that will
never die — the names of men whose achievements
will never perish, who when they sink as their
predecessors have done to their rest will leave,
as Harvey and Jenner left in former times, a
priceless inheritance to mankind at large, whose
labors will not have been in vain, and of whom
the world will acknowledge that the talent en-
trusted to them has been productive of abundant
fruit, that of a truth they have left the world
better and richer than the)- found it.

I can see hundreds of others who are aiming at
this high standard, who by their individual
labors are raising the great tower of knowledge,
and whose lives, though not illumined by the
torch of genius, will yet leave behind them the
undying results of patient labor in well-doing ;
and I see, in all, the roll of a great brotherhood,
strong in their efforts to advance the common
weal, and doubly strong in the strength of union.
To us, as medical men, all science is of tran-
scendent interest : Init, not unnaturally, the sci-
ences which bear on life and death stand, for us,
in the forefront ; and to each generation as we
pass across the stage of existence, it becomes im-
perative to seek to add something to the store of
that knowledge by which life is rendered more
endurable, is robbed of some of its attendant
evils, some of its sorrows and some of its suf-
ferings.

Our fathers, under disadvantages we are
scarcely able to appreciate, did great things. Are
we better than our fathers were ?

1889.]

PRESIDENT'S ADDRESS.

259

Will you quarrel with me, if, in welcoming you
to this our great annual festival, I ask you, for a
few brief moments, to ponder over this important
question with me ?

Life, and with life the progress of science, has
ever been chequered with sunshine and shadow.
Evil and bright days must follow each other ;
good times and bad must balance one another,
and if in the great battle for existence, we in-
cline sometimes to lay down our arms and to
capitulate, we have the authority of one of the
sweetest of sweet singers to revive our fainting
courage :

Be still, sad heart, and cease repining.

Behind the clouds is the Sun still shining ;

Thv fate is the common fate of all, [

Into each life some rain must fall : i

Some days must be dark and dreary ; I

and the lives into which, on the other hand, |
some bursts of sunshine of even more than usual
brilliancy do not occasionally force their way are,
I would fain hope, very few. . . .

The bill of fare we have provided for your en-
joyment will meet, we hope, with your apprecia-
tion and approval ; and if we have ventured upon
the introduction of some few novelties and varia-
tions in the usual plan of the annual programme,
we have done it in the sincerest hope that we
may thereby advance and increase the interest of
your sojourn among us.

My duty is an easy and a pleasant one. I am
precluded from speaking to 3'ou on any of the di-
rectly special subjects with which we are called
upon, whether as physicians or as surgeons to
deal.

Medicine will be discussed, and all that can be
said of it will be brought before you by one of
the leading physicians of the day ; and in Dr. J.
Hughlings Jackson will find an exponent to
whom you will join me in listening with heart}'
interest and attention.

Surgery, and the progress it has made and is
making, will be dealt with by ray friend and col-
league Mr. T. Pridgin Teale, and for, I believe,
the first time in the histor>- of the Association,
an address in Psychological Science will be offered
j'ou, and this we have placed in the ven,^ able
hands of our former tried and ever welcome
friend Sir James Crichton Browne.

Our Sections will be presided over bj- men,
who, each in his own department, will tell us all
that it is necessar>' for us to know to keep us
abreast with its latest and highest developments,
and, as individuals, j-ou will have an opportunity,
in the discussions which have been arranged for
you, to bring forward any special matters with
which 3-ou wish to deal, on which you may per-
sonally wish to be heard, or to impart to us any
information which you have acquired or have
worked out. To do this has ever been, and is
still, the great object of our Association ; and

who can calculate the advantage that has accrued
to us, as a profession, from the accumulated labor
of the fifty-se\'en years during which it has
existed ?

Union is strength, and that which men by in-
dividual labor never could have accomplished the
principle of association has enabled us to do ;
and by yearlj' repeated meetings such as this
upon which we are entering — with the aid of a
journal by which the labors of each one may be
made the common property of all — a fund of
wealth which must otherwise have died with
individuals has been preserved to us for ever.

Of what comparative general value were the
labors of individuals in the early days of the
present century in comparison with what thej-
are now?

However brilliant the work that was done, or
however intrinsically valuable, what oppor-
tunities were there of its being made known be-
yond the limited area of the worker himself;
and how much excellent work must have been
lost to the world in consequence ?

THE COMPARATIVE ISOLATION OF PRACTI-
TIONERS IN FORMER TIMES.

We, in comparison with preceding generations,
have been possessed of advantages of incompara-
ble magnitude. Not only in our own, but in
every other science also, knowledge and the fa-
cilities for the spread of knowledge have so in-
creased that comparison is almost impossible.
Think for a moment of the changes that one gen-
eration only has seen ! The facilities for per-
sonal communication that have come with the
advent of railways, of steam, and, above all, of
the developments of electrical science, by which
not individual portions of our own kingdom only,
but all the nations of the earth have been
brought into inter-communication. What great
discovery can now be made that does not in-
stantly become the property of even the remotest
nations of the world, and is not, by any omni-
present press, brought to the personal knowledge
of ever}' votary of science ?

Does America give birth to anaesthesia ? And
in what part of the world does the blessing of
painless surgerj' remain unknown ? Does Sir
Joseph Lister satisfy his own mind of the infinite
powers of antiseptic surgery, and in how short a
period of time is his brilliant discovery the common
property of every surgeon in the world ?

What did the surgeon of fifty years ago know
of the powers of "germs," of "bacteria," of "ba-
cilli," and of their capability to destroy his most
elaborate and perfect work ? And where is the
.student of surgery of the present day to whom
they are unknown, or who is unprepared to do
battle with them, one and all, and to baffle or to
\ modify their evil influences ? What the medicine
and surgery of the iSth and preceding centuries

26o

PRESIDENT'S ADDRESS.

[August 24,

were, we are only able to conjecture. Its medi-
cine we believe to have been little more than an
empiricism founded on close observation, and led
by a few master minds, and its surgery we know
was crude, and, as compared with that of to-daj-,
was even barbarous and cruel, and few of us I
imagine would care to witness a major operation,
as then performed, by even the most renowned
and skilful surgeon.

But the light, even then, was breaking, and
not many years of the present century were to
run ere truer principles of both medicine and
surgery were to be made known to the world,
and each was, as a science, to be established on
a surer foundation than any on which it had
hitherto rested.

THE GENERAL PRACTITIONER OF THE EARLY
PART OF THE PRESENT CENTURY.

Let me endeavor to draw a sketch of the aver-
age practitioner of ' the commencement of the
present centurj^ and there may be some, at any
rate, in this room who can follow me and judge
whether I paint him correctlj-, or whether, trust-
ing too much to tradition and report, I do him
injustice.

He was usually a hard-working industrious
man, who thought little of bodily exertion, and
who spent the greater part of his time in his sad-
dle, which was his only way of getting about the
country ; a hard-thinking man, but one whose
mental training had not been great, nor his edu-
cation elaborate ; whose opportunities for the ac-
quisition of professional knowledge had been few
and short ; of whom it might be said that that
which he knew was, in the main, either the fruit
of his own observation, or of his own observa-
tion added to the traditions of the place or prac-
tice in which he had been brought up.

Knowledge and practice alike were purely em-
pirical with him, and though he could treat dis-
ease v.'ith skill, and could, in most cases, give a
good account of his warfare, it was purely by
empirical means that he did it. His great
panacea for all ailments was blood-letting, and
his pocket was never unarmed with the all-potent
lancet.

As a Physician. — No matter what the case
might be, so long as it was " acute," venesection
must precede everything else ; then followed a
superabundance of mixtures, powders, draughts,
pills, lotions, etc., with which he hoped to effect
a double purpose, first, to cure liis. patient, and,
secondly, to remunerate himself for his attend-
ance ; for, so trifling were the charges he was
able to make for his personal labor, and at so low
a rate was that estimated by his patients, in com-
parison with the amount of medicine he gave
them, that, except for the additional charges
made for it, his remuneration would have been
infinitesimal. He had a good sound knowledge

of drugs in general, and of what the}- could do ;
he was sadly too read}- to rely on them, and his
patients were compelled not only to swallow-
most nauseous compounds, but too swallow them

\ also in inordinate quantities. Of the morbid
anatomj- of diseases he knew something, but not
much ; of pathology, in its true sense, he knew
nothing, for physiology, whether healthy or
morbid, was not one of the sciences of his day.
When he ' ' walked the hospitals ' ' for the few
months required of him, he saw a few post-
mortem examinations, and had the opportunity
to mark the ravages and the appearances left bj'
various so-called diseases, and these he was apt
to regard as the diseases themselves. His treat-

I ment was chiefly based on nomenclature ; he
could tell you what was good for " fever," what
for "tic," for "rheumatism," for " indigestion,"
for "scurvy," and for innumerable other com-
plaints ; and he who w-as believed to possess the

I greatest number of formulae for the greatest

I number of complaints was regarded as the clev-

; erest and most desirable doctor.

As a Surgeon.- — As a surgeon he was, as a
rule, further behind the practitioner of to-day
than he was as a physician. His education, such
as it w-as, had taught him to rel}-, in this branch,
more on the skill of others than on his own.
There were certain men, well known in their
several districts, as the men to whom to appeal in
cases of surgical emergency, and they were the
men who made world-wide reputations. . . .

SURGICAL OPERATIONS IN FORMER TIMES.

A surgical operatioii in those daj-s was an
ordeal of fearfully diiferent magnitude to any-
thing known to us to-da)-, and, naturally enough,
the patient had a large say in the matter. Con-
fidence in operations themselves and confidence
in the skill of the operator were not then what
they are now, and it must be remembered that
when, as the only means of escape with life, an
operation had to be performed, it had also to be
endured in all its unalleviated agony. Courage
and endurance, unfortunately are not given alike
to all, and many a life which would be saved to-
day was at that time voluntarily laid down, not
simph- for want of faith in the capability of the
surgeon, but from sheer inability to face the ter-
rible ordeal of bodily sufi"ering involved. . . .

THE MEDICAL SCIENCE OF THE PRESENT DAY.

That the medical science of our time is in ad-
vance of that of the time of which I have been
speaking is beyond question, and that the effects
produced by increased knowledge and research
have given advantages to the world of indescrib-
able value no one will deny. Look where you
w'ill, whether over the domain of medicine or of
surgery, and the facts are indisputable. The
field is enlarged, the culture of the field is im-

1889.]

PRESIDENT'S ADDRESS.

261

proved, and the han^est is, beyond all question,

infinitely greater, and it is surely worth our while
on an occasion such as this, to ascertain, if we
can, wherein lies the secret of our advance.

In a large measure it is due to our possession
of vastly improved instruments of precision.

To our ancestors the revelations the microscope
has made to us were but a dream. They could
theorize, and argue and believe, but the things
upon which they could onl}' theorize, and argue
and believe, are living verities to us. To them
the existence of a materies morbi was onlj' an
argument, whereas now, we know not onlj^ that
the causes of many diseases are indeed material,
and even tangible, but that we are able to demon-
strate and .see them, to recognize their individu-
alit\-, their specific forms, and the phenomena of
their growth, propagation, and development.

I call to mind a story of two great Scotch pro-
fessors— the one a theori.st, the other a materialist.
The materialist would argue that certain forms of
disease must be due to the presence of germs,
and were the direct results of their development,
propagation, and multiplication ; and the theorist
would cry ' ' here is j-our microscope, show me
but one of these germs and I will believe ; but,
until you do, I cannot ;'" and, being unable to do
this, his friend could onh- fold his hands and wait
patiently, hugging his belief, meanwhile, but
with the conviction of certainty none the less.

Gentlemen, picture these two professors now,
if they could meet, and know onl)' as much as
we know of bacteria and bacteriology, and of the
field of germ pathologj-. And meanwhile, yet
another Scotch pathologist as fully convinced as
though he could see or had seen the whole range
of modern pathological development, so ponders
the theory, and acts upon what he believes its
possibilities to be, that, at last, he lays at the feet
of his profession the whole science of antiseptic
surgery. So, in like manner, and little by little,
the microscope has revealed to us manj^ of those
hidden mysteries which constitute the whole
science of physiologj-, has shown to us the
beauties of capillary and lymphatic circulation,
has enabled us to understand and comprehend
the processes of absorption, of disintegration,
and of recuperation, and has placed at our dis-
posal the kej' to mysteries of which our prede-
cessors could have but faint imaginings, but
which we know, and know with a certainty which
constitutes our knowledge science indeed.

Thus medicine and surgery have alike been
founded on a rock of knowledge, from which
they can never henceforward be dislodged, and
from which in their future progress light may be
made to shine, which will illumine their path
along whatever roads they may advance, and
will dispel many a doubt and darkness which,
in former times, would have been insuperable
barriers to their progress. And so, by other in-

struments of precision, barrier after barrier has
been removed from our path, doubt after doubt
has been cleared away, and we now see clearl)^
where heretofore we had only seen as " in a glass
darklj' " and unassailable stores of knowledge
have thus been placed at our disposal. What
shall I say, for instance, of our advance along the
pathway opened up to us b}- electrical science ?
Is not this alone one which, uncomprehended in
former times, has enabled us to build up knowl-
edge of phenomena, without which the infinite
intricacies of the action of the ner\-ous system
must have remained shrouded in profound dark-
ness, and out of the chaos of former mysteries to
see, clearly defined, order and law where ignor-
ance, hypothesis, and mystification formerly had
reigned supreme. And while physiology has
thus grown into a true science, pathology has
also advanced with equallj' rapid and giant
strides. We see, indeed, as our ancestors did,
the ravages made and left behind in the track of
disease, but we see them only as the evidences of
deeper ph3^siological mj'steries ; we study them
as the effects of processes which have constituted
the true phenomena of disease, and we seek to
unravel them one b}' one until we see clearly how
they have arisen, and what they denote. And
so, with ceaseless patience, we endeavor to track
down mischief to its origin and birth. Year after
year our patience is rewarded by fresh discoveries,
fact is added to fact, uncertainty after uncertainty
is dispelled, and thus, each j'ear, the tree of
knowledge puts forth fresh shoots and brings us
a more and more abundant yield of goodly fruit.
Advances, however, of such kinds as these,
and in such directions, do not, in m}- opinion,
constitute the chief or highest glorj- of modern
medicine.

PUBLIC MEDICINE.

A common reproach is often brought against
both medicine and its practitioners that it is a
sceptical profession ; that its practitioners are es-
sentiall}- materialists in their views ; that medi-
cine, as a science, leads to free thinking, and
seeks, in a rational explanation of everj- fact
with which it is brought into contact, to under-
mine our belief in things spiritual, and to lessen
our faith in all that we cannot see, and handle,
and account for ; that constant contact with pain
and suffering tends to numb our sympathy and
to diminish our pity for the sufferings of mankind.

On this point I would venture fearlessly to
challenge any other calling or profession to pro-
duce a parallel to the modern development of
" Public Medicine," a science which seeks ever,
even at the risk of its own extinction, to exter-
minate the causes of disease and death, and to
eradicate from the world the verj- springs and
sources from which thej' arise.

"It is a Commonwealth sustained and gov-

262

PRESIDENT'S ADDRESS.

[August 24,

erned bj^ the desire existing in the minds of each
of its members to do as much good as possible to
ever}' other member." It looks upon prevention
as better than cure, and asserts, as is now clear
to all, "that a large part of human suffering is
preventable by improved social arrangements,"
and sets itself to the task of sweeping away all
such preventable causes.

' ' Its compassion is all the deeper, its relief
more prompt and zealous, because it does not
generally, as former generations did, recognize
such calamities to be part of man's inevitable
destiny ; and it hurries with the more painful
eagerness to remedy evils which it feels ought
never to have befallen."

"When the sick man has been visited, and
everj'thing done which skill and assiduity can do
to cure him, modem charity goes on to consider
the causes of his malad)' ; what noxious influ-
ences besetting his life, what contempt of the laws
of health, in his diet or habits, maj- have caused
his sickness, and then to inquire whether others
incur the same dangers, and maj- be warned in
time."

" Our Great Example commanded His first fol-
lowers to heal the sick and give alms, but He com-
mands us and all His followers in this age to in-
vestigate the causes of all evils, to master the
science of health, to consider the question of edu-
cation with a view to health, and while all these
investigations are made with free expenditure of
energy and time and means, to work out the re-
arrangement of human life in accordance with
the results thej' give ; and if, instead of undoing
a little harm, and comforting a few unfortunates,
we have the means of averting couritless mis-
fortunes, and raising by the right employment
of our knowledge and power of contrivance, the
general standard of happiness, we lessen the
necessary evils of life, lengthen the term of
human existence, wipe out the causes of innum-
erable griefs and sufferings, make life more en-
durable and happy, can it be said that we are
failing to obey the commands or to undermine
the teaching of our great Master.'"

Can it be denied that these are among the chief
aims and objects of our profession in this our day?
Is not every community provided with its officer
of health ? Is not disease of everj- kind assidu-
ously and ceaselessly tracked to its hidden birth-
place ? Can an epidemic now run riot as it did
in former times ? or devastate a whole country,
as it formerly was wont to do ? Look at the great
scourges of the earth as described in history — at
malarial fevers, at small-pox, at typhus, at
cholera, at the whole host of epidemic diseases
which, born of and fostered by insanitary- condi-
tions revelled in the unprotected homes of this
and other countries, and sapped the health and
strength of nations.

> Ecte Homo, chap, xvii, "The Law of Philanthropy."

Are we not adding year by year to the vast
stores of our knowledge ? Are we not, by our
ceaseless search after the seeds of disease, the
bacilli, the micrococci, and the germs of which it
comes, and b}' our cultivation of sanitarj- science,
doing a mighty work in the renovation of the
world and the diminution of suffering and pain ?
Can any work be nobler? any search after truth
be more innately religious ?

Thus at least I argue when I hear our profes-
sion charged with irreligion, and thank God for
that spirit of ceaseless inquiry which impels us to
seek truth and truth only, and, when we have
found it, to hold it with a grasp whose tenacity
cannot be broken.

So then in our daih- life as the servants of
our suffering fellow creatures, in our eager
race after improvements, in our efforts to spread
abroad over the earth the results of the knowledge
we attain, I hold that the practitioners of medi-
cine of the now closing nineteenth century have
not been left behind in the race of life ; that we
have won our laurels, and have been faithful to
our trust. And as we exult in the progress we
have made, and are humbly thankful, so let us
hope will those who follow after us, outshine our
accomplishments and leave us in turn verj' far
behind them in knowledge and in power for
good. . . .

I have endeavored to recall to your memory
the character, the achievements, and the capa-
bility of the practitioner of former times. I
have shown you how infinitely greater is the
knowledge and the utility of the practitioner of
the present day. We know how he has brought
every region of the body, even those which were
formerly deemed whollj' beyond the sphere of his
influence, such as the contents of the cranium,
the vital organs of the chest, of the abdomen,
and of the pelvis, under the dominion of our sci-
ence ; that by the institution of preventive medi-
cine, he has swept away many of the opprobria,
and of the direst scourges of former times ; and
it only remains to indicate in very few words the
still vast field of further utility that lies open for
cultivation b}- the practitioners of the future.
There is one plague spot, I fear, which even he
will fail to conquer ; which will remain to fester,
to kill its thousands, to maim, disfigure, and to-
sap the health of millions, of deserving and of
undeserving alike, and, as the great curse of hu-
manity, to baffle all our efforts to arrest the pro-
gress of disease, and to render them futile and
abortive. You know the curse to which I allude;
the curse that steadily and vindictively pursues
the track of licentiousness, of ungoverned pas-
sion, of hateful sensuality : and you will admit
with me that so long as human nature remains
what it is, and is left in unbridled posse.ssion of
the means of gratification, no ray of either light
or hope will fall on that dark track.

1889.]

INTERNATIONAL COMITY IN STATE MEDICINE.

263

Some day men may have become suiSciently
enlightened to submit to necessan- legislation
and restrictions on this, and cognate subjects ;
but, until they do, the foul stream of syphilis
will continue to meander, hither and thither, and
whithersoever it will through the world of life ;
will poison its springs, will wither even its fair-
est blooms, and destroy its richest fruits without
selection and without mercy.

By the cultivation of bacteriology and cognate
sciences, by a deeper and more profound acquaint-
ance with natural phenomena and laws, I can
foreshadow in my mind the time when the whole
range of zymotic and exanthematous diseases
will have been subdued and conquered ; when
the seeds of each will have been isolated, and so
studied that their individuality will be recogniza-
ble ; the soils in which they will grow, and those
in which thej' will lie sterile will be known and
appreciated, and be brought under cultivation by
the hands of the medical men of the daj- ; when
the methods of dealing with them will be such
that they may be reduced to- harmless quantities;
and when, bj' the spread of sanitary- science, the
whole human race may be protected from their
evil influences.

It will not be in our day that these mighty
triumphs will be won, but our successors will un-
doubtedly achieve them ; and the time will cer-
tainlj^ come when the kingdom of disease will be
so closely narrowed down that onlj- the necessarj'
accompaniments of the changes and vicissitudes
of natural laws, the evils attendant upon the wil-
ful disobedience of those laws, the innumerable
accidents to which life and limb must be for ever
liable, and the inherent defects and deficiencies
in the harmonious working of the parts of a ma-
chine so exquisitely and delicately constructed as
is the frail body which, for a time, we inhabit
will be the only kingdom in which the professors
of medicine and surgery will be called upon to
exercise their sway. Then will the victorj' of
our science be complete, and the day will have
come when the world will be called upon to ac-
knowledge that the labors of the physician and
surgeon, patient, enduring, untiring, as they
have been through all time, have not been in
vain, and have reached their final consummation.

ORIGINAL ARTICLES.

INTERNATIONAL COMITY IX STATE
MEDICINE.

Read in the Section 0/ State Medicine at the Fortieth Annual Meet-
ing 0/ the American Medical Association, June 25, 1889.

BY JOHN B

SUPER VISING-SURGEON-GEXERAL U

H.\MILTON

Dr. J.\mes L. Cabell, Professor of Anatomy
and Surgery in the Universitj- of Virginia, died
at Overton, \'a., on the 13th, aged 76. He was
graduated in medicine at the University of Mary-
land, in 1S34. During the war he had charge of
the Confederate militarj- hospital in Charlottesville.
He was Chairman of the National Sanitary Confer-
ence at Washington during the yellow fever epi-
demic at Memphis, and subsequently was Presi-
dent of the National Board of Health.

M.D., LL.D.,

MARINE-HOSPITAL SERVICE .

Mr. President : — The last quarantine conven-
tion held in this country was held in Montgom-
ery, Ala., March 5, 6, and 7, 1889, pursuant to
a resolution of the Alabama Legislature. The
conference was largely attended, and although
called for the purpose of considering quarantine
alone, the meeting resulted in the formulation of
some well known principles of sanitation, but
which, not having been codified, were, neverthe-
less, in a somewhat nebulous state. Among
other propositions the conference agreed to the
following, which I here recite as the text of this
paper :

"Resolved, That this conference is of opinion that it is
a duty devolving on all Nations to take measures to erad-
icate any plague centre from their territorj^ and that the
existence of such plague centres is a menace to all other
Nations, and that our State Department be requested to
take measures through proper diplomatic channels for
the conveyance of this opinion to the Governments
deemed obnoxious to the opinion as herein expressed."

The medical part of International law is a re-
cent creation. The International sanitary confer-
ences that have been held in Paris, Constantinople,
Vienna, Washington, and Rome, have succes-
sively been the arenas where these questions have
been discussed, and so far there has been little re-
sult, if we except the International quarantine
maintained at the Suez Canal by the French, and
the Consular system of notification inaugurated
by the United States. At these conferences, with
all the conservatism underlying the action of di-
plomatic representatives, the views of the techni-
cal delegates, while not always fully adopted,
have not seemed too r-adical, and the mere fact of
the calling together of these conferences, is itself
proof that Nations are now acting in formal re-
cognition of the necessitj- of a new chapter in the
International Sanitary Code.

I speak of the " International law," although
it is well known that " there is no legislative or
judicial authority, recognized by all Nations,
which determines the law that regelates the re-
ciprocal relations of States." (Wheaton.) But
there are interpretations of the Jus genlhtm which,
by common acceptance and long usage, have been
the guiding principles on which diplomatic dis-
putes have been settled for many years.

Without entering upon the question of whether
it is strictly correct to use the term laze as appli-
cable to mere rules governing the conduct of in-
dependent Nations with one another, we may at
least admit that there are certain moral obliga-

264

INTERNATIONAL COMITY IN STATE MEDICINE.

[August 24,

tions resulting from natural rights, which Na- era be displayed by those Nations owning dis-
tions at peace respect and observe. Mr. Madison j ease-breeding foyers,
defines International law as "consisting of those There has been a great increase in the comity
rules of conduct which reason deduces as conso- between Nations in regard to sanitary matters in
nant to justice, from the nature of the society ex- '• the past few years. The first step is clearly that
isting among independent Nations, with such inaugurated by the Vienna Conference of 1S74,
definitions and modifications as may be estab- ' where the danger of cholera importation having
lished by general con.sent." (Wheaton.) been recognized, by general consent, the French

" To this favor, then, we come at last" in dis- Government took charge of the quarantine ser-
cussing this question, that whatever is done or vice at the southern entrance to the Suez Canal,
admitted, is by general consent. Most of the since which time cholera has not passed beyond
terms of the International law have been settled , Egypt. It is true that cholera appeared in Eu-
by treaty. ' rope in 1883, but it came by a different route, /. c.

One of the absolute rights of independent States : by French troop-ships from Tonkin, and the dis-
resting upon general consent and common usage, ' ease was thence disseminated to Spain, Italy, Sici-
and acknowledged as the most important, is the ! ly, Sardinia and South America,
right of self-preservation. "This right," says j The next important step in International sani-
Wheaton, "necessarily involves all other inci- tation, I am glad to say, was taken by our own
dental rights, which are essential as means to give , country. Dr. John C. Peters, of New York, in a
effect to the principal end." It follows logically, letter written to the late Surgeon- General Wood-
that preservation from epidemics falls within the worth shortly after a visit to Havana, wrote that
rule, and a Nation should have a right to view | "an international public sentiment should be are-

as equal acts of hostility the sending out of a pi-
ratical craft, or of a ship infected with yellow fe-
ver, cholera or other contagious disease. That
division of commerce known as the carrying trade,
is too impatient of sanitary restraint, it should be
stripped of its power to convey disease, and by
International treaties the carrying trade may be
so regulated. There need be no interference with
shipping. Modern machinery of disinfection has
taken the place of " detention." But even this

ated against the filthy and careless ways of the
authorities, which cause so much suffering and
death among the mercantile and public navies of
the whole world." (Woodworth on Quarantine,
Transactions International Medical Congress of
Philadelphia, 1876, p. 1068.) That officer (Jno. M.
Woodworth) in a report to Congress in 1874, had
invited attention of Congress to the necessitj' for
" prompt and authoritative information to threat-
ened ports of the United States of the shipment

regulation will not go to the root of the evil, for 1 of passengers or goods from a cholera infected
the existence of a plague centre in any countrj' district," and he suggested that the Consular
is a constant menace, and the carrying of fomites officers of the United States should be instructed
may sometimes escape the utmost vigilance. to place themselves in communication with the

Therefore it seems that the y«5^f «//«;« requires j health authorities of their respective localities,
that any Nation, having within its territory an 1 and to advise promptly, by cable, of the outbreak

agency capable of destroying or injuring another,
suppress that agenc}'. This is not a strained in-
terpretation, for we may find the general princi-

of cholera, and the sailing and destination of any
vessels carrying passengers and goods from in-
' fected districts. This suggestion, so eminently
pies recognized in the restrictions placed upon a 1 practical, was finally adopted by Congress in the
neutral. A neutral must restrain from fitting 1 law of April 29, 1878, which now forms the basis
out, or sailing of armed cruisers of belligerents, ; of our existing Consular sanitary regxilations.
and must prevent their territory from being made I Through the kindness of the Honorable the See-
the base of belligerent operations; not only that, retary of State, and the courtesy of the efficient
but a reasonable vigilance must be exercised. ( chief of the Consular Bureau, I was permitted to
(Wharton, International Law Digest.) And fur- recast the last revision of the sanitarj- portion of

ther it was claimed, and the claim has been ad-
mitted, that it is the duty of the sovereign of any
country to restrain agencies likely to injure an-
other country, such as by predator^' Indians or
other marauders, or mob injuries. (Wharton, loc.
cit. ) The diversion or obstruction of navigable
waters without the consent of the injured Nation,

the Consular regulations (188S), and I am of
opinion that our regulations on this subject are
at present in advance of tho.se of any other coun-
try. The Bureau Causuttatif cf Hvi^ieiie, of Paris,
in its last report, invited the attention of the
Minister of Foreign Affairs to these regulations,
and recommended that the French Consuls re-

has also been successfully claimed as a violation ' ceive similar instructions. Our government has
of International rights. Why then should not | gone much further in this direction. We have'
the claim be insisted upon, that under the abso- employed a competent inspector in Havana since
lute right of self-preservation, we shall demand \ 1879, who is attached to the Consulate as medical
of certain other countries that reasonable diligence I adviser, and who makes personal inspection of the
in suppressing small-pox, yellow fever and chol- 1 shipping bound to the United States, and who

1889.]

NEW METHOD OF FEEDING.

265

attends to the sanitary welfare of American ves-
sels in that port. When the cholera became epi-
demic in Europe in 1883, by my recommendation,
a medical inspector was attached to the Consulates
at Liverpool, London, Havre, Bremen, Hamburg,
Marseilles and Naples, who, under instructions
from the Bureau, made careful inspections of emi-
grants, baggage and merchandise bound to the
the United States. No government has yet pro-
tested against these inspections except Spain,
which country took exception to the continued
presence of the United States Inspector in Havana,
but that powerful country withdrew the objection ;
when it was pointed out that, without such pre- :
liminary inspection, under municipal regulations
of our ports, the carrying fleet would be greatly
delayed, and at some ports shut out altogether
during the summer months.

Our National quarantine laws are now much
more rigid than heretofore, and year by year the 1
stations are becoming more completely equipped,
but much trouble would be saved, and danger
avoided, by enforcing the international rule now !
asked, as a right. [

What excuse can exist for apathy in countries j
where yellow fever and cholera are respectively i
epidemic ? It is not a friendh' act for a Nation 1
having a contagion-breeding centre, to fail in the 1
exercise of such vigilance as might prevent the
emanation of the disease germs.

I again quote Woodworth (loc. cit.). "The
endemic homes of cholera and yellow fever are the
fields which give the greatest promise of satisfac-
tory results to well directed' and energetic sanitary
measures, and to this end an international senti-
ment should be awakened, so strong as to compel
the careless and offending people to employ ra-
tional means of prevention."

In the volume by Dr. E. C. Wendt, of New
York, on "Asiatic Cholera," New York, 1885,
I wrote concerning this subject: "A National

Government during its existence as

a Government, must assume certain responsibili-
ties, among which are those affecting the physi-
cal and pecuniary welfare of the people. A Gov-
ernment must, under the natural limitations of
human rights, take proper and necessary meas-
ures to protect its subjects against pestilence or
famine by such wise and prudent acts as the ne-
cessities of the time may seem to warrant. A
failure so to do would subject such a Government
in the eyes of all civilized peoples to just con-
demnation, and as the safety of Nations makes
them mutually inter-dependent, whether they
will it or not, so the safety 'of a particular Na-
tion is dependent upon the physical integrity of
its several municipalities, as well as upon the
physical integrity of its neighbors. . . . Modern
Nations have tacitly recognized these responsi-
bilities, and endeavored to meet them by ' inter-
national conferences,' rarely, however, with any

view to mutual concession. At each 'conference*
thus far held, the commercial phase of the ques-
tion has, although purposely kept in the back-
ground, seemed to be paramount, and although
there has been substantial agreement, first as to
the responsibilitj' of any Nation having epidemic
disease within its borders that such disease should
not be allowed through negligence to afflict its
neighbor ; and second as to the desirability of a
synchronous united effort looking toward final
eradication ; yet the moment the details by which
these desirable ends were to be attained were dis-
cussed, harmony was at an end, and so it has hap-
pened that each Nation for itself assumes its own
responsibilities towards its citizens, and allows its
neighbor to adopt in turn such independent meas-
ures as in its judgment the occasion warrants.
It is, therefore, clear that interna-
tional public sentiment must be created to compel
these Nations owning cholera and yellow fever
centres to no longer afflict the globe b}- their
apathy and indifference to the general welfare.
"Who can doubt that if the action of
Russia in respect of the plague, and of the United
States in regard to yellow fever, were imitated by
Great Britain, Burmah and China, as regards
cholera ; Spain, Brazil, Central America, Mexico,
the West Indies, and the occidental littoral of
Africa, in regard to yellow fever, that those two
diseases would speedily disappear from the earth."

There is then a plain dutj' before this great
Association which embodies the combined medi-
cal wisdom of the United States, and that is to
lend its powerful aid toward the humanitarian
side of this great question. Let this Section re-
affirm the Montgomery- resolution, and commend
it for adoption by the Association. Its object is to
enhance the welfare of humanity, and its accom-
plishment is within the bounds of possibilit}'.

Washington, D. C., June 15, 18S9.

THE METHOD OF FEEDING IN CASES OF

INTUBATION OF THE LARYNX BY

POSITION, HEAD DOWNWARD,

ON AN INCLINED PLANE.

BY W. E. C.\SSELBERRY, M.D.,

PROFESSOR OF MATERIA MEDICA AND OF THERAPEVTICS AND OF
LARYNGOLOGY AND RHINOLOGY IN THE CHICAGO MED-
ICAL COLLEGE; LARY"NGOLOGIST TO THE SOCTH
SIDE FREE DISPENSARY. CHICAGO.

Since the presentation to the Chicago Medical
Society, in September last, of the preliminary
verbal report on this method of feeding as just
then devised by me, the subject has assumed
such importance, and the method, as modified
through further experience, has been so success-
fully practiced within a limited circle, that it is
desirable to widely promulgate the device in its
perfected and modified aspects.

The unavoidable entrance of food material into

266

NEW METHOD OF FEEDING.

[August 24,

the lower air-passages in process of deglutition
has been the most serious drawback to the oper-
ation of intubation of the larj-nx. It has influ-
enced many surgeons to reject or to abandon the
procedure in favor of tracheotomy. Others have
sought to obviate the danger bj' strictly with- i
holding liquids — a plan which occasions in feb- 1
rile patients indescribable agony from thirst,
which is not relieved b}- the substitution of semi-
solids and ice. The cri,' of water! water! water!
from these little patients, alike when awake, dur-
ing sleep, and in delirium, is yet ringing in our
ears.

Many and ingenious were the devices to over-
come the difficulty ; the nasal feeding tube, the
rubber epiglottis, the metal epiglottis tube, deep
intubation, etc. — none of them adequate, and
some of them not a little dangerous.

In June, 1888, through the courtesj- of Dr.
Frank Gary,- 1 performed the operation of intu-
bation of the larj'nx in a case of diphtheritic
croup. We encountered the usual difficulties in
feeding which I had before so frequently expe-
rienced. The nasal feeding tube was used with
the customary partial degree of success only, ice
was given, and still there was an incessant pitia-
ble cr}' for water. We were much distressed on
this account, and in despair for some exp)edient
whereby liquid could be administered, it suddenlj'
occurred to me to stand the child on its head and
let it drink. A moment's thought sufficed to
modify this radical position to one in which the
inclination of the body head downward was just
sufficient to prevent gravitation of liquid through
the tube into the trachea, and to cause, rather,
any portion which had been forced into the end
of the tube during pharj-ngeal deglutition to flow
back into the pharj-nx. By action of the phar-
yngeal and oesophageal muscles the liquid," of
course, could be swallowed upward equally as
well as downward, just as happens when one
drinks, when leaning far over, from a spring.

In this position, illustrated in Fig. i, the child
would suck through a rubber tube from a glass
and swallow without the slightest difficulty all
the liquid which it desired.

In another case, treated through the courtesy
of Dr. Frank Billings, a metal epiglottis tube was
inserted, and an opportunity was thus afforded of
testing the efficacy of the lid alone. In the up-
right position, with the epiglottis tube /;/ situ, the
patient could not swallow water or milk without
coughing, indicating entrance into the trachea ;
while in the inclined position, head downward,
it drank freely without difficulty.

The same degree of success has since obtained
in other cases. Many of the younger patients
will suck more readily from the nipple of an or-
dinary feeding bottle, although an open tube from
a glass is the more rapid means with older chil-
dren. A few have been found to swallow better

when fed, on the same principle, in the inclined
abdominal decubitus ; but the inclined dorsal
decubitus is usually to be preferred, on account
of the facility' in assuming the position and of the
greater certaint}' in maintaining a proper angle,
although it is largelj- a matter of suitability to the
individual case, whether the child should be in-
clined on the back, the abdomen, or even on the
side. Some surprise is occasioned from the sim-
plicity of the matter, that it had not previously
been adopted. Two or three thousand cases had
now been treated by intubation, and in all the
necessity for a method such as this must have
been apparent, but exhaustive inquiry has failed
to elicit a previous use of the device in connection

with intubation of the larj-nx, notwithstanding
the publication by Dr. R. Norris Wolfenden,' in
1887, of a note entitled "A Simple Method of
Procuring Deglutition when such is Impeded bj'
reason of Extensive Ulceration of tlie Epiglottis,"
in which he described a patient suftering from
the tuberculous ulceration of the larynx, who
could swallow not more than a tea.spoonful of
liquid at a time, and " this only at the cost of
much pain and terrible paroxysms of coughing,"
who had learned for himself and subsequently
demonstrated to Dr. Wolfenden, the "wrinkle"
of lying stomach downward upon a couch, with
head and arms hanging free over the end, in
which position he could drink a large tumblerful
of water with the greatest ease and comfort.

' The Lancet, July i. iSS-. The Journal of Laryngologj- and
Rhinology, August, 1887.

1889.

PORTAL BLOOD.

267

Regarding the exact position, an angle of in-
clination of 20° is suitable to most cases, although
this may vary slightly in either direction.

During the process a little fluid will gravitate
into the naso-pharynx, to remove which the child
must be made to swallow three or four times after
the vessel of liquid has been taken from its
mouth, and before it is permitted to regain the
erect posture, otherwise this naso-pharj-ngeal re-
siduum will gravitate through the tube and ex-
cite cough.

The patient can be inclined without inconve-
nience for a minute or more, although less time
will suffice.

One element of danger, '' schluck ptieiimonic"
and a vast amount of deprivation and suffering
are thus removed from the operation of intuba-
tion of the larj-nx, which, freed from the odium
attached to these disadvantages, must become
more general and exhibit better results ; not that
the entrance of food material into the lungs is
the sole cause' of pneumonia occurring in the
course of diphtheritic lan-ngitis, for this compli-
cation frequently arises apparently b}- simple ex-
tension of the diphtheritic inflammation down-
ward, and occurs, at times, after tracheotomy,
when deglutition is unimpaired. Indeed, in 116
autopsies of intubation cases, presumabh' fed in I
the upright position, recorded by Dr. Northrup,
of New York, not a particle of food could be
found in the bronchial tubes, which would seem
to prove the danger of pneumonia by aspiration
to have been over-estimated : but as water and
milk, the materials most likely to enter, would
be the most difficult of identification after death,
aspiration of them in considerable quantitj- must
still be regarded as an exciting factor, and one ,
which is capable of originating pneumonia in the
absence of other causes.

Since it is now conceded that the use of rather
small and loose tubes is preferable to tight fit-
ting ones, the danger of their slipping out while
in the inclined position cannot be disregarded.
The liability is minimized b}- using an angle of
inclination the smallest that will accomplish the I
desired result. Feeding unaccompanied b}- cough
is then less likely to result in dislodgement of the
tube than when the erect position is maintained ;
and violent expulsive cough is excited at everj' [
act of deglutition.

Since June, 1S88, Dr. E. Fletcher Ingals has
nourished thus, very successfully, five cases, and
Dr. F. E. Waxham has reported thirtj- cases,
in all except two of which, he informs me, feed-
ing was accomplished without difficulty by this
means. Of this series he saved 50 per cent., an
excellent result, to which, doubtless, the improved
method of feeding contributed in large measure.
70 Monroe Street, Chicago.

ON THE PASSAGE OF PORTAL BLOOD

INTO THE GENERAL CIRCULATION,

AND ITS PROBABLE RELATION

TO TOX/EMIA.

Delivered in theSection of Ptactice of Medicine. Materia Medica and
Physiology, at the Fortieth A nmtal Meeting of the A merican

Medical Association, June, i88g.

BY CH.\RLES G. STOCKTON, M.D.,

OF BrFFALO, N. Y.

The coma which occurs in some cases of cir-
rhosis of the liver never has been explained satis-
factorily. It has been ascribed to a form of
toxaemia, but just why there should be a toxsemia
presenting such a history it is not easy to under-
stand. This is but one of many interesting
symptoms, the origin of which is attributed to
toxic conditions of the blood — a subject just now
receiving much attention.

One view of the matter appears to have been
overlooked, and to this I ask your attention. It
is the current opinion that the blood from the
portal vein before it is fitted for the general circu-
lation must first filter through and be modified —
refined — by the liver. When the liver is con-
gested and there is overfullness of the portal vein
it doubtless happens that the blood traversing the
liver is imperfectly acted upon by the hepatic
cells and as a result irritating, toxic substances
enter the general circulation, producing those
symptoms known as biliousness. That this inad-
equacy of the liver does occur there is abundant
authority to uphold, and I have no argument
against it. On the contrary' it is contended by
the writer' that to whatever extent the liver fails
to metamorphose the portal blood, to just that
extent the blood departing in the hepatic vein is
of the nature of portal blood, and is likeh^ to in-
duce systemic derangement.

We now come to an important proposition : It
is that there exists inosculations of the branches
of the portal with the systemic veins, which per-
mit the flow of portal blood into the general cir-
culation without having passed through the liver
at all. Some of these inosculations are normally
present, some of them are anomalous, and still
others result either from diseases of the liver itself
or from inflammatory processes involving its cap-
sule and other surrounding structures.

Of those ino.sculations which are normally
present, one of the best known is that which
occurs in the haemorrhoidal plexus, formed by
tributaries of the inferior mesenteric, which ter-
minate in the internal iliac. "The portal and
general venous systems have a free communication
by means of the branches composing this plexus. ' ' "
Besides this there are anastamoses between the
portal vein and branches of the vena cava ; be-
tween the gastric and the oesophageal veins ; be-
tween the left renal and veins of the intestine ;
between superficial branches of the portal and the
phrenic veins ;' [recognized by Tiernan and found

268

PORTAL BLOOD.

- [August 24,

by Freirich to exist in even' case in which he had '
injected the portal :'] between the epigastric, et al,
and branches of the portal, as first described by
Sappe}'," an anastamoses which probably is the
same as that described by Luscha, [Anat. 11, p.
339] as the vena parumbilicalis, and which he
claims occurs in man and most mammals as a
normal condition.

SchifiF found that the circulation persisted in
the liver after ligating the portal vein and the
hepatic artery, and explained the fact by the en-
trance of blood through the para-umbilical veins.'"
Finallj', Lauder Brunton"" states that a portion of
portal blood, by collateral circulation, enters the
systemic veins without entering the liver. Now
as to those intercommunications which occur as
anomalous and somewhat rare conditions, there
are reported to medical literature many well-
authenticated cases. A branch of the portal
communicating with the iliac vein is reported by
Giacomini.' Another remarkable case is reported
by Sperino.' HyrtP relates an instance of the
union of the splenic vein with the vena azygos.
In a very interesting article bj- F. Champneys'
reference is made to a large number of similar
inosculations, normal and anomalous, mentioned
by Henle, Rokitansky, Cruveilhier, Meniere,
Serres, Reynard and others. Further data bearing
on this point may be found in the writings of J. H.
Russell,'" Meniere," Peygot,'" Burow,'^ Bamber-
ger,'' Klob,'-' Schulze," and Monro.'"

The fact that such intercommunications are
established as a result of cirrhosis of the liver and
other diseased conditions obstructing the ordinary
current of portal blood, is attested by so much
evidence that citations here are less necessary.
In some instances there appeared such marked
varicosis that the current in the vena porta was
reversed, the congestion of the viscera relieved,
and the ascites, previously existing as a striking
symptom, was made to disappear. This passing
away of ascites has been noted b)- many clinicians,
and has generally been attributed to the causes
mentioned, although it should be stated that por-
tal sj'stemic anastamoses of considerable size often
exist while the ascites remains present. F.
Champneys' relates an interesting case wherein
dropsy subsided owing to ana.stomosis, and paral-
lel cases reported by Sappey, Hoffman and Hanot,
are cited by Thierfelder," and, on the other hand,
the same author accounts for the oedema of the
lower extremities, and a relatively early oedema
of the abdominal integument, by the back- flowing
of the portal blood into the crural veins and epi-
gastric veins respectively, thus impeding the re-
turn flow of venous blood to the center. It would
seem highly probable that in those cases in which,
after frequent tapping, the ascites entirely disap-
pears, as stated by Flint" and others, the reason is
to be found in the establishment of collateral por-
tal circulation.

Anatomical evidence that collateral portal cir-
culation is set up in cirrhosis of the liver, is ex-
tensive ; amongst other authorities may be men-
tioned Gubler, Lyons, Virchow, Monneret, Renaud
and many besides these. It is also well known
that after peri-hepatic inflammation there fre-
quently remains adhesions which unite the liver
and diaphragm to such an extent that, through
many small inosculations, there is a free commu-
nication of blood from one to the other. Such
unions from inflammation are not rare, and it
would seem that after examining the testimony
all must admit that portal blood maj- pass around
the liver and join the blood in the systemic veins,
thus escaping those elaborate changes which the
liver is supposed to bring about in the blood com-
ing from the organs of digestion ; furthermore, it
would seem as though this fact were, by normal
anatomical arrangement, made possible to some
extent in healthy individuals : and it appears that
in some anomalous and pathological conditions
the communicating passages are so extensive that
torrents of portal blood may enter the general cir-
culation in the manner described.

Let us now pass to the consideration of the
second proposition, namely : The blood of the
portal vein is toxic. The liver intervenes and,
acting the part of a physiological quarantine sta-
tion, hinders the admission of disqualified ma-
terial and hence prevents toxaemia. That the
portal blood varies in its toxicity there is ample
proof, but that it is generally unfit for systemic cir-
culation there is every reason to believe. In the
labors of Claude Berjiard, Hegar, SchifF, Lauten-
bach, Jaques, Brunton, Roger, Bouchard, Gautier
and others, affirmation of this statement is to be
found. Peptones were discovered in the portal vein,
and these substances when injected into the circu-
lation were found by Ludwig, Schmidt, Muhlheim
and later observers to be poisons.

Hegar, in 1873, found that nicotine when made
to pass through the liver disappeared from the
economy : SchifF, in 1877, found this true of other
alkaloids: and Jacques, in 1S80, found that some
were destroyed in the liver and that others were
stored up by the gland, at some later day to pass
into the circulation, or to be excreted. Since the
studies of Bouchard, Gautier, Vaughan, and
others relating to animal alkaloids and extrac-
tives, we are better prepared to understand the
real nature of the toxic substances which the liver
is made to resist or modify, and we now more
readily perceive how intestinal fermentation on
the one hand, and intestinal antisepsis on the
other, excites or retards the auto- intoxication well
known to exist under certain conditions.

G. H. Roger, '" in a thesis published at Paris in
1887, relates the results of numerous experiments
as to the toxicity of the blood, in which he shows
that the blood of the portal vein is far more poison-
ous than that from other sources ; and he further-

1889.]

PORTAL BLOOD.

269

more shows that the "supra-hepatic blood" —
that is, blood immediately after leaving the liver
— while far less toxic than that in the portal, is
more toxic than than which circulates in the
other veins. To this matter we shall after a time
recur. It would seem unnecessary to devote
further time here to the demonstration of a theory
which is pretty well determined.

Having shown that the blood of the portal vein
finds more or less ample channels for flowing into
the general circulation without passing through
the liver, and having shown that the portal blood
is always more or less toxic, and sometimes in-
tensely so, it is now incumbent to answer the
natural inquiries, first, Why is it that there is not
in all individuals an ever-present toxcemia, occa-
sionally reaching a dangerous, or even fatal de-
gree ? And second, Wh}' is it that when free
anastamoses occur as a result of cirrhosis of the
liver or other affections, coma, delirium, diarrhoea,
propeptonuria and glycosuria do not occur as per-
sistent symptoms ? Admittedly these questions
must be answered, and in turning to the replj- let
us first consider the next proposition, which is :
Normally there exists in the portal vein a lower
blood pressure than in the systemic veins. It
will be seen that as a natural result of this, in-
stead of the portal blood coursing into the sys-
temic veins, in health the systemic blood would
find its way into the vena porta. The low pres-
sure in the portal vein is doubtless determined by
the pump-like action exerted on the liver by the
diaphragm during respiration, and by the fact
that, unlike the veins of the general system, the
branches of the portal lack the support and pres-
sure of the muscles. However it comes about, it
is maintained, as stated by Lauder Brunton,^'
that the blood- pressure in the portal vein is verj'
low.'^

Is it not reasonable to suppose, then, that this
difference in blood-pressure is the means by which
nature protects the system from the toxaemia
which would probably follow the free passage of
portal blood into the general circulation ?

There can be no question, however, but that
when the anastamoses are very large and numer-
ous, the inflowing systemic blood would soon
practically equalize the pressure, but even in
these cases the tendency would be towards the
portal current and not away from it, save in in-
stances of obstructive liver disease or the equiva-
lent. So it would appear that under ordinary cir-
cumstances toxaemia would not result from even
free anastamosis.

But extraordinar\- circumstances occur. From
indiscretions in diet, from sedentary habits, from
the irritation of drugs, or from exposure there
super\-enes a congestion of the liver, an obstacle
to its circulation ; from this impediment to the
portal stream there is established an unusual por-
tal pressure, a pres.sure greater than that in the

systemic veins. Naturally the portal blood
freighted with its peptones, its bile, its animal
alkaloids and all its poisons, finds its way in
greater or less proportion into the general circu-
lation and toxaemia is the result. How often are
there cases accompanied by haemorrhoids, tender-
ness over the hepatic region, languor, a coated
tongue, anorexia, headache and the multiplicity
of toxaemic symptoms : how often do we give
cathartics to deplete the portal circle ; and how
often success follows our measures. Certainl}- such
experiences are suggestive, but they are not so con-
clusive as are those which we have in cases of cir-
rhosis of the liver, when the portal vein is always
found distended, when from collateral circulation
the neighboring veins are enlarged — when from
anatomical-* as well as from physiological reasons
we may be sure there is a blending of the
streams.

And finally, when ascites di.sappears and the
other signs and symptoms of cirrhosis continue,
the most doubting must confess that here, indu-
bitably, the portal blood invades systemic veins,
and produces certain results. To name these re-
sults would be to mention many of the sj'mptoms
of hepatic cirrhosis, the most striking of which
is that one spoken of in the begining of this
paper — the coma of cirrhosis — a symptom for
which J. Hilton Fagge confessed himself unable
to account.

But, I have been asked, why is it that this
symptom is so rare in a disease which is so com-
mon ? Why is it that patients do not present
symptoms of intense toxaemia more persistent^ ?
Why is it that acute symptoms follow a tempor-
ary obstruction of the liver while insignificant
symptoms attend a chronic obstruction ? In reply
I would suggest that this is quite parallel to what
ordinarily happens in other acute and chronic
maladies ; that the organism gradually accommo-
dates itself to circumstances. A further answer
may be found in the following proposition, viz.:
When the integrity of the blood is not seriously
diminished it is equal to the metabolism of nu-
tritive substances, and to the destruction of toxic
substances, coming to it under certain conditions.
Any man may satisfy himself of this by remem-
bering well-established facts in physiology-. The
blood in the hepatic vein is more poisonous than
that in the vena cava. After a meal it contains
glucose, fat, albumens, and sometimes peptones.
Further along in the veins they disappear ; what
has become of them ?

The thoracic duct carries besides fat, proteids,
glucose, extractives, etc., to the vena cava. They
disappear in the blood : and one must admit that
this fluid has a function of assimilation and dis-
assimilation that reminds a person wonderfully of
the liver. Perhaps we do not sufficiently recog-
nize how the organs lend and borrow : and that
neighborly kindnesses in serv-ices rendered exist

270

PORTAL BLOOD.

[August 24,

inside as well as outside of us. At any rate,
proof of this function of the blood can be seen j
unmistakably in what takes place in the portal
vein ; for, whereas at its beginning it, during I
digestion, is found loaded with peptones, these, 1
in good health, have almost entirely disappeared '
before reaching the liver. It is apparent that i
these statements must pass unchallenged, and so, 1
I think, will the proposition. '

Now it seems to me that the blood is for a pe-
riod able successful!}' to oppose, and partly to
appropriate that which the portal empties into
it : but there comes a time when its integrity is
diminished, when its resistance is overcome, and
then its toxicity in one respect or another be-
comes such that definite sj'mptoms thereof be-
come apparent. It would be interesting, perhaps,
in this connection to make some reference to lith-
iasis, glycosuria, transient albuminuria, etc., and
to those individuals who, during life, are cachec-
tic, splenetic, and sick, but who show on autopsy
no lesions which adequately explain the condi-
tion ; but circumstances will not permit.

278 Franklin St., Buffalo, N. Y.

DISCUSSION.

Dr. J. H. MussER, of Philadelphia, congratu-
lated Dr. Stockton on the very ingenious argu-
ments he produced to maintain his thesis. The
question, however, obtains so much of a physio-
logical aspect that he felt quite incompetent to
discuss it. Clinicall}' he had never seen any cases
of hepatic coma, so-called, or the coma of cirrho-
sis, that could not be accounted for either by
cholaemia, uraemia, or a toxaemia due to loss of
function of the liver. This, of course, was only
his experience. He would state that in all cases of
hepatic coma there was either pneumonia, active
congestion of the lungs, or some inflammatory !
condition, however small, suificient to overthrow !
the balance of the economj', and hence disturb I
the functions which destroy any deleterious mat-
ter in the blood, if such is the power of that tissue,
or to interfere with glandular activitj' bj' which
ptomaine-poisoning or the like is made possible.
Such disturbance of the circulation and ner\-ous
system as a local inflammation induces coma will

' Nutrition in Lithieraia, Stockton, Trans. N. Y. State Medical
Assoc, Vol. ii, p. 371.

-Gray's .Anatomy, 1SR7, pp. 632 and 634.

^Plivsiological .-Vnatoniv, Todd & Bowman, 1859. Vol. ii, p.
348.

^Diseases of the T.iver, Wood's Edition, Vol. ii. p. 81.
5 Sappev. Traits d'.^natomie, 2d edition, iv, Pans. p. 329. Also
-Bulletin de I'Acad^niie de M^-dicinc, Paris, 1839, Tom. xxiv.

^C.Giacomini: Giorn, d. R. Academia di Med. di Torino.
Torino, 18^3, xiv ; ser. 3, 584-621 ; 2 lao,

7Sperino, Torino, 1879. Repr. from Giorn d. R. Acad, di Tor-
ino,

^'Mcdiz. Jahrbiiches dcr K. K. Oesterreichis chen staaten. Bd.
xxvii, and in Lvischa. Anat. des menschlisden Branches, p. 338.
''Jour, of .-Vnat. and Pliys., London, 1873, vi, 417-420.
't'ldem, 1873, viii, 149.
"Arch. edn. de M^-d., Paris, 1862, x, 381.

•■' Quoted l)y Cruveilhier, Anatomic pathologiquCj 183S, Vol. 2.
n Archiv. fur Anat. und Phys. von I. Muller, Berlin, 1838.
M Schmidt's Jahrbiicher, Leipzig, 1857.

cause such changes of function as Dr. Stockton
argues to arise from other circumstances.

Dr. Osler, of Baltimore, thought that the
point referred to by Dr. Stockton is one of serious
import. He was not sure, however, but that it
is only partially true. He doubted whether the
question thus received its solution. He believed
that the collateral circulation is a constancy. This
must meet the blocking up of the channels. The
same condition obtains as in narrowing of a valve
of the heart. Every one has found in post-mor-
tem examinations, extreme cirrhosis of the liver
without a single symptom during life, and yet in
such instances a great proportion of the portal
blood passed into the general circulation. Fur-
thermore, in cases of fibroid obliteration of portal
vessels, the portal blood for 3'ears passes through
the circulation.

Dr. Tremaine, of U. S. A., thought that the
essayist had made a mistake in regard to the por-
tal circulation : it is part of the venous circula-
tion only interposing the liver. The purposes
for which the venous blood passes through the
liver are not clearlj' understood. He would rather
explain the results by a defect on part of the ac-
tion of the cells, whose ofiice it is to eliminate the
toxic elements.

Dr. H. A. Hare said that he thought perhaps
Dr. Stockton had lost sight of the more recent
studies of Schiflf and Lautenbach, viz.: that any
capillars- network is capable of rendering blood
containing toxic sub.stances innocuous. The
lungs, for example, are similarly destructive
agents. Capillaries are oxidizing agents per se,
as a shallow pebbly brook is an oxidizing agent.
That oxidation does occur is proved by the high
temperature of the blood leaving the liver. Fur-
ther, all peptones are not poisonous, but it is rath-
er the pana-peptone, or hemi-albumose, which is
abnormally absorbed and caused toxjemia. Pep-
tones are normally absorbed, and predigested food
by the rectum ought to cause toxaemia if all pep-
tones were poisonous. Again, the argument of
Dr. Stockton is faulty since the inoculations are
constant and the toxaemia is rare.

Dr. Stockton, in reply, said he felt much
gratification over the discussion to which the pa-
per had given rise. He did not consider that the

'5Leitschr, d. Gesellsch. d. aerzte zn Wien, iSso. ii, 46.

'^■Disput. anat. select. V. Albertus Haller, Guttingen, mdccl.

'7 Elements of Anatomy, 1^25, ii, 2S.;.

'^Zierassen's Cyclopa^tfia, Vol. ix, p. 1S9.

ic See Diseases of the Liver, p. 20. Dujardin-Beaumetz, .\m. ed,,
1 888.
* ^^ Lauder Bruuton, Disorders of Digestion, p. 25.

-> Idem, p. 43.

" In Thesis, Paris, 1SS7, Action du foie snr Ics poisons, p. 97,
chap. iv.

-! Disorders of Digestion^ p. 25.

•■4 Dujardin-IK-aunictz. Diseases of the Liver, p. 153.

--' I am permitted to mention a series of experiin cuts made by my
colleague. Prof Julius Pohlman. of Buffalo, demonstrating that in
each of a number of dogs examined— some while fasting, some just
after eating, some between fasting and feeding— the blood-pressure
of the portal vein was far below that in the svsttmic veins. During
digestion the portal pressure was increased, ^>ut it was never near

■ port
the pressure m the 'systemic veins,
published.

These experiments will be

I889.J

MEDICAL PROGRESS.

271

criticisms, in the main, were contrary to the claims
made in the paper. Notwithstanding the late
investigations mentioned by Dr. Hare, the fact
remains that peptones disappear in the blood
without passing through a capillar}' network.
The claim made that the blood- pressure in the
portal vein is lower than in the systemic veins,
thus making a protection to the systemic circula-
tion, was not spoken of. This should be ex-
plained. When the portal pressure becomes the
higher, toxic conditions appear ; and but for the
action of other organs than the liver, and of the
blood to purify itself more conspicuous symp-
toms would appear. When the resistance of the
blood fails, then toxic symptoms do occur.

MEDICAL PROGRESS.

On a New Diuretic in Heart Diseases. —
Experiments and investigations made by M. Ger-
main See ( Paris) concerning the effect and value
of milk in heart diseases, have led to the following
conclusions : . 1

1 , Lactose constitutes at the same time the most
powerful and the most inoffensive diuretic. It
alone imparts to milk its diuretic properties. The
other principles of milk, especially the water and
the salts, have no manifest or useful effect, the
chlorate of soda does not add anything to the
polyuria, which is due to milk sugar, and even
the salts of potash have but a limited action,

Milk taken in quantities of 2 litres causes diu-
resis, but in quantities of 4 litres (each of which
contains 50 grams of lactose) it induces at the
same time a pronounced glycosuria, a transitorj'
diabetes, as a quantity of 200 gr. of sugar thus
absorbed is eliminated b)' the urine. At the same
time a considerable excretion of urea indicates a
destruction of the albuminates. There is conse- '
quently glycosuria and azoturia at once.

Milk sugar renders it possible to avoid these
inconveniences and dangers. One hundred gr.
of lactose in a draught produce an enormous diu-
resis which we are not sure to obtain with 4 or 5
quarts of milk. With the lactose there is neither
gh'cosuria nor azoturia. In milk the effect of
lactose is impeded by caseine and fat.

2. The polyuria resulting from the internal use
of 100 gr. of lactose exceeds all the other artifi-
iicial pol^'urias ; it increases rapidly to 2'_. litres,
and almost constantly rises to 3'i and even to 4
and 4' J litres on the third day. Then it remains
stationary- or decreases to 2'.. litres for several
days. During that time the dropsical symptoms
disappear with almost absolute certainty, the
blood is freed from hydrates, and this is the rea- j
son why the diuresis is no longer as intense as at
the beginning of the treatment. But after a few
days of rest another dehydration of the blood and ,

resorption of dropsical accumulations may be ob-
tained in the same way.

3. Effect on dropsy of cardiac or renal origin.
It may be said that lactose has a sure effect on
dropsy of cardiac origin, but its action is doubtful
or even nothing in dropsy of renal origin. In
affections of the heart it fails onlj' in cardiacs
where the kidney is affected with Bright' s disease,
and when the albumen increases to 0.60 or i gr,
per litre. As long as the quantity of albumen is
small the result is favorable, which leads to the
supposition that in these cases there is no renal
lesion, but simply a stagnation of the blood. By
diuresis from lactose the degree of alteration in
the kidney may also be measured.

4. Time for the cessation of the diuresis. Ad-
ministration of lactose. Sometimes the diuretic
action is found to be interrupted by causes other
than lesion of the kidney's. A diarrhoea may en-
sue which naturally diminishes the diuresis. In
other cases the patients have for a longer or short-
er time profuse sweats or accidental transpirations
which diminish the polyuria, but it soon reappears.

The medicine is generally well borne. It should
be given for eight or ten days, which would suffice
to bring about a noticeable dehydration of the
blood ; then a pause is made of a few days, when
its administration may begin again. The lactic
draught is somewhat insipid, but its taste may be
improved by adding a little brandy or peppermint.
In all cases it is of importance to diminish or even
to stop all other drinks, including bouillon and
especially milk, which becomes useless as a diu-
retic, and encumbers the stomach and impedes
digestion of other nourishments. Also in this
respect lactose has great advantages, as it permits
the patient to eat all kinds of food, even meats,
which are often indispensable to sustain the sink-
ing forces of a cardiac patient who has arrived at
the last stages of the disease.

5. How lactose acts. Therapeutic comparison
with other diuretics. The above facts being known
the question arises concerning the mode of action
(which might be called physiological) of this new
diuretic. We know that diuretics often act through
the high blood pressure which they cause, but with
the present substance pulse and pressure are not
altered. The alkaline salts are credited with pro-
ducing the diuresis by virtue of their osmotic
power, and especially the salts of potash possess
this. But we do not obtain any better results by
adding 2 gr. of potash to each litre of lactose po-
tion than by the lactose alone. As the latter does
not pass the kidneys it can act only through os-
mosis, and we must admit an elective and selective
action of lactose upon the secretive elements of
the kidneys ; it is a renal physiological diuretic.

On comparing it with the other diuretics we
find the following : Those which augment the
blood pressure, the cardio-vascular substances, to
wit : digitalis, convallamarine, strophanthus, act

272

MEDICAL PROGRESS.

[August 24,

much more feebly, less surely and less effectively
upon drops}^ than lactose. Bucquoy, with his
well-known honesty and genuine scientific mind,
has recognized its superiority in this respect to
strophanthus, which he himself had favored.

A second group of diuretics, the only one thor-
oughly established so far, comprises the renal diu-
retics proper, in the first place caffeine. It forms
part of a chemical series which begins with xan-
thine, includes theobromine and ends with caffeine,
the most methyled of these substances. It is al-
ready known :

1 . That caffeine and theobromine are renal diu-
retics like lactose.

2. That both of them act independently of vas-
cular pressure, for one may cut the vaso-motor
centres and destroy the vascular nerves without
hindering in any way the caffeine diuresis.

3. That they have no tonic effect upon the heart,
as was supposed, and in this regard they likewise
resemble lactose. But caffeine causes nervous and
cerebral troubles unknown to lactose.

6. We possess, therefore, in lactose, the diuretic
for heart troubles at the asystolic period, the gen-
uine cure for dropsy of cardiac origin, even for
those kinds of dropsy which resisted other polyuric
agents. In asystole there is another extremely
dangerous accident liable to occur — dj'spnoea ;
against this lactose is powerless, so it must be
aided by iodide of potassium. This substance
constitutes through the iodide and the potassium
the proper medicine for heart and circulation. It
lacks only diuretic power. To meet all indica-
tions iodide should be combined with lactose. —
Le Bulletin Medical, No. 47, 1S89.

Diagnostic Significance of Increase of
THE Knee Phenomenon and of the Foot Clo-
nus.— In an interesting article on this subject by
Th. Ziehen, published in the Corresp. Bl. des
Allg. (jrztl. I'ereins von Tliihingcn, No. I, 1889,
the author arrives at the following conclusions :
An increase of the phenomenon in both knees may
be regarded as morbid, and significant onl}' if
foot clonus exists at the same time. An increase
of the phenomenon in one knee only is always a
symptom of disease. In healthy adults foot clo-
nus is extremely rare, consequently a pathologi-
cal symptom. In children, even when healthy,
foot cloinis occurs parallel with a physiological
increase of the tendon phenomenon : especially in
early years increase of the knee phenomenon seems
the rule. For adults the following holds good :
Foot clonus not accompanied by other marked ob-
jective symptoms is indicative of epilepsy or neu-
rasthenia ; with heraianaesthesia of the sensitive
nerves ; of hysteria ; in acute atrophies of amyo-
trophic lateral sclerosis ; with simultaneous intes-
tinal trembling of multiple sclerosis ; foot cloiuis
with spastic-paretic walk of spastic spinal paral-
ysis and progressive paralysis ; with disturbance

of speech and idiocy of progressive paralysis,
multiple sclerosis and epilepsy ; with anaesthesia
and paralysis of the lower half of the body ; of
dorsal and cervical meningitis. Foot clonus on
one side with hemiplegia or monoplegia of one
leg indicates a cerebral organic or hysterical af-
fection more frequently than a spinal organic affec-
tion.— Wiener Medicinische Wochcnschrift, No. 33,
1889.

Regarding the Centres of Innervation
OF THE Small Intestine. — ^J. Pal and J. E.
Berggrvn studied in Strieker's laboratory the
changes in the peristaltic movements of the intes-
tines under the influence of vagus irritation on
dogs poisoned with curare, and found {Med. Jahr-
biiclier, i88g) that the movement of the small in-
testine (jejunum and ileum), after irritating the
peripheral vagus pedicle, did not ensue regularly
until the spine had been cut in the neck. They
inferred from this that by cutting the spine in the
neck impediments are removed which prevented
the peristaltic movements before cutting. Further
experiments showed that the obstructing fibres
extend through the medulla oblongata and as far
as the g>'rus sigmoideus. From the fact that
after cutting brisk injection of the intestine fol-
I lowed, the authors concluded that vascular nen,'es
run alongside these inhibiting fibres. The irrita-
bilitj' of the duodenum from the vagus does not
follow that of the jejunum, but that of the pylo-
rus region of the stomach, as previous experi-
ments have shown. — JViener Med. Wochcnschrift,
No. 23, i88q.

On the Distinction between Koch's Bacil-
li AND the Bacillli OF Finkler-Prior. — M.
ScHENK ( Vienna) tried to raise microbe cultures
on the albumen of the lapwing ej'e, and succeed-
ed in discovering differences in the evolution ot
microbes the distinctive character of which had
not previously been found. So the cultures of
Asiatic cholera ( Koch ) and of cholera nostras
(Finkler-Prior), which had not appeared so far to
be different, acted differently on albumen of the
lapwing eye. The bacillus of Finkler-Prior lique-
fies and discolors the centre of the culture, whilst
that of Koch leaves it intact. — Lc Bulletin Medi-
cal, No. 45, 1889.

Ox Hysterical Coxalgia. — M. Ballet pre-
sented to the Societe de Biologie a patient who
had all the symptoms of a genuine coxalgia :
fle.xion with slight abduction of the thigh, atrophy
of the muscles, etc. It was only a case of hys-
terical coxalgia, however ; the remains of an
ancient hemiplegia of the same nature, resulting
from excessive use of alcohol. This fact is inter-
esting, since it proves once more that hysterical
paralysis may be accompanied by atrophj'. — La
Shnaine Medicate, No. 27, 1889.

1889.]

EDITORIAL.

273

Journal of the American Medical Association

PUBLISHED WEEKLY.

Subscription Price. Including Postage.

Per Annum, in Advance $5.00

Single Copies 10 cents.

Subscription may begin at any time. The safest mode of remit-
tance is by bank chect or postal money order, drawn to the order
of The Journal. When neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
letters.
Address

JOURNAI, OF THE AMERICAN MEDICAL ASSOCIATION,
No. 68 Wabash Ave.,

Chicago, Illinois.
All members of the Association should send their Annual Dues
to the Treasurer, Richard J. Dunglison. M.D., Lock Box 1274, Phila
delphia. Pa.

London Office, 57 and 59 Ludgate Hill.
SATURDAY, AUGUST 24, 1889.

THE FORM.\TION OF GALL STONES.

The rationale of the formation of gall stones is
not well understood. We know they are usually
formed in the gall-bladder, and they may also
form in the common, the cystic, the hepatic duct,
and in the intra-hepatic ducts. They occur most
often in the female, and usuallj' in middle life.
Sedentary habits and local peculiarities of climate
are seemingly predisposing causes. Taurocholic
acid or taurocholate of sodium is the agent which
holds the solids of the bile, cholesterin, biliary
pigments, lime, salts, etc., in solution. Why
these solids should be precipitated to form calculi
is the point in doubt. Foreign bodies in the
biliary passages will form nuclei for calculi, and
calculi with parasites, fruit seed, particles of
mucous have been found in the ducts, but rarely,
if ever, in the gall-bladder. Evidently other
causes must exist. It is known that fermentation
of the bile will cause a precipitation of its solids.
Retention of the bile in the gall-bladder and
ducts, from any cause, will render the bile less
fluid by the absorption of the waterj' portion,
and favor precipitation of the solids. F. Mar-
CHAND {Deutsche Med. ]\'ochenschytft, 1888), be-
lieves that tight lacing and the corset liver
{Se/nuir Leber), is the cause of the more frequent
occurrence of biliary calculi in the female. In
many post-mortem examinations he has verified
his observation. The pressure of the corset or
waist-band is applied over the neck of the gall-
bladder or cystic duct, causing retention of bile,
and consequent condensation of it. A rough

condition of the mucous membrane of the biliarj-
passages and gall-bladder will also favor the
formation of calculi. Carcinoma of the gall-
bladder or ducts is usualh' complicated with
calculi. This formation in carcinoma is also due
doubtless to retention of bile.

Catarrhal inflammation of the biliarj- passages
is said by most authorities not to predispose to,
or cause, the formation of calculi. That this is
an erroneous idea is proved by clinical evidence.
In chronic catarrhal duodenitis or gastro-duode-
nitis the biliarj^ ducts often become involved,
causing sufficient retention of bile to so condense
it that perfect casts of the common bile duct are
often found in the faeces. That such casts are
not oftener found is doubtless due to the non-
examination of the faeces. It is fair to infer that
a chronic catarrhal inflammation maj' extend
from the bowel through the ducts to the gall-
bladder. With such an inflammatory progres-
sion, would naturally go the fermentative germs
of the bowel. Such a condition would directly
favor the precipitation of bile solids in the gall-
bladder ; that is, retention from partial or com-
plete temporary occlusion of the hepatic duct,
and fermentation of bile through the zymogenic
germs from the bowel. The increased mucus in
consequence of the inflammation would also be
present to form nuclei. Chronic catarrhal duode-
nitis is a very common disorder, and occurs more
frequentlj' in females than males, probably be-
cause females take relativelj^ more of the hydro-
carbons than males.

SUGGESTIVE THERAPEUTICS.

Very little scientific attention has been given to
hypnotism in this countrj^ and an opportunity is
now presented to American phj-sicians to become
acquainted with the subject as presented by Dr.
H. Bernheim in his treatise on the nature and
uses of hypnotism, which has been recently trans-
lated by Dr. Christian A. Herter, of New York.

The hypnotic state, according to Bernheim, is
not the exclusive lot of rare neuropathic cases.
According to Liebault one-fifth or one-sixth of
all subjects are hypnotizable, and while some of
the susceptible are hard to hypnotize, most of
them can be overcome by a little perseverance
and determination on the part of the operator.
The hypnotized person is hy no means a lifeless

274

SUGGESTIVE THERAPEUTICS.

[August 24,

body, or one in a state of lethargy, as some may
imagine ; though he is inert he hears, is conscious,
and often shows signs of life. He may laugh, or
trj- to smother a laugh. He maj' remark upon
his condition. He sometimes pretends that he is
cheating, or that he is trj-ing to be obliging. The
majority, however, feel that they are influenced ;
that they are in the power of the operator.
Hypnotism manifests itself in different ways in
different subjects. There maj' be simple drowsi-
ness, or other induced sensations, as heat, prick-
ing, etc. This is the lightest influence. When
the suggestion affects motilitj^ there may be more
marked effects, the cataleptic condition may be
developed, there is inability to move, and there
are contractions and automatic movements. When
the suggestion affects the will and causes auto-
matic obedience it is still more decided. All
these manifestations of motion, will, and even
sensibilit}', says Bemheim, can be affected by
suggestion with or without sleep, and even when
it is powerless to induce sleep. In a more intense
degree suggestion produces sleep or the illusion
of sleep.

To define hypnotism as induced sleep, says
Bernheim, is too give too narrow a meaning to
the word ; such a definition overlooks the many
phenomena that suggestion can bring about inde-
pendently of sleep. Bernheim defines hypnotism as
the induction of a peculiar psychical condition
that increases the susceptibility to suggestion. It
is often true that the sleep that may be induced
facilitates suggestion, but it is not the necessary
preliminary. It is suggestion that rules hj-pnot-
ism. Suggested sleep does not differ from natural
sleep. The same phenomena of suggestion can
be obtained in natural sleep, if one can succeed
in putting one's self into relationship with
the sleeping person without awakening him.
The new idea that Bernheim proposes concerning
the hypnotic influence, the wider definition that
he gives to the word hypnotism, permits us to
include in the same cla.ss of phenomena all the
various methods that, acting upon the imagina-
tion, induce the psychical conditions of exalted
susceptibility to suggestion with or without .sleep.
Such is the case with fascination induced by a
brilliant object, or by the gaze. Some subjects
submit to the influence without sleep ; thej' are
susceptible to suggestions in the waking states.
They remember afterward what they have done,

and do not know why they were unable to keep
from following and gazing at the operator. Others
do not remember what has happened ; thej' have
been in a somnambulistic state with the eyes
open. In this somnambulistic fascination cata-
lepsy and hallucinations may be induced, often
by a simple word, a gesture, or a position com-
municated to them without previous fascina-
tion.

Various phenomena are manifested or maj' be
induced in hypnosis. Nervous subjects some-
times have muscular twitchings of the limbs and
febrillary contractions of the face while asleep ;
but the majoritj^ are inert, or become so after
suggestion. Sensibility is more or less modified ;
in light sleep it is preserved ; in deep sleep it is
diminished or totally destroyed. In a few cases
the hypnotic insensibility is enough to enable the
most diSicult surgical operation to be performed ;
but hypnotism can by no means take the place of
ether and chloroform. Changes in motility' are
more easily induced than changes in sensibility.
But a deeper degree of hypnotic suggestion is
required for the induction of automatic move-
ments than for simple catalepsy. Suggestion also
induces paralysis as well as contracture. This
suggestive paralysis has special characters, which
may be distinguished from other paralj-ses of
organic origin. At the will of the operator gen-
eral sensibility and the special senses may be
modified, increased, diminished, or perverted, and
in the advanced degrees of hypnosis all illusions
and hallucinations may be successfully carried
out with great precision, and all actions that the
operator commands are successfully carried out.

According to Braid the pulse and respiration
are at first slower than normal in hj-pnotism ;
but as soon as the muscles are put into activity a
tendencj' to cataleptiform rigidity is produced,
with increase of the pulse-rate and rapid and
laborious respiration. Heidenhain noticed an
augmentation of the salivary secretion, and Tam-
burani and Seppili noticed that at the time of the
transition from the waking condition to the hyp-
notic state, the respiratory movements became ir-
regular, unequal, and more frequent, the cardiac
and vascular pulsations increased, and the face was
congested. But Bernheim claims that these symp-
toms are not induced in patients hj-pnotized b^- the
quiet method of suggestion, who retain their mental
tranquility ; nor by those that having been al-

1889.]

CONSIDERATE JUDGMENT.

275

ready hypnotized several times go to sleep with
confidence and without emotion or agitation.
Suggestion may act upon the vaso-motor circula-
tion ; a red spot may be produced upon the body
by suggestion, or even a blister may be raised,
and haemorrhages and bloody stigmata may be
induced. Bernheim suggests that experiments
might be instituted to determine to what degree
imagination may influence certain functions in
the waking condition. We know that micturition
and defecation are greatly influenced by the will,
idea, and imagination. By concentrating the
mind upon the phenomenon, can we not also
produce an increase of heat in certain regions of
the body, perhaps even without hypnosis ?

That hypnotic suggestion is a valuable thera-
peutic agent there can be no doubt. It has been
employed successfully in organic afiections of the
nervous s};stem. True the results obtained are
often transient ; but even a brief respite from the
troubles of organic nervous afi"ections is a blessing
to the patient. Even in chronic and incurable
affections suggestive therapeutics is not useless.
It is of undoubted value in hysterical aSections.
It is important that the suggestion be varied and
modified according to individuality, and its eflS-
cacj' varies according to the subject and the cir-
cumstances. It has been found useful in various
neuropathic affections^ in epilepsy, insomnia, re-
peated headache, gastric and general neuroses,
neuro-arthritis, rheumatic and nervous pains,
melancholia, anorexia, writer's cramp, etc. Bern-
heim does not claim that hypnotic suggestion is
a cure-all. He has written an interesting and
instructive book upon a subject that deserves
careful study.

CONSIDERATE JUDGMENT.

Theories are of human invention, and are but
portraitures of human limitations and human
weaknesses. Facts have a kind of divinity above
and beyond the sphere of human agencies. While
theories may perish in a day, they alone are un-
changeable.

The world is full of theories^while its greatest
poverty arises from its need of facts. So great is
the want of them, that the bringing to the light
of one hitherto undiscovered practical truth ren-
ders a life worth living. And all the fine spun
theories that have found their expression in suc-
cessive phases of medical literature have only been

abiding, as they had their foundation in fact.

It is a confession of human weakness, yet not
a matter of surprise, that theories have had their
birth in every yesterday ; their development in
every to-day, and their deaths in everj^ to-morrow.
The mesian line which segregates the knowable
from the vast unknowable which lies beyond is
so mysterious and so obscure, that perception,
reason and judgment alike confess their weakness
and the limitation of their powers. In the study
of biology, of physiology, of pathology, and of
their modifying environments, the student of med-
icine often stands as upon enchanted ground. He
is painfully conscious that he is within the do-
main of the knowable ; that grand truths are at
his finger tips, and he longs to grasp and bring
them clearly into light. It is just here that the
majesty of great minds is manifest. The power
of self-control, to calmly bide the time until be-
yond question a fact is clearly demonstrated, this
is the crowning act of a master mind, the exer-
cise of considerate judgment.

This power of deliberate estimate of evidence
more than anything else has been the need of the
medical profession in the past, and more than anj'-
thing else, it is its need to-day. Fancies often-
times overleap the facts in their haste. Men
build their theories upon such foundations, only
to wonder that they come to nought so soon.

What the medical profession most needs is the
revelation of new facts. What best can serve the
world is the revelation of such facts, and there
are no such benefactors . as those who are giving
themselves to original research and the discover-
ing of new truths. We have had our fill of finely
devised theories. The present and the future de-
mand is and will be for facts. And we must pa-
tiently wait for the demonstration of these facts.
We are on the confines of new discoveries as to
the agencies of microbes in the production of dis-
ease. We have nearly everything yet to learn
with reference to their development, their poten-
cies, and the methods of their control.

We are confronted with new questions as to the
respiratory powers of the leucocytes and their
agencies in the production of animal heat, and with
the modifications of their form which govern the
activities of their oxidizing powers. We may
thus perhaps be led to apprehend more clearly the
modus opera7idi of antipyretics in the control of
temperatures.

276

EDITORIAL NOTES.

[August 24,

We are yet to learn the connection of electricity
with the trophic activities of the tissues, and by
what means false growths are retarded, and even
obliterated.

Many such are the questions which invite —
nay, which challenge investigation, and with ref-
erence to which, while we wait in eager expec-
tancy, we can bj^ no means afford to form prema-
ture opinions. We must bide the needed time for
actual demonstrations, that our conclusions ra.z.y
be of permanence and value. In nothing more
do we need considerate judgment than in our
estimates of remedial agents. Here fancy and
the wildest imaginations run riot. Not a theory
of cure but has its devotees ; not a remedy or a
nostrum but has its unqualified certificates of cure.

Men with reason and meu less gifted alike
contribute exaggerated expressions of their faith
in all sorts of treatments and of remedies. If ever
there was need of the culture of considerate judg-
ment it is here.

And just now, we commend this need to those
who are canvassing the merits of Brown-Sequard's
Elixir of Life. Let a calm and dispassionate con-
sideration of facts on the part of those who pro-
pose to give this article serious attention precede
the formation and expression of definite judg-
ments. And we forewarn those who propose to
make practical demonstration of its virtues to ex-
ercise at least the caution that Hammond enjoins,
lest septicaemia and embolism and death follow
speedilj' in the footsteps of reckless experimenta-
tion.

EDITORIAL NOTES.
HOME.
The License Act in New Hampshire. — The
law recently passed by the Legislature of New
Hampshire for the regulation of medical practice,
has had but a short life. A decision has been
rendered, by a full bench of the Supreme Court,
that it is unconstitutional to require a license as a
prerequisite for medical practice. The medical
registration act of Maine had a shorter life, even,
than that of New Hampshire : since the signature
of the Governor was hardly drj' upon the bill be-
fore that official changed his mind and drew his
pen through his name. The President of the
State Medical Society, Dr. Stephen H. Weeks, of
Portland, took the ground that the bill having
once been signed, the subsequent erasure of his

name by the Governor was null and void, and a
suit at law has been going on for a year or more
to determine which should hold good, the signa-
ture or the erasure. The decision has just been
reached, in the Supreme Court, and this is ad-
verse to Dr. Weeks and his contention on behalf
of the bill. The importance of the registration
act to the profession in that State is so great that
an effort to pass a like bill de novo will be made
by the State Societj', when the Legislature next
convenes.

Examining Board for Tennessee. — Under
the law recently enacted in Tennessee, the Gov-
ernor has appointed the following to serv'e as a
Board of Medical Examiners : Drs. James B.
Murfree of Murfreesboro, T. J. Happel of Tren-
ton, E. E. Hunter of Elizabethtown and Heber
Jones of Memphis, all members of the State Med-
ical Society ; also W. B. Halbert, eclectic, and T.
H. Hicks, homceopathist. Under the terms of
the act, not more than four of the six examiners
may be representatives of the same ' ' school of
practice." The Board has met and organized by
the election of Dr. Murfree to serve as President,
and Dr. Happel as Secretar}- and Treasurer. Dr.
Happel is the retiring President of the State Med-
ical Society.

The Peril of a Physiologist. — Dr. Weir
Mitchell has recently given in The Century a de-
cidedlj- unpleasant experience which befell him
him while pursuing his investigations concerning
the poisons of serpents, especially of the rattle-
snake. The snake generally aims his stroke with
his poison-fangs with accuracy, but he maj'make
a failure. "The serpent sometimes misjudges
distance and falls short, and may squirt the venom
four or five feet in the air, doing no harm. I had
a curious experience of this kind, in which a
snake eight feet long threw a teaspoonful or more
of poison athwart my forehead. It missed my
eyes by an inch or two. I have had many near
escapes, but this was the grimmest of all. An
inch lower would have cost me my sight and
probably my life." And yet with all his wierd
experiences Dr. Mitchell confesses to a certain
degree of fascination for the horrid crotalus, and
he actually speaks in a tone of regret of the
rapidly approaching extermination of the reptile
in this country. Dr. Mitchell further states that
by the u.se of the "serpent-staff," a contrivance

1889.]

EDITORIAL NOTES.

277

which jugulates the snake close to the head, the
dangers of laboratory work have been reduced to
a minimum, and the phj^siologist has no need to
bring his forehead into direct range with the
thrust of the rattler's fangs.

Dr. Oscar J. Coskery, a member of the Asso-
ciation since 1885, has died at Baltimore in his
forty-seventh year. He was graduated from the
University of Mar3-land in 1865 and immediately!
joined the volunteer staff of the State forces as
assistant surgeon. He was not yet 30 years of
age when he was elected to the Chair of Surgery
at the College of Physicians and Surgeons, Balti-
more. He was a prominent contributor to the
transactions of the Medical and Chirurgical
Faculty of his State, generally in regard to some
question of surgery' or of hospital organization.
He was for manj' years attending physician to St.
Joseph's Hospital. His death occurred on July
5th, from general tuberculosis. He was a man
of more than ordinary ability and of high aims,
and when we consider his relative youth he had
accomplished much.

Constitutional Law. — The Legal Adviser\
says : A State statute which requires every phy-
sician to procure a certificate from the State Board
of Health that he is a graduate of a reputable
medical school, or has practiced in the State ten
years, or had passed a satisfactorj- examination as
to his qualifications, and which makes the prac-
tice of medicine without such certificate a misde-
meanor, is a constitutional regulation, and does
not deprive a physician who has practiced in the
State for six years before the passage of the Act j
of his liberty or property, without due process of
law. There is no such ' 'vested right' ' or ' 'estate' '
in a profession that the State can not at any time
impose upon its exercise such reasonable and ap-
propriate qualifications as are demanded by the
public welfare. Dent v. West Virginia, 9 Sup.
Ct. Rep. 231. (The court distinguish Cummings
V. Missouri, 3 Wall. 277, and ex parte Garland,
lb. 333, as being cases in which the alleged qual- '
ifications were, in reality, penalties imposed for
past acts, and not reasonable qualifications im-
posed upon the exercise of professional callings. '
Thiese decisions, it is said, merely decide that
preachers and lawyers ' ' can not be deprived of
the right to continue in the exercise of their re- 1
spective professions by the exaction from them
of an oath as to their past conduct respecting
matters which have no connection with such
profession").

FOREIGN,

A Benevolent Empress. — The Empress of
Japan takes a great interest in the welfare of her
suffering subjects. In a year she has contributed
$7,500 out of her "pin money" to assist the
Tokio Female Hospital in its good work.

The Plague in Arabia. — The south-west
coast of Arabia, bordering on the Red Sea, is
again the situation of a reported recurrence of
the plague. The Lancet of July 20, states that
active sanitary measures will be enforced to pre-
vent the spread of the disease. The dates of
former visitations of the plague, at this locality,
were 1853, 1874 and 1879.

In France an association " for the protection
of the interests of the medical press," has re-
cently been founded in Paris. The Chamber of
Deputies, on a proposition made bj' Dr. Javal,
have decided to exempt the fathers and mothers
of seven children from personal or house taxes.

In Germany five years is to be the obligatory
period of medical study, including the term of
military service. Prof. Engler, of Breslau, has
been appointed to the chair of Botan}' in Berlin
University. Dr. von Gossler, Prussian Minister
of religion, education and medicine, desires to
revive the study of the history of medicine in
the Prussian Universities. Dr. Stahl, Professor
of Botany at Jena, will leave for Java in Oc-
tober, to make botanical researches there.

In Great Britain, Prof. Robert Bentley, the
venerable and able instructor in botany and
materia medica has withdrawn from active labors.
The British Pharmaceutical Conference meets at
Newcastle-on-Tyne, on September 9. The Royal
College of Physicians will cooperate with the
Father Damien Memorial Committee. Surgeon-
General Galbraith died at Cairo on the 31st ult.
The Milroy Lectures on State Medicine will be
delivered next j'ear by Dr. Ransome, of Man-
chester, the Goulstonean Lectures by Dr. G. N.
Pitt, the Lumleian Lectures by Dr. Hughlings
Jackson. The Croonian Lectures for i8go, will
be given bj' Dr. Ferrier ; those for 1891, bj' Prof.
Burdon Sanderson. Dr. Macon, Master of the
Rotunda Hospital, has been elected King's Pro-
fessor of Midwifery in the University of Dublin.
The medical schools of Dublin are about to
amalgamate.

278

TOPICS OF THE WEEK.

[August 24,

TOPICS OF THE WEEK.

THE FUNCTIONS OF PROTOPI.ASM.

The Crooniau Lectures delivered duriug the present
year by T. Lauder Brunton, M.D., before the Roj'al
College of Physicians of London, are so eminently sug-
gestive, and so replete with instruction, that they com-
mend themselves not only to the reading, but to an
exhaustive study, by all those who seek bv means of
physiological research explanation of the specific ac-
tions of remedies.

We quote from his third lecture, contained in the
British Medical Journal, his observations, with refer-
ence to cell movement, cell respiration, and its relations
to temperatures :

1 . Movements of Cells. — On observing isolated cells,
such as the leucocytes of the blood, we can see that they
are endowed with life, and will continue to move about
on the stage of the microscope as independent organ-
isms for a considerable time after the death of the animal
from which they have been taken. Their movements are
of two kinds, viz., one of simple contraction or exten-
sion of the protoplasm in various directions, while the
cell remains in its place, and secondly, movements from
place to place. I call your attention specially to those
kinds of movement because both are probably of practical
importance. The movements from place to place eti-
able the leucocytes, as was first observed by Addison and
then bv Waller, to move out of the blood-vessels. The
importance of this diapedesis, and of the further move-
ments of the leucocyte amongst the cells of the tissues
has been clearly demonstrated by Cohnheim and his
followers ; but it seems probable that movement of the
protoplasm in a cell while it remains in situ may be no
less important.

2. Respir.\tion in Cells. — Kiihne showed that iso-
lated cells have the power of absorbing oxygen, by placing
them under the microscope in water containing a little
oxy-hsemoglobin. After a while they absorbed the
oxygen from the haemoglobin and reduced it. This re-
duction was discovered by looking at the solution \\ ith
the microspectroscope, and noticing that it gave the band
of reduced haemoglobin instead of oxy-ha:moglobin as at
first. The experiments of Ludwig and his scholars upon
circulation through single organs or parts of the body i
isolated from the rest, and also those of Pfliiger and his
school upon the gases of the blood, have shown that o.xi-
dation and reduction occur in the tissues, but that the
amount of each is not always the same, oxidation being
sometimes predominant, and, at other times, reduction.
Similar results have been obtained in living men by ;
Pettenkofer and Voit. It was found by Harley that the
absorption of oxygen and the elimination of carbonic
acid by blood could be altered by admixture with various
poisons. The power of quinine to lessen such processes
was not only discovered by liinz, but brought by him into
close relationship with the antipyretic power of the drug,
and his researches formed a starting point for numerous
investigations into the action of antipyretics generally.

In the admirable lectures which he gave before this

college last year, Dr. MacAlister gave such a complete
account of the pathology of fever that I need not do
more here than just recapitulate one or two of his chief
conclusions.

Increased temperature may depend upon (a) lessened
loss of heat by radiation or conduction, or (b) increased
formation of heat by greater oxidation in the tissues, and
especially in the glands and muscles. The oxidation by
which heat is formed in these tissues is regulated by two
or three nerve centres within the cranium. Antipyretics,
he informed us, appear to lessen oxidation within the
body and diminish the formation of heat by stimulating
these centres, but he did not discuss the mode in which
stimulation of the thermal centres alters the processes of
respiration in the tissues, and thus lessens oxidation.
This point of the question I propose to take up now, but
before I can deal with the action of drugs as antipyretics
I must ask your attention for a short time to some ob-
servations which have been made upon the respiratory
functions of the cell.

3. O.xiDATiON .\ND REDUCTION. — From such experi-
ments as those I have already mentioned, it has been
known for some time that cells possess the power of tak-
ing oxygen from the air, from liquids containing it in so-
lution, or from substances like haemoglobin, which con-
tain it in a loose state of combination. To this power of
removing oxygen from other things the term " reducing "
is given, while that of "oxidizing" is applied to the
power of giving off oxygen to other substances.

Double Action of Hinnoglobin. — Some bodies, like
hamoglobin, possess both powers to a large extent. A
solution of haemoglobin mixed with air absorbs the
oxygen from it, and thus has a reducing action, but if
this oxidized haemoglobin be then mixed with some fer-
rous sulphate it gives up the oxygen to it, oxidizes it, and
forms ferric sulphate. It thus loses its o.xygen and be-
comes reduced, the ferrous sulphate having acted upon
it as a reducing agent.

Comparative Degrees of Affinity for Oxygen. — Sub-
stances differ in the degree of affinity which they have
for oxygen, it being greater in some and less in others.
Thus it happens that we might draw up a scale containing
a number of bodies each of which would have a greater
affinity for oxygen than the one above and less than the
one below it. Each one would therefore abstract oxygen
from the one above it, and act as a reducing agent
towards it, while it would give up oxygen to the one be-
low it, and thus act as an oxidizing agent. — British Med-
ical Journal, June 29, 1S89.

ANTISEPTIC MIDWIFERY.

In the August number of the American Journal of
Medical Sciences, Dr. Henry J. Garrigues, of the New-
York Maternity Hospital makes special reference to the
use of corrosive sublimate and creolin in obstetrical
practice.

As the result of extended research he is able to cite
twenty-two cases in which the use of corrosive .sublimate
has been attended with fatal results. In the majority of
these cases he is confident that a too strong solution was
used. He recommends that the solution be made \ : 5000

1889.]

TOPICS OF THE WEEK.

279

as yielding the necessary antiseptic action, and less dan-
gerous to the patient.

He speaks secondly of creolin as one of the latest anti-
septics, and highly recommends it for thorough trial. It
is obtained from English coal, and has the color, consis-
tence and smell of coal tar, and up to 12 per cent, it forms
an emulsion with water.

It is rated as second only to bichloride of mercur}- in
antiseptic value, a 3 per cent, solution being fatal to
germs in one minute. A 3 per cent, solution causes no
unpleasant sensation upon the skin, but a 5 per cent,
emulsion causes a feeling of smarting. Solutions of ^
to 2 per cent, are well borne upon mucous surfaces. Ap-
plied in this strength to indolent ulcers it cleanses the
wounds, stimulates granulation and healing, often when
all other substances had failed. It leaves the surface to
which it is applied soft and pliable; and a point of special
importance in its use lies in the fact that it is nearly if
not entirely innocuous. The following are his conclu-
sions as to the use of these two articles:

1. The solution of bichloride of mercury- used for vagi-
nal and intra-uteriue injections ought not to be stronger
than 1 : 5000. .

2. No more than i^i quarts should be used.

3. The fluid should be removed from the uterus and
the vagina.

4. No injections should be used in normal cases after
the birth of the child.

5. Intra-uterine injections should not be given oftener
than once or twice in twenty-four hours, vaginal every
three hours.

6. The symptoms aud signs of absorption should be
constanth- looked for and the use of bichloride discon-
tinued at their first appearance.

7. The S3-mptoms and signs of abortion should be care-
fully looked for and the use of bichloride discontinued
at their first appearance.

8. It is safest to abstain from the mercurial injections
altogether until experience shows that the corrosive sub-
limate gives better results than any other antiseptic.

9. Corrosive sublimate should be used for disinfection
of the outer surfaces of the patient, for the hands of
doctors and nurses and for materials brought in contact
with the patient.

10. Carbolic acid is perhaps as dangerous an injection
as corrosive sublimate.

11. Other less effective germicides may occasionallv
answer a good purpose.

12. Creolin is an excellent antiseptic; little poisonous,
a powerful haemostatic, and makes all surfaces slippery
— properties that recommend it especially in obstetrical
practice.

ACUTE ARTICULAR RHEUMATISM.

In the treatment of this disease Dr. H. Linderborn
thinks that sodium diosalicyate No. II is destined to sup-
plant the use of salicylate of soda. " The dithosalicylic
acids Nos. I and II are two isomeric bodies, each of which
consists of two molecules of salicylic acid linked together
by two molecules of sulphur. No. II (sodium salt) is a grey-
ish-white powder, very hygroscopic, and easily soluble

without residue in water, .\ccording to Hiippe, a 20 per
cent, solution kills anthrax bacilli in forty-five minutes, in
which time the ordinary saliej'late has no perceptible ef-
ect; similar!}- with other bacteria. Four cases of poU-artic-
ular and one of the monoarticular rheumatism were treat-
ed, also one of gonitis gonorrhica complicated with iridio-
choroiditis ; the dose was 0.2 gram (3 grains) morning
and evening — oftener in the more severe cases. The
slighter cases showed disappearance of joint-swelling,
pain, and fever in two days, the more severe cases in six
days. One case was a relapse after salicylate treatment ;
nausea and noises in the ears were complained of, severe
sweating occurred only when 0.8 gram (12 grains) were
taken^;'<7 die. The last mentioned of the above cases was
from another hospital, and the patient left cured in ten
days. The advantages of this drug over salic3date acid are:
stronger action, therefore smaller doses ; tolerance by
the stomach (the insoluble dithiosalicylic acid is precipi-
tated from the sodium salt in an acid solution); and ab-
sence of unpleasant after-effects. — British Medical Jour-
nal.

GASTRIC MrCOrS MEMBRANE.

The power of reproduction with which the mucous
membrane of the stomach is endowed seems wellnigh in-
credible. Prof. L. Griffini and Dr. G. Vasalle, after
a series of experiments upon fifteen dogs, formulated the
following conclusions:

1. The mucous membrane of the fundus of the stom-
ach, removed in dogs, for a considerable extent and in
its entire thickness is always reproduced, including the
peptic glands.

2. The newly formed glands are developed from the
new epithelial layer which in the beginning covers the
wound. This epithelial layer itself is developed from
the epithelium of the glands on the borders of the wound,
thus demonstrating the possibility of the development of
an epithelial layer in its totality from true glandular epi-
thelium.

3. The pepsin cells of the newly formed tubular glands
are developed in the beginning through a differentiation
of the cells of the tubular glands themselves, and this
formation originates in the bottom of the tubules, whence
the cells are pushed upward.

4. The reproduction process of the peptic glands finds
its exact prototype in the process of embryonic develop-
ment.

5. The reproduction was quite rapid in all the animals,
which were strong and healthy and placed amid favor-
able surroundings. In one case the development was
tardy, owing to a considerable loss of tissue (6 cm. equals
2.36 in.) and an unsuitable diet.

6. Perforation of the wall of the stomach never fol-
lowed removal of the mucous membrane, even though
the muscular tunic had been seriously injured. — Deutsch.
Med. Zeitutig, May 9, 1889 ; The Medical Bulletin.

renal DIURETICS.

Dr. Germain See is studying another group of diuret-
ics, which he calls "renal diuretics." They consist of
caffeine aud theobromine.

28o

SOCIETY PROCEEDINGS.

[August 24,

SOCIETY PROCEEDINGS.

Xe'sv Yoi'k; Academy of Medicine.

Section on Orthop.bdic Surgery.

Stated Meeting, March 75, i88g.
A. B. JUDSON, M,D., IN THE Chair.

CICATRICIAL CONTRACTION OF FINGERS.

Dr. a. M, Phelps presented a patient on whom
Tie had operated four weeks ago for restoration of
motion to the fingers, which had been flexed in
the palm by a cicatrix in the wrist of eight years
standing. He had freed each tendon from the
•cicatricial tissue, and had secured healing by
blood-clot, with the hope that new sheaths would
be formed in the clot. The wound was dressed
antiseptically, and the first dressing was changed
at the end of three weeks. The prospect of re-
covery of motion was good.

Dr. R. H. S.ayre said that Paget had long
ago recognized the organization of blood-clot af-
ter subcutaneous tenotom}'. The case presented
hy Dr. Phelps shows that advantage can be taken
of it after open incision under antisepsis.

hysterical equino-varus.

Dr. N. M. Shaffer presented a patient, a girl
of 12 years, who had been affected for ten weeks
with hj^sterical equino-varus and rhythmical
movement of the left foot. The talipes was re-
duced manually, but the motions were persistent.
There was inability to walk, the result of the
disability of the quadriceps extensor group. Be-
fore coming under Dr. Shaffer's observation, plas-
ter-of-Paris had been applied to the limb for sev-
eral weeks, but without benefit.

Dr. a. B. Judson thought that choreic elements
were seen when the patient attempted to walk.
He recalled a ca.se of rhythmical myoclonus re-
ported b}^ Dr. Peckham in the Archives of Medi-
cine, in 1883, in which the patient had been sub-
jected to a great variety of treatment, and finally
recovered after the hypodermic use of atropin.

Dr. vS. Ketch suggested treatment by hyp-
notism.

Dr. R. H. Sayre thought that the ca.se illus-
trated the fact that abnormal muscular contrac-
tion can produce degrees of deformity as marked
as tho.se caused by bony distortion.

Dr. L. W. Hubbard thought the case allied
to chorea, being the result of nerve irritation or
exhaustion. He suggested absolute rest or re-
cumbency for a long period, with efforts to im-
prove the nutrition.

Dr. a. vS. Hunter had treated with success a
case of hj'Sterical hip by the administration of
ignatia amara. The u.se of this drug in a num-
ber of cases of this kind had led him to value it

highly when the disturbance was limited to
groups of muscles only ; but he thought it was of
little value in the treatment of general choreic
conditions.

Dr. V. P. GiBNEY had had a favorable effect
in a case of rotary spasm of the neck, from the
fluid extract of gelsemium, given in five minim
doses, and pushed almost to toxic effects.

Dr. H. W. Berg said that the contractions in
the case shown could not be due to ner\'e lesion,
because it yielded so readily to manual replace-
ment. Where there is irritation of motor nerves,
as in spastic paralysis, it is extremel}^ difficult to
reduce the limb to a proper position. He sug-
gested the ordinarj' treatment of chorea with elec-
tricity to make an impression on the mind rather
than on the nerves.

The paper of the evening was read by Dr.
Phelps, entitled

THE management OF HIP-JOINT DISEASE FROM
AN ANATOMICAL BASIS.

In regard to the pathologj' of hip disease, Dr.
Phelps believes that it is a local tuberculous af-
fection, due to accidental inoculation and not to
a constitutional or strumous condition. Follow-
ing ^'■olkmann, Albert, and Konig, he believes
that the inflammation, at first simple, becomes
tubercular by inoculation, and then purulent.
The irritation of the peripheral extremities of the
nerves in or about the joint produces muscular
spasm, which in turn distorts the joint by trauma,
aided by the bacilli of tuberculosis.

In regard to treatment, he relies on mechanical
treatment, believing that if we immobilize a joint
and remove the intra-articular pressure. Nature
will take care of the tuberculous material. His
experiments on dogs had convinced him that im-
mobilization of healthy joints does not produce
anchylosis. Encouraging motion in an inflamed
joint is a violation of the surgical law that an in-
flamed part requires rest. He believes that the
muscular spasm, which is a most serious element
of destruction, should be overcome by extension,
and that while extension is necessary to secure
immobilization, it is not sufficient of itself. He
therefore resorts to a combination of extension
and fixation ; the e.xtension always to be in a line
corresponding to the axis of the neck of the
femur.

Treatment, as a rule, should be begun in bed,
extension being made in two directions, /. e.,
toward the foot-board and laterally, the body and
well leg being fixed to a long splint extending to
the axilla. If the deformity does not yield to
extension properly applied, the tissues at fault
should be divided subcutaneously, or by open in-
cision. Abscesses are to be incised through their
entire length, and thoroughly .scooped out and
washed, strict antiseptic precautions being ob-
served. Distension of the capsule should be re-

1889.]

SOCIETY PROCEEDINGS.

281

lieved bj' aspiration or incision ; then traction
■will not produce pain.

He exhibited a patient in a portable bed, which
is an ingenious substitute for the wire cuirass,
made with a board cut in an outline of the body,
and plaster-of-Paris. The child is laid on the
board, and then the whole enveloped with plas-
ter-of-Paris bandages from the foot to the axilla.
The plaster is then cut awa}' in front, the interior
comfortably padded, and the patient held in place
by lacings or bandages. Extension and fixation
in bed are to be continued until the active symp-
toms and the deformity have entirely disappeared,
and the spasm of the muscles is no longer pres-
ent. Adults are then given crutches, and a por-
table splint which has a perineal crutch, extension
bj' adhesive plaster, an abduction bar, and an
upper (thoracic) ring to prevent flexion and ex-
tension at the hip. Children, after treatment in '
bed, are to have the portable bed, and then the
portable splint, with or without the high shoe
and crutches.

Dr. J. RiDLON was much pleased to hear the
author of the paper take the ground that hip
cases should be cured without deformity. He
recalled a case of a patient in which the muscular
spasm had been relieved by pinching the muscle.
The child was very thin, and it was found that
when the adducters were separated from the
other muscles, and the bell\- of the muscle was
pinched without an)- attempt at fixation, there
was as much relief as could have been afforded
by lateral traction.

Dr. Shaffer said that the paper had sug-
gested to him the importance of .separating in
our minds the disease from the deformit}-. It is
a question how far we are justified in meddling
with the deformity, which is simplj' an expres-
sion, or so to speak, a symptom of the disease.
In his experience, attempts at speedy reduction
■of the deformitj- had been followed b)- disastrous
results. Nature gives a verj' positive indication
in the acquired position of the thigh — that in
which the immobilization of Nature reaches its
maximum, and the diseased parts receive the
greatest relief from reflex muscular spasm. If
Ave forcibly interfere with this effort on the part of
Nature, we inflict a distinct traumatism.

On the threshold of treatment, the important
question is, not whether traction is to be made in
the line of the shaft or the neck, but how to se-
sure an artificial immobilization in the position
nature assumes as the one that affords the most
protection to the inflamed parts. He believed
that if the joints were protected from traumatism,
in other words, if traumatic contact of the in- 1
flamed joint surfaces is removed, and this can
readily be done by the use of portative apparatus
without entailing immobilization of the entire
bod}' from the head down, the joint is placed in
the best known local condition.

The portative traction treatment is compatible
with fresh air, sunlight, and moderate exercise,
which are the best means of combating the
tubercular disease, and the tubercular diathesis.
More lives have been saved, and better results
have been thus secured, than by any other method
which has been thoroughly tested.

Dr. R. H. Sayre agreed with Dr. Shaffer as
to the importance of maintaining the general
health, and the inadvisability of general immobi-
lization of the body, if the diseased joint could
be controlled without it. He thought that com-
plete immobilization of the hip-joint in young
children was very difficult to secure ; and that
the movement that stopped short of producing
muscular spasm and pain, was not harmful.
For poor children particularly, he thought the
portable bed was an admirable contrivance.

The relief obtained in some cases by pinching
the muscle could be explained on the supposition
that it stopped the reflex action of the muscle.
It is known that firm constriction of the bellj- of
a muscle will, in certain cases, abolish spasm.

Dr. Chas. L. Scudder, of Boston, advocated
a more frequent resort to the results of experi-
ment on the cadaver. He recalled Dr. Bradford's
experiments made in 1880, in which it was found
that in an adult a force of one hundred pounds
was not sufficient to .separate the head of the
femur from the socket ; while in the shallow and
not j-et completely ossified acetabulum of a ^-oung
child, a moderate force caused separation, and
still less force was required in the fcetus. Dr.
Scudder believed that in hip disease of children,
a tractive force of from three to five pounds
would separate the joint surfaces as was illus-
trated at the Children's Hospital in Boston, in
the case of a joung boj^ who had hip disease and
night cries. The joint cavity was opened and a
small quantit}' of pus evacuated. While the boj-
was under ether, it was found that traction made
with the hand separated the joint surfaces to such
an extent that the finger could be placed between
the head and the acetabulum.

Dr. Hubbard thought that no one at the present
time held the opinion that anchylosis is caused by
immobilizing the joint affected with chronic in-
flammation. He had found it difficult to get
anchylosis in cases where it was desirable, as in
disease of the knee. The first object is to give
rest to joint, which is best done b)- traction ; not
to separate the surfaces, but to overcome articular
pressure which leads to muscular spasm. He be-
lieved the long hip splint gave sufficient im-
mobilization for all practical purposes. It is
more easily managed than the portable bed of
Dr. Phelps, which from neglect would be likely
to cause excoriations. As the disease seems to
be a struggle between the tubercle bacilli and the
vitality of the organism, he thought it especiall}-
important to place the system in the best possible

282

SOCIETY PROCEEDINGS.

[August 24,

condition to resist attack. He had rarely seen
constitutional disturbance from abscesses which
had been let alone, although in exceptional cases
acute and painful conditions are certainly greatly
relieved by surgical interference.

Dr. Judson commended the title of the paper.
It was an admission that hip disease is not to be
cured by treatment, but so managed that the
almost inevitable recovery by natural processes
should be with the minimum of disability and
deformity. He thought that more emphasis
should be placed on the importance of protecting
the joint from the traumatisms of standing and
walking, as is done by the use of Hutchison's
extra long crutches and high sole on the well
foot. But in every case there are long periods of
exemption from pain, when this simple apparatus
will be discarded. The ischiatic or perineal
crutch of the hip splint, however, cannot be
willfully discarded ; and when it is seen that the
rack and pinion not only furnish traction, but
also a convenient means of adjusting the length
of the upright, the hip-splint appears to come
very near perfection as an instrument for the
management of hip disease. He had never rec-
ognized either the trauma said to be caused by
reflex muscular contraction or the alleged me-
chanical counter- action of the muscle by traction.
He believed, and had alwaj-s held, that the hip-
splint mitigates reflex muscular contraction by
allaying the inflammation which gives rise to it.
This it does by arrest of motion and prevention
of pressure ; motion being arrested by traction
brought about by the use of the key, and pres-
sure being averted by the perineal or ischiatic
crutch, which makes the limb a pendent member.
As the inflammation is resolved the reflex muscu-
lar contraction ceases.

The last annual report of one of our ortho-
paedic institutions contains a table, from which it
appears that there have been under treatment
371 cases of di.sease in the hip ; 6 in the shoulder;
85 in the knee ; 3 in the elbow ; 27 in the ankle ;
and 5 in the wrist ; an aggregate of 4S3 in the
lower, and 14 in the upper extremit}\ Shall we
draw the inference that the incipient osteitic
focus is found only or chiefly in the cancellous
tissue of the lower extremity, or that a focus in
the upper extremity more readily undergoes reso-
lution by reason of its comparative exemption
from violence ? If the latter view is correct, it
follows that the limb is to be made a pendent
member by the persistent u.se of the axillary or
ischiatic crutch at the earliest recognition of the
disease. In some ca.ses, an earlier diagnosis may
be facilitated by the following simple method :

Let the patient sit on a table with the legs hang-
ing and the knees separated ; in this position,
swinging the leg laterally is po.ssible only with
rotation of the femur ; and if one leg oscillates
in a less arc than the other, it induces or con-

firms a suspicion of the integrity of the joint.
He did not believe in treating abscesses and
sinuses excepting indirectly through the general
and local management of the bone disease in
which they have their origin.

Dr. Gibney was in favor of securing absolute
immobilization, but sometimes he would rather
have less perfect immobilization, if by so doing
he could secure a change of air and climate, with
the consequent improvement in the general nu-
trition.

Ordinarj^ hip disease is managed satisfactorily
by the portable traction splint, with or without
the rack and pinion ; and he had been agreeably
surprised with the facility with which the.se pa-
tients ran around in the tenement houses. They
come to his clinic onlj- every three or four weeks
for adjustment of the apparatus ; and, during
these intervals engage in the most active sports ;
they certainly do not lie in bed in dark rooms
and die of pysemia. It is unsafe to put these
children in an appliance like a cuirass or the
portable bed, unless one is certain of being able
to see and attend to them at short interv^als. It
had been his lot to see cases in which he had
been unable at times to obtain proper co-opera-
tion on the part of the patient's family. He had
often seen abscesses burrowing up to the spinal
column and down to the knee ; and such cases
seemed to baffle even attempts at surgical inter-
ference. We must be guided a good deal by cir-
cumstances, and if we can protect the hips from
trauma and give the patient the benefit of out-
door exercise, abscesses will generally be insig-
nificant.

He believed in correcting the deformity speedily,
if necessary by dividing tendons and bone under
an anaesthetic ; for by so doing, we save much
time and lose nothing. In regard to aspirating
the joint over-distended with fluid, it was almost
impossible to diagnosticate an over-distended
hip-joint. The position of the limb does not de-
pend on the quantity of fluid in the joint, but is
due to reflex spasm, and the efforts made bj- the
child and nature to secure fixation.

Dr. J. H. GiRDNER described an experiment
on the cadaver in which great force was applied
without separating the surfaces of the hip-joint.
He also cited a case in which it had been neces-
sar\' to keep the hand applied to the face for nine
weeks in the course of a plastic operation on the
nose. At the end of this time, there was no
limitation in the motions of the elbow and wrist.

Dr. Ketch believed that hip disease is so
often characterized by exacerbations that all at-
tempts at a division into stages are of no practical
value. He thought that the hip-splint could be
often of use for the reduction of deformities even
in those periods when the patient is confined to
his bed. In general, he believed it was a great
mistake to make use of any apparatus which can

1889.]

FOREIGN CORRESPONDENCE.

283

be entirely left to the care of the patient or family
for long periods. The explanation of the relief
of pain bj- compression of muscles was to be
found in an involuntarj' action on the part of the
patient which secures fixation and traction at the
same time.

Dr. Berg, speaking from the standpoint of the
general practitioner, who frequenth- saw children
in the very beginning of hip disease, related the
histories of three cases which had presented the
symptoms of early hip-joint disease, and yet re- '
covered perfectly after rest in bed for a few weeks. ,
He now insisted on all such patients remaining
in bed for several weeks before commencing any j
other treatment.

Dr. Phelps, in closing the discussion, said '
that many cases in tenement houses, whether
treated by the long traction splint or by the por-
table bed, are deplorably neglected; but this does
not argue against the use of either apparatus ; it
simply illustrated one of the difficulties with
which all practitioners have to contend. He
valued the portable bed because he desired im- j
mobilization Of the affected joint, and this could
not be obtained witli splints having joints in
them, and not including the trunk. He could
relieve his patients better in bed during the
period of deformity, and so adopted this method
of treatment. He had seen patients in England
who had been in bed for several years, and were \
still in excellent health. He did not, however,
advocate prolonged bed treatment. Believing i
that the cases in question are inoculations of the ;
bacillus tuberculosis on a previously inflamed
surface, and not instances of constitutional tu-
berculosis, he explained the frequencj' of tuber-
cular joint diseases in the lower extremity, by the
statement that the joints of the lower extremities
being more subjected to traumatic inflammation,
furnish good ground in which the bacillus of
tuberculosis could more readily reproduce itself.
He had presented his honest convictions, and
hoped to report his cases later in such a way that
others could disprove his statements, or he could
substantiate his views. I

FOREIGN CORRESPONDENCE.

LETTER FROM LONDON.

(from our own correspondent.)

T/i£ Nature of Arro-w Poison — The Proposed In-
quiry into the Management of 3fetropolitan Hospi-
tals— The Action ofAntipyrin — Tubercular Abscess
of the Breast — The Aversion of sofne A^iimals to
Sacchari7i — Miscellaneous Items.

Some of our medical journals are di.scussing the
nature of the arrow poison which proved fatal to
several of H. Stanlej-'s followers during their mem-

orable journey from the Congo to Lake Nyanza.
Hitherto it has been asserted, with ver}' little evi-
dence in many cases, that all the arrow poisons of
savages have been extracted from vegetable sub-
stances. But according to Mr. Stanley's recent
experience ants are the source of the poison. Five
members of the expedition were hit by these wea-
pons and four black men died verj' shortlj' after-
wards, their sufferings having been intense. The
fifth man hit was a white man, and he had a very
narrow escape. The poison of the arrow which
hit him had become drj' and so he did not experi-
ence its full effects. It was afterwards found that
the poison is manufactured from the dried bodies
of red ants, which are ground to powder, cooked
in palm oil, and smeared over the wooden points
of the arrows. Some think that this poison must
consist of formic acid. Others argue that some
kind of ptomaine or animal alkaloid is thus ob-
tained from the dead ants ; but as these insects
are dried and pulverized and aftersvards cooked in
oil, it is difficult to see how any ptomaine could
be formed, for these animal alkaloids are the prod-
uct of putrefaction, and it is not stated that the
ants are allowed to putrefy. Hence it is not im-
probable, as The Lancet was the first to suggest,
that the terrible poison of these arrows is formic
acid or some organic derivative of that acid, more
or less allied to prussic acid.

The petition for an inquirj- into the manage-
ment and organization of metropolitan hospitals
has been energetically taken up by a verj' large
number of leading physicians and surgeons and
others who have special means of understanding
what is wanted. More than 450 medical men
have signed the petition, the great majority of
whom are professors, lecturers, phj-sicians and
surgeons actuallj' connected with hospital work.
There is realW most excellent reason to believe
that if our London hospitals and dispensaries were
onlj- organized proper!}- there would be no need
for the constant appeals for public aid in the form
of hospital shows, bazaars and other wasteful
means of raising funds. The petition draws spe-
cial attention to the glaring defects in our present
lack of system. Out-patient departments are gen-
erally gorged with a crowd of people suffering
from trivial complaints. Many of the applicants
belong to classes for which charitj- is quite unnec-
essar>'. Another great administrative flaw is the
total absence of au}^ clear and definite division of
labor between voluntary hospitals and dispensa-
ries and those provided under the Poor Law. A
scheme might be devised which would create spe-
cial relations between neighboring hospitals and
dispensaries, grouping them together, and provid-
ing means for the transference of cases from one
to the other. But supposing these points to be
satisfactorily settled, there will still remain the
most difficult and delicate task of all in dealing
with the sporadic establishment of unnecessary

284

DOMESTIC CORRESPONDENCE.

[August 24,

hospitals. It is absurd to allow the waste of
money which takes place everj' 3'ear by the foun-
dation of new special hospitals almost under the
shadow of great institutions in which whole wards
are lying idle for want of funds. None of these
difficulties are easy to deal with, and there can be
no doubt that a well chosen select committee will
be able to clear up much that is obscure and sug-
gest the outline of a better order of things.

Dr. C. R. lUingworth has published the follow-
ing important suggestion : He says antipyrin
has been lauded as a haemostatic. It is his opin-
ion that as such it acts by preventing the forma-
tion of fibrin so thoroughly and effectually that
there is less resistance to the flow through capil-
lary blood-vessels in the vicinity than into the
atmosphere, and more attraction. This power of
antipyrin and its allies, he suggests, should prove
serviceable in the treatment of sanguineous apo-
plexy, reducing the lesion to a minimum, and
rendering complete recovery possible in mau)^
cases if taken early enough.

An important paper was recently read by Mr.
Shattock on " Tubercular Abscess of the Breast."
In the course of the paper it was stated that in
the cow ' ' tubercle of the udder ' ' was a well
known disease, so much so that on the Continent
its hygienic importance was generally and practi-
cally recognized. Dr. Hamilton, a distinguished
Aberdeen professor, has expressed the opinion
that tuberculous milk from cows may often be the
cause of what is popularly known as " consump-
tion of the bowels." He cites a case of a per-
fectly healthy child, born of equallj' healthy pa-
rents, which was given to a wet nurse to be
suckled. The woman was tubercular and the
child verj' quickly contracted meningitis and died.
The nurse's milk, on examination, was found to
contain the bacilli of tubercle. Both Mr. Shat-
tock and Dr. Hamilton have been impressing
upon the public the necessity for always having
milk cooked before it is used. It is suggested
that the addition of a little sugar to the milk
when boiling gives it quite a new flavor, and
makes it more palatable than uncooked milk.
For those who do not like what is sweet, a pinch
of salt may be put in, and that again produces a
substance having a totally different taste from
plain boiled milk.

It has been discovered that animals such as
dogs and cats have a curious aversion to saccha-
rin. In .some experiments recently neither ca-
resses nor threats could induce them to eat bread
on which only a very small portion of saccharin
had been strewn. Water sweetened with small
quantities of saccharin, which was poured down
their throats was instantl)' vomited b}- them. In
another case a very small quantity of .saccharin
was mixed with the food of three cats which they
only received once a da)-. In each case tliey left
it absolutely untouched. In spite of their being

very hungry, as was quite evident from their cries
and movements, they did not meddle with the
food during four hours. After this food free from
saccharin was placed before them, which they
quickl)^ devoured, after they had sniffed it some
time. It is considered that these experiments
prove saccharin to have a peculiar odor which is
easilj' perceived by the animals mentioned, but
does not affect the human being.

The Bradshaw Lecture will be given this year
by Dr. Norman Moore, of St. Bartholomew's Hos-
pital. The subject chosen is " The Distribution
and Duration of Visceral New Growths."

Surgeon Parry, of the Indian Medical Depart-
ment, says he saw the jet black hair of a rebel
Sepoy turn grey in half an hour, while he was
under examination and half mad with fear, and
he also relates the case of a gentleman who left
home on his wedding tour with dark hair. When
he came back a month later his hair, his beard,
and even his eyebrows, had become snow-white.

A new clinical thermometer has appeared con-
structed with a layer of rubj- red or other colored
glass behind the bore, backed by a layer of opaque
enamel. By these simple means the contents of
the bore, as well as the divisions on the glass, are
more readily made visible.

The work on Diseases of the Lungs, which oc-
cupied the late Dr. Wilson Fox during many
years, is now in the press and will shortly appear.
It presents the thorough method which alwaj's
characterized the writings of this author. The
editor. Dr. Sidney Copeland, was one of Dr. Fox's
pupils. It will be in the hands of the public dur-
ing the autumn. A. B.

DOMESTIC CORRESPONDENCE.

LETTER FROM NEW YORK.

(from our own correspondent.)

T/ie NcTc Mausoleum Plan for the Disposal of
the Dead — Dr. John M. Pcacocke and Dr. A. N.
Bell diseiiss the subject — Executions by Electricity —
Dr. IV/n. A. Hammond and the B)0~un-Sequard
Elixir.

Of late the new mausoleum plan of disposal of
the dead has attracted considerable attention in
this city. The project seems likely to meet with
much favor both from sanitarians and the public
at large, and a company, in which many clergj--
men and physicians are interested, has now been
organized for the purpose of erecting suitable
buildings in the leading cities of the country-.
W'hile the objections to the prevalent mode of
di.sposal of the dead are generally recognized,
cremation meets with much opposition, and it is
believed that this new sanitary .system will be
widely adopted as a substitute for burial.

The buildings, each of which will contain from

1889.]

DOMESTIC CORRESPONDENCE.

285

ten to forty thousand sepulchral spaces, will be
constructed, in the most substantial and durable
manner, of concrete prepared from the best Port-
land cement, sand and broken stone. Concrete
is the basis, the corner-stone of the new sj-stem,
and without concrete it would not be practicable.
The sepulchral spaces will be constructed with
conduits conveying fresh drj- air into the casket,
whence it is carried by forced drafts to a central
furnace in the sub-cellar. To this furnace the
gases and vaporized fluids of the bod}- are thus
borne, and there consumed ; so that the escape
into the atmosphere of any noxious matter is
perfectly prevented. There are left behind the
mineral and solid parts of the body, in a properly
dessicated condition, with the form and features
intact, and wholly inoffensive to sight or smell.
The tissues become cellular and sponge-like as the
moisture is extracted, and while the weight of
the subject is reduced two-thirds at least, there is
no marked emaciation. The process was first thor-
oughly tested under the observation of the late Dr.
A. Y. P. Garnett, of Washington, who declared that
the principle of the new mausoleum was one of
scientific accurac}' reduced to a practical fact.
More recently the experiments have been con-
ducted in this city under the supervision of Drs.
C. I. Pardee and Rudolph St. Witthaus, of the
Medical Denartment of the University of New
York.

The mausoleum buildings will be of handsome
architecture, with granite facings, and the roof
constructed of glass and iron. The interior plan
will resemble that of a well-appointed library,
with a main corridor and diverging halls leading
to the different sections. The sepulchres of solid
concrete, four inches thick, seamless and jointless,
will be arranged in tiers of six upon either side of
the hallways, and the opening into each will be
provided with two doors ; the inner one of plate
glass, hermeticall}' sealed, and the outer one of
metal or stone, decorated according to taste.
Family vaults will be arranged in separate com-
partments of various sizes, and each mausoleum
will have a beautiful chapel. There will be no
possibility of stealing the dead, and the buildings
will be absolutely fire-proof.

In an elaborate paper on " The Disposal of the
Dead," read a short time since before the Medical
Society of King's County, Dr. John M. Peacocke
expressed himself as follows in regard to the pro-
posed new method : ' 'The dessicating process has
many commendable features. It complies with
all the sanitary requirements, and meets the
medico-legal demand that the evidence of crime
shall not be destroyed. The rapid abstraction of
moisture by this method will do away with the
factors in the production of ptomaines which
might vitiate the result of a cheraico-legal exam-
ination. This system is devoid of everj'thing that
can shock sensitive minds or offend refined tastes.

It does not conflict with the widespread and deep-
seated reverence felt for the remains of the dead.
The mass of mankind looks not only with aver-
sion but with feelings akin to horror on any pro-
cess that aims at immediate destruction of the
body. This may be all sentiment, nevertheless
no amount of specious reasoning can readily or
easily overcome the tender and universal defer-
ence for the beloved departed, for it is woven into
the veiy warp and woof of the human heart, and
has the religion, the tradition, and the custom of

centuries associated with it It

is evident that the introduction of any change in
the present method of disposal of the dead will
naturally encounter suspicion, criticism and oppo-
sition ; except in the case of the method of des-
sication, which seems to have been received, as
far as presented, with marked favor."

In the discussion of the paper Dr. A. N. Bell,
editor of The Sanitarian, stated that the single
sentiment to which he wished to give utterance
was, the necessity for so disposing of the dead as
not to endanger the life of the living. In the
course of his remarks he said : ' ' There is a propo-
sition now on foot to build grand mausoleums in
connection with or independent of the cemeteries,
as the case may be, where the sentiments of cer-
tain people can be gratified, if they do not wish to
bury their dead, or are prohibited from, as they
certainly should be in many cases, from burying
them so as to endanger the living, and are unwil-
ling to have them cremated. I mention this as
only one of the means of disposing of the dead
without danger to the living, because it overcomes
the objection which touches the sentimental
emotions of individuals «ho think cremation
lacking in sacredness, and too rapidly destructive.
. . . . But the new mau-soleum process fully
meets this sentiment, while it also overcomes the
medico-legal objection urged against cremation,
and, like it, effectually disposes of the dead with-
out danger to the living."

In the case of the murderer Kemmler, the first
criminal condemned to execution by electricity in
accordance with the new law relating to capital
punishment, the counsel for the prisoner some
time since obtained a stay of proceedings. They
claimed that the law was unconstitutional, on the
ground that death by electricitj^ is a " cruel and
unusual " form of punishment, and for more than
a month expert testimony has been taken before
a referee in regard to the effects of electricity upon
the animal economy. There can be little doubt,
however, that the chief incentive for the proceed-
ings to test the constitutionality of the law is the
objection of the electric light company whose ap-
paratus has been solicited for the execution of
crimiuals to having it employed for this purpose,
lest those using it for other purposes should get
the impression that the current is dangerous to
human life. The matter has in realitv resolved

286

DOMESTIC CORRESPONDENCE.

[August 24,

itself into an inquir}' whether, upon the whole,
the Legislature was justified in passing the law
in question ; and it is certainl)- a fact that if this
appeal is successful, capital punishment will have
been abolished, or at least suspended, in the State
of New York, since there is no warrant in the law
as it now stands for putting a man to death in
pursuance of a judicial process bj' any other
means than the application of electricity.

Still, the testimony obtained as to the efficiency
of the alternating electric current for the desired
purpose has been so conclusive that it seems alto-
gether probable that this attempt to prevent the
execution of the law will fail. Among the wit-
nesses examined was Dr. A. D. Rockwell, the
specialist in electro-therapeutics and nervous dis-
eases, who assisted in the experiments made upon
animals at the Edison laboratory before the law
was passed by the Legislature, and he unhesita-
tingly testified that, from his knowledge of the
subject and the experiments he had witnessed, he
believed that an electric current can be artificially
generated which will kill a man instantly and
painlessly in every case where it is scientifically
applied ; also that the electrodes can be so placed
upon a criminal in the apparatus proposed to be
used in electrical executions that there will be no
probability of his being burned. He expressed
his conviction that an alternating current of 1,000
volts would always destroy life, and in this opin-
ion he was confirmed bj- Edison, the electrician.
In regard to an alternating current of 1,500 volts,
such as it is proposed to employ in executions.
Dr. Rockwell stated that he had no doubt what-
ever that it would inevitably kill. Such a cur-
rent, he said, would of necessity produce a rup-
ture of the muscular tissues and immediatel}' stop
the action of the heart ; causing a paralysis of the
nerve centres.

Mr. Harold P. Brown, the electrical expert who
has contracted to furnish to the State the apparatus
to be used in executions, has recenth- arrived at
Auburn, where the prisoner Kemmler is confined,
and in the presence of Dr. Carlos F. MacDonald,
late Superintendent of the State Asylum for In-
sane Criminals, and others, he will make a series
of experiments with the identical apparatus which
it is proposed to use in the case of Kemmler. Mr.
Brown states that he has a list of no less than
ninet}' individuals who have been killed bj- con-
tact with electric wires. Twenty-seven of these
were killed by the alternating current and fifteen
by the Westinghouse dynamo, which is to be
used in the execution.

Dr. Wm. A. Hammond, who like most others
was at fir.st disposed to pooh-pooh Brown-Se-
quard's alleged discovery of the rejuvenating
power of the testicle, now announces that the
results of a number of experiments which he has
him.self made are .such as apparently to confirm
the correctness of Browu-Sequard's assertions.

In the experiments he used the testes of freshly
killed lambs, in preference to the rabbit or guinea
pig, emplo}-ed in France ; great care being taken
to thoroughl}' filter the solution employed in the
injections. He began his experiments first on
himself, to make sure that the method was not
dangerous to the patient. Since then he has ex-
perimented on several old men without their
being aware of what was being done to them,
and in the case of one of them, he states that the
result was quite remarkable. He was about 60
years of age and had his arm so nearh^ paralyzed
with rheumatism that for nearl}- a j-ear he had
not been able to raise his hand to his head; while
soon after one injection he could move it in any
direction and almost as vigorousl}' as he had ever
done. Of course. Dr. Hammond does not claim
anj' conclusive results with the limited number of
experiments thus far made, but he says he feels
justified in proceeding further with the investiga-
tion. P. B. p.

Audi Alteram Partem.

To the Editor. — In an editorial in the last issue
of The Journal which I have read with a great
deal of interest, you attempt to draw a compari-
son between the results of the medical and the
surgical treatment of acute intestinal obstruction,
and you claim that whereas 30 per cent, recover
after medical treatment, 68. 9 per cent, succumb
to surgical treatment. If you will permit me
to venture an opinion upon this subject, I would
suggest that you are not stating the proposition
fairlj'. You no doubt are aware that only those
patients are subjected to surgical treatment who,
in spite of the old and classical opium treatment,
continue to grow worse : and that operative inter-
ference is, as a rule, unfortunately delaj'ed till the
patient is greatly exhausted and his physician and
friends realize that death is inevitable without the
same. As in cases of intestinal obstruction, there-
fore, medical treatment is adopted at the very out-
set, and surgical treatment only resorted to after
medical treatment has failed, a comparison be-
tween the results is scarcely feasible. And yet the
statistics you adduce prove that, even under pre-
vailing circumstances, the results after surgical
treatment are slightly better than those of medi-
cal treatment. How much better they will be in
future, when we have learned the important lesson
that in order to prove successful, grave operations
have to be undertaken in "good season," can
onlj' be surmised.

I have noticed with a great deal of regret that
in recent editorials of The JorKN.\L an effort is
made to discourage grave operations, particularlj-
in obscure abdominal affections ; for every unbi-
ased physician will readily admit that especially
in abdominal affections operative interference has
been crowned with marvelous success, and that

1889.]

MISCELLANY.

287

thousands of lives are now saved that without |
such interference would be doomed to an earl^'
death. And I am persuaded that even today ten
lives are lost for the want of timely and early sur-
gical interference to everj' one sacrificed by an
unnecessary and premature operation. Within ,
the last year I have seen two patients with stran- !
gulated hernise die; in both cases the incarcerated
intestine had sloughed, and yet the attending phy-
sicians seemed to think that they had done their
duty to their patients by feeding them on opium
and letting them die.

Every practitioner knows how much a patient
dreads the knife and ho%v difficult it is, as a rule,
to obtain his consent to an operation which really
offers the only chance for his recovery. Every
one knows, too, how often even physicians dis-
courage operations, even in cases where they are
imperatively demanded, for no other reason than
that they are not prepared or unable to perform
the same.

It would seem that for these reasons it is of
questionable prudence for any prominent medical
journal to deprecate any operation which already
has saved many lives, and which will in the fu-
ture, as the technique of the same becomes more
and more improved, undoubtedly show a still
larger nercentage of recoveries.

H. H. ViNKE, M.D.

St. Charles, Mo., August 16, iSSg.

public hygiene led to his appointment as presi-
dent of the National Board of Health, a position
filled by him for several years with great ad-
vantage to the public service and to the cause of
sanitary science in this countrj'. He was the re-
cipient of many honors and a member of many
important societies, nearh- all of which profited,
from time to time, by the contributions of his
learning and ripe judgment. He was in his
seventy-sixth year at the time of his decease.

Dr. Alexander Mott.

NECROLOGY.

Dr. Jauies L. Cabell.

Dr. James L. Cabell, who died at Overton, Va.,
on the 13th inst., was one of the early members
of and a frequent contributor to the reports of
the American Medical Association. He was for
more than fifty years identified with the Uni-
versity of Virgina, in its department of medicine.
He was an alumnus of that University in 1833,
in arts. He obtained his medical degree at the
University of Maryland in 1834. He studied
abroad and at home, for three years, preparing
himself for the professorship at Charlottesville,
which came to him in 1837, when he was only
24 years of age. His first chair was that of
anatomy and surgerj'. He continued with the
University until the end of the session recently
closed, when he retired to make room for his
former pupil, Dr. Barringer, his health rendering
the step expedient. He was prominent in his
State RIedical Societ)*, and in the American Pub-
lic Health Association, becoming the presiding
officer of each in 1876 and in 1878, respectively.
He was Chairman of the Health Conference at
Washington, during the epidemic of yellow
fever at Memphis. His eminence in the field of

The readers of The Journ.\l will regret to
learn of the death of Dr. Mott, on the 1 2th of the
present month. He died at Yonkers, of pneu-
monia, after a sickness of two days. Dr. Mott
was a well-known member of a well-known fam-
ily. He was a son of Valentine Mott, the world-
renowned surgeon. Alexander Mott was born
in New York in 1826. Few surgeons were as
well known in New York up to i860, when he
organized the medical corps of the militia work.
He was commissioned a surgeon in the U. S.
Volunteers in 1862, with the rank of Major. He
founded the United States Army General Hos-
pital in New York, and about the end of 1864 he
became medical inspector of the department of
Virginia, and was attached to General E. O. C.
Ord's staff. Dr. Mott was at the memorable con-
ference between General Grant and General Lee
when the terms of surrender were arranged, and,
with the brevet of Colonel, was mustered out of
the service on July 17, 1865. He then resumed
practice in New York, and helped to found Belle-
vue Medical College, where he was Professor of
Surgical Anatomy and remained until 1872. He
leaves a son, Dr. Valentine Mott, who is also well
known in the medical profession.

MISCELLAINY.

Hygiene. — It is the province of hygiene to seek out
and determine the causes of disease, and to formulate
rules for their prevention and removal. It may thus be
called also preventive medicine. The progress of hygi-
ene, such as it was, rested for many ages upon an empir-
ical basis; and indeed, to a large extent, this is still the
case. The subject has, however, in later times at least,
been studied to considerable advantage, though much re-
mains to be done.

Two centuries ago the mortality' of London was So per
1,000; at the present day it is under 23. A century ago
ships could barely keep the sea for scurvy, while jails
and hospitals were in many cases the hotbeds of fatal
diseases. Now, these conditions are rectified, or at least
the means of rectifying them are known. Thirty 3'ears
ago the English troops at home died at the rate of 20 per
1,000, now their death-rate is less than one-half of this.
A knowledge of the causes and modes of propagation of
disease being necessary in order to provide rules for its
prevention, it is obvious that hygiene must be largely
dependent upon the advances made in pathology and

MISCELLANY.

[August 24, 1889.

etiology; hence the impossibility of any yearly marked

progress in former times, by reason of the imperfection
of the collateral sciences, and the want of the appliances
more recently made available for inquiries of such diffi-
cult and recondite character.

Within this century, however, and especially within
the last forty or fiftj- years, it has been possible to follow
out the subject on a more strictly scientific basis, and so
to lay a foundation at last on which to build a structure
which may one day entitle hygiene to a place among the
more exact sciences. — Plumber and Gasfitters' Review.

New York State !\Iedic.\i, Associ.\tion (Fifth Dis-
trict Br.\nch1. — The seventh special meeting of the
Fifth District Branch will be held in the Fowler House,
Port Jervis, at 2 p.m., on Tuesday, August 27. The fol-
lowing scientific papers will be presented: "Some Ob-
ser%'ations on the Use of Concentrated Lactic Acid," by
W. E. Eager, M.D.; " The Treatment of Typhoid Fever,
with special reference to the Cold Water Method," bv
J. H. Hunt, M.D.; "A Case of Empyema," by H. B.
Swartwout, M.D.

For those who ma)- desire to remain over night, a drive
to Mil.ford, Pa., to visit the Sawkill Falls I with supper at
the Fauchere House) has been arranged for. Friends of
the Fellows — both medical and lay — are cordially invited
to participate in this excursion. Ladies are especially
invited.

The total expenses for the whole trip, which includes
the railroad return ticket between New York and Port
Jervis, dinner at the Fowler House, drive to Milford and
return, supper at Fauchere' s and accommodations over
night at Port Jervis, will not exceed I6.50 for each per-
son. If there is a large attendance this amount will be
considerably reduced.

The latest arrivals of new remedies in this market
include wrightine, frequently mentioned in journals of
late, condurangin, kawain, from Kava Kava, and pyro-
techin, used by photographers. — Xotes on Xew Remedies.

Dr. N. Senn has been proposed for honorary member-
ship in the National Academy of Jledicine of Mexico.

The United States Hay Fever Association will
hold its sixteenth annual meeting on the 27th inst., at
Bethlehem, N. H.

SuivFONAi,. — Dr. T. Lauder Brunton says, in one of the
Croonian Lectures, that sulfonal appears to be one of the
most effective of all the newly introduced hypnotics, and
although it does not, like morphine, compel sleep, it in-
duces sleep in a pleasant manner and has few disagree-
able effects and little or no danger. Sulfonal has recently
declined in price.

An IniJants' Summer Hospital has been established
by the citizens of Rochester, N. Y., at Charlotte, on Lake
Ontario. Dr. E. M. Moore is President of the Associa-
tion, and Dr. Cieorge W. Goler is attending physician.
Any child suffering from intestinal trouble is treated free
of charge. There are accommodations for twenty pa-
tients, and many children who would otherwise have re-
ceived no medical treatment have been cared for. — N. }'.
Medical Journal

Wis. : Dr. Andrew J. Coey, Chicago ; Dr. F. Wertz, Jas-
per, Ind.; Dr. Chas. E. Sajous, Philadelphia; Thomas
Leeming & Co., New York ; Dr. R. Har\-ev Reed. Mans-
field, O.; Dr. Thomas Elliott, Worth, Tex'.; Dr. Harold
N. Moyer, Chicago ; Smithsonian Institute, Washington ;
Dr. Lachlan Tyler, Washington ; Subscription News Co.,
Chicago ; Dr. C. Eugene Riggs, St. Paul, Minn.; Dr. Jas.
Dudlev Morgan, Washington; Dr. C. H. Smith, Lebanon,
Ind.; Dr. O. H. Merrill, Corinna, Jle.; Dr. R. F. Sutton,
Deer Park, Md.; W. P. Clearv, New York ; Malted Milk
Co., Racine, Wis.; Dr. Wolfred Nelson, Pine Bluff", Ark.;
Dr. R. L. Brodie, Charleston, S. C; J. B. Lippincott,
Philadelphia; Nichols & Shepard, Three Rivers. Mich.;
British Medical Journal, London, Eng. ; Dr. J. M. Em-
mert, Atlantic, la.; Gaunt & Janvier, New York; Dr.
Wm. Bock, Fort Bidwell, Cal.; Dr. H. G. Chritzman,
Welsh Run, Pa.; Dr. J. E. Davidson, Unity Station, Pa.;
Dr. Benjamin F. Gibson, Midwav, Tex.; Dr. Wni. D.
Ruhl, Sheldon, Ind.; Dr. T.Walton Todd, San Diego.Cal.;
Dr. Wm. B. Atkinson, Philadelphia.

LETTER.S RECEIVED.

Dr. Pinkuev Thompson, Bowling Green, Kv.; Dr. F.
M. Haners, Buffalo, N. Y.; Dr. E. J. Mellisli, Is'hpeming,
Mich.; Dr. J. J. Bland, Hounia, Tex.; J. Walter Thomp-
son, I, H. Bates, New York ; Dr. J. M. Dunham, Colum-
bus,6.; Dr. J. H. Bennett, Coldwater, Mich.; Dr. J. F.
Thompson, Lexington, Kv.; Dr. .\. L. Hummel, Pliila-
delphia; Dr. D. V. Lincoln, Nantucket, R.I.; Dr. R. J.
Dunglison, Philadelphia ; Dr. IL Y. Ogden, Milwaukee,

Official List oj Changes in the Stations and Duties of
Officers Serving in the Medical Department, U. S.
Army,Jrom August 10, i88g, to August i6\ iSSg.

Major William H. Gardner, Surgeon V. S. Arm 3-, Wash-
ington Bks., granted leave of absence for one month.
Par. I, S. O. "183, Hdqrs. Div. of the Atlantic, Govern-
or's Island, New York Cit\', August 13, i8Sg.

Major Washington Matthews, Surgeon U. S. Army, pro-
moted to Surgeon U. S. Armj-, with rank of Major, to
take effect from the loth daj- of July, 1SS9, vice Tonn,
promoted. War Department, Washington, D. C, Au-
gust 14, 18S9.

By direction of the Secretary of War, a board of medi-
cal officers, to consist of Lieut. -Col. Anthony Heger,
Surgeon, Capt. John O. Skinner and Capt. James C.
Merrill, Asst. Surgeons, will assemble at the V. S. Mil-
itary Academy, West Point, N. Y., on August 25, 1S89,
or as soon thereafter as practicable, to examine into
the physical qualifications of the candidates for admis-
sion to the Academy. Par. 9, S. O. 1S5, A. G. O., .'Au-
gust 12, 1SS9.

By direction of the Secretary of War, Capt. Joseph Y.
Porter, Asst. Surgeon, now at Jacksonville, Fla. , will,
if the state of his health will permit, proceed to Jack-
son Bks., La., and report to the commanding officer of
that post for temporary duty, and by letter to the com-
manding General, Div. of the Atlantic. Par. 16, S. O.
186, A. G. O., .•August 13, 18S9.

Capt. Valery Havard, Asst. Surgeon U. S. Army, granted
leave of absence for one month, to take effect about
October I, 1SS9, with permission to apply to Division
Hdqrs. for an extension of one month. Par. 3, S. O.
So, Dept. Dak., St. Paul, .Aug. 10, 1SS9.

Official List of Changes in the Medical Corps of the U. S.
Navy for the Week Ending .-lugust ij, iSSg.

Surgeon B. F. Rogers, detached from U. S. S. " Alliance "
and wail orders.

Surgeon G. E. H. Harmon, ordered to the U. S. S. " Con-
stellation." August 13, 1SS9.

Asst. Surgeon C. H. T. Lowndes, ordered to the U. S. S.
"Constellation." .\ngust 13, iSSg.

Asst. Surgeon C. J. Decker, detached from V . S. S " Lan-
caster " and granted four months' leave of absence.

P. A. Surgeon L. B. Baldwin, lictached from U. S. S.
"Ranger," ordered home and wait orders.

Surgeon H. P. Harvey, ordered to the I". S. S. " Ranger."

P. .\. Surgeon P. \. Lovering, ordered to the receiving
ship "Wabash," at Boston Navy Yard.

Surgeon C. \. Siegfried, ordered to the naval station at
New London, Conn.

THE

J ournal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.
PUBLISHED WEEKLY.

Vol. XIII.

CHICAGO, AUGUST 31, 1889.

No. 9.

ORIGINAL ARTICLES.

ABSTRACT OF A PAPER ON THE

CHOICE OF TREATMENT OF

URINARY CONCRETIONS.

Read in the Section of Surgery and A natomy at the Fortieth An-
nua! Meeting of the American Medical Association, held at
Ne'i'port,June 2S, l88g.

BY JOHN W. S. GOULEY, M.D.,

SVRGEON TO BELLEVl'E HOSPITAL.

In the examination of the several modes of
treating urinarj' concretions, the question of their
indications and contraindications is worthy of
special attention, since adherence to a single pro-
cedure belongs to the medicine of a remote past.
Modem medicine demands that preventive meas-
ures be taken in threatened calculous affection at
the first sign of coming of hyperlithaemia ; that
when hyperlithuria exists, medicinal treatment be
resorted to; that when calculi are formed, mechan-
ical means be promptly applied for their removal ;
that when the calculi have been removed, the cure
be accomplished by suitable after-treatment ; and
that when mechanical treatment is contraindi-
cated, a judicious course of palliative treatment
be adopted. Therefore the treatment of urinary
concretions is now arranged into the preventive,
medicinal, palliative, mechanical and post-
mechanical treatment.

The preventive treatment embraces hygienic,
medicinal and mechanical means. The needed
hygienic observances comprise diet, exercise, ab-
lutions and raiment. The medicinal means of
prevention are directed against dyspepsia and in-
testinal and hepatic inaction. The mechanical
means of prevention are applicable to cases of
bladder injuries, of foreign bodies in the bladder,
and of stagnation of urine.

The medieinal treatment is applicable to cases of
persistent hyperlithuria, nephralgia, and verj' small
uric acid concretions, but is of no avail as a dis-
solvent of medium sized or even of small calculi.
It has long beeir supposed that alkalies taken by
mouth and excreted by the kidneys-act chemically
upon uric acid stones, forming soluble salts, and
so disintegrating these stones. Such, however,
according to Denamiel, is not the case. He be-
lieves that much good is accomplished by the use

of alkalies, that they act little, if at all, directly
upon the saline constituents of stones, but rather
upon their mucous cement, thus disgregating
without disintegrating the calculous particles and
rendering the stones inordinately friable. In
persistent h3-perlithuria, continuance of the me-
dicinal part of the preventive treatment, and the
use of solutions of salts of potash, soda, and
lithia — natural preferable to artificial solutions —
in moderate doses for two or three weeks ordin-
arily fulfil the indication of dissolving uric acid

i sand and of preventing the formation of stone,
besides relieving the irritation caused by the
sharp-pointed crj'stals. Soap pills, and potash
and soda solutions, long continued, greatly dis-
turb digestion and even tend to increase uric acid
formation.

The palliative treatment is indicated in patients
who are enfeebled by intercurrent disease or by
grave lesions of the urinary organs caused by the
presence of a stone which cannot be safely re-
moved, and comprises medicinal and mechanical
means designed to mitigate pain and prolong
life. In such a case the failing strength of the
patient is supported bj- suitable food and mild
stimulants. The teasing spasms of the bladder
are relieved by the judicious use of belladonna,
and the pain assuaged by opium. Much comfort
can be obtained from cleansing the bladder with
acidulated warm water, which tends to counteract
the bad effects of ammoniacal urine ; from occa-
sional vesical injections of mucilaginous decoc-
tions ; and, in the case of phosphatic calculus,
from irrigations with acetate of lead solution,
which maj' cause such a decrease in the volume
of the stone as materially to mitigate the suffer-
ing. Hot fomentations to the hypogastrium, hot
hip baths, posture, etc., and all useful adjuvants.
. The meehanieal treatment consists in the appli-
cation of means adapted to the removal of calcu-
lous concretions by the natural route to the blad-
der or by an accidental or an artificial route to
the urethra, bladder, ureter or kidney, according
to the particular exigency.

Preparatory treatment is needed in the great
majority of cases. The required instruments are

j rendered aseptic, and all operations are performed
with antiseptic precautions, even simple cathe-
terism.

290

TREATMENT OF URINARY CONCRETIONS.

[August 31,

For the purposes of surgeons the mechanical
treatment of urinarj' concretions is arranged into
lithecboly, lithexaeresj', litholysy, lithotomy and
lithotrity.

Lithecboly— the casting out of stone, stone ex-
pulsion — occurs spontaneouslj', but is often
brought about by artificial means, medicinal or
mechanical, generall}' by both combined. Dur-
ing spontaneous lithecboly the stone has been
known to perforate the renal pelvis or the ureter
and finally make its exit through the lumbar re-
gion, or enter the peritoneal cavity and cause
fatal peritonitis. It has made its way from the
bladder to the rectum, from the urethra to the
perineal or the scrotal connective tissue, sometimes
giving rise to the fatal infiltration of urine. There-
fore when spontaneous lithecboly has begun it
should be aided by judicious artificial means.

Lithexaeresy — the extraction of calculi — is re-
sorted to when the bladder contains small calculi or
fragments that can be removed by means of special-
ly constructed forceps, by the spoon lithotrite, and
also bj' hydro-pneumatic aspiration, or, when such
calculi lodge in the urethra, by means of forceps
adapted to the urethra.

Litholysy — the dissolution, or more properly
the decomposition of stones in the bladder — is
applicable only to phosphatic stones ; the agents
proposed for the dissolution of other stones being
of such a nature as to destroy the bladder before
acting upon the stone. They are therefore re-
jected. One of the most efficient methods of
litholysy applied to phosphatic stones is that sug-
gested by Dr. Hoskins, of Guernsey. It con-
sists of vesical irrigation with an aqueous solution
of acetate of lead rendered clear by the addition
of a trace of acetic acid. B3' this method there
is no di.ssolution, but a double decomposition, re-
sulting in the formation of an insoluble phosphate
of lead in an impalpable powder, and a soluble
acetate of the bases. Another method that often
renders much sendee in the case of phosphatic
gravel, or stone, is the daily irrigation of the
bladder with warm water, to which may be added
one minim, and sometimes two minims of hydro-
chloric acid to the ounce.

Lithotomy, in the sense of cutting for stone,
embraces nephro-, uretero-, cysto-, and urethro-
lithotomy.

Nephro-lithotomy means to cut open the kid-
ney for the extraction of a stone or several stones
lodged in a caly.K, in its pelvis, or in its substance,
whether the calculus or calculi fill the pelvis or
have partly obstructed the ureteric orifice and
caused pyonephrosis. The operation is generally
performed through the loin, and is indicated
when, medicinal treatment having failed, the dis-
tre.ss caused by the stone is unabated, the urine
continues to be purulent with occasional copious
admixture of blood and small calculi or particles
of the main calculus. When it has not been too

long delayed, nephro-lithotom5' has given good
results, and a very small mortality. The explor-
atory operations have not been mischievous
though many have been performed and no stone
found.

In the lumbar operation the renal pelvis is
sometimes directly opened without interference
with the substance of the kidney. In this case
the operation is stricth' a pyelo-lithotomy, rather
than a nephro-lithotomy.

Uretero-lithotomy maj' be performed in two
situations ; first, by a preliminary trachoelo-cyst-
otomy, when the calculus is lodged at or near the
lower extremity of the ureter ; second, in the
lumbar region, but in this region the diagnosis of
impacted calculus is attended with many diflBcul-
ties. If however it be made, it is possible to in-
cise the ureter longitudinally upon the stone, after
whose extraction the ureteric wound can be
stitched with very fine silk properly sterilized.
The objects being to prevent a lumbar urinary
fistula, and to avoid nephrectomy. It is also
possible to perform uretero-lithotomy near the
sacro-iliac synchondrosis through an incision such
as is made for ligature of the primitive iliac
artery.

Cysto-lithotomy has been performed in modern
times with much greater frequency than lithotrity,
partly because the indications and contraindica-
tions of these two operations have not been as
generally studied as they merit. There are too
many surgeons who perform exclusively cysto-
lithotomy or lithotrity, instead of striving to
adapt to individual cases the modes of treatment
which are most likely to meet their requirements.
This is probably owing to the fact that there are
good lithotomists who have never been able to
perform lithotrity with success, and skilled lithot-
ritists who have not taken the pains to acquire a
practical knowledge of lithotomy. Both opera-
tions are indeed very difficult and demand patient
study, as well as carefully conducted experiments
on the cadaver, before thej- can be intelligently
practiced upon the living. In lithotomj-, success
is not attainable without this preliminary train-
ing. In lithrotrity, failure to acquire the neces-
sary manual dexterity and delicacy of touch after
repeated trials on the dead clearly shows that
upon the living this operation can be safely under-
taken only by those who have attained the
requisite skill.

The desirable and objectionable features of the
different cutting operations for ridding the blad-
der of a stone or of .several stones are so closely
balanced that it is difficult to state with precision
in what may consist the superiority of one method
over another^

When it is decided that cysto-lithotomy .shall
be performed, the question naturally arises, what
special method seems best suited to the ca.se ? A
cursory review of the origin, features and results

1889.]

TREATMENT OF URINARY CONCRETIONS.

291

of each method may aid in the settlement of this
question.

The operations of C5'sto-lithotomy are arranged
into the infra-pubic and supra-pubic.

The infra-pubic operations comprise the peri-
neal and the recto-vesical.

The perineal operations are : the lateral, the
medio-lateral, the bilateral, the prerectal, the
medio-bilateral, the median (Berlinghierian), the
median (Allartonian), lithoclastic trachoelo-cyst-
ectasy (Dolbeauian), and modifications of most of
these methods.

The recto-vesical operations are : the external
urethro-recto- vesical (Sansonian), the external
recto-vesical (Sansonian), the internal recto-vesical
(Sleighian), and their modifications.

The supra-pubic operations comprise many
modifications of the original Franconian method
to the present time.

Lateral perineal cysto-lithotomy is indicated :
in young children, to whom, however, all the
methods of perineal lithotomy may be applied
with greater success than to adults ; in adolescents
whose bladders are unduly irritable ; and in the
case of those adults who are suffering so much
from cj'stitis that complete drainage of the blad-
der is of as much consequence as extraction of
the stone.

This operation is contraindicated in patients
suffering from calculi of small size that can be
destroyed at one or two lithotriptic sittings, or in
cases of friable calculi of one inch or even one
inch and a half in mean diameter where the blad-
der may tolerate a prolonged sitting with extrac-
tion of the fragments. It is also contraindicated
in cases of elderly men suffering from urethro-
vesical prostatic obstruction. In such cases ,
trachoelo-cystectasy with median incision or ex-
cision of the "bar," or tumor, as the case may
be, is likely to fulfil the two indications of re-
lieving the obstruction to urination and of per- j
mitting the extraction of the stone. 1

The desirable features of the lateral method
are : it affords an ample outlet for stones of me- .
dium size ; it effects complete drainage of the
bladder ; and it is particularly suitable in young
children and also in adults when the bladder
needs rest and efficient drainage.

The principal accidents of this method are :
failure to reach the groove of the staff and conse- \
quent injury of the adjacents parts ; wound of i
the rectum ; wound of the interior of the bladder ; '
excessive haemorrhage ; urinary fever ; infiltration
of urine ; laceration of the vesical neck in forcible
extraction of _ a large stone ; general cystitis ;
peritonitis ; arid pyosapraemia. Most of these
accidents are common to the other methods of
perineal lithotomy.

In the lateral and in most of the other methods |
of perineal lithotom)-, injurj' is very rarely done
to the seminal ducts with the knife. These ducts

are, however, very liable to be destroyed by the
general laceration incident to forcible extraction
of large calculi, the result to the patient being
impotenc}-. On this account all stones exceeding
one inch in diameter should be broken before
extraction.

The mortality from the lateral method is com-
puted at 12 per cent. The great majority of
deaths after lithotomy are, however, attributable
to long-existing disease of the urinary tract,
rather than to the operation itself. Probably the
the best results ever obtained by any individual
surgeon were those of Dr. Dudley, of Kentucky,
who operated b)^ the lateral method upon 225 pa-
tients, only seven of whom died. Dr. Valentine
Mott had performed lithotomy fifty times and
lost only one patient, afterwards he had more
fatal cases.

The medio-lateral operation, performed upon a
rectangular staff by Sir James Earle, Dr. Nathan
R. Smith, and Dr. Mercier, was, in 1846, adopted
by Dr. Buchanan, of Glasgow, who asserts that it
is of easier and more rapid execution than the
lateral method ; that it is less formidable owing
to a more limited division of the parts ; and that
the risks of haemorrhage, injury to the rectum,
and infiltration of urine, are less than in the
lateral method. The operation has many times
' been performed by Dr. Buchanan, Dr. Lawrie,
Dr. Alan P, Smith, Mr. Henry Lee, and others.
The raortalit3' is about 10 per cent.

The bilateral operation has for its main feature
the double incision, which permits the extraction
of a larger stone than can be safely removed
through the tract of the unilateral incision. The
mortality from the bilateral method in the time
, of Dupuytren was over 20 per cent. It has since
been reduced to about 1 1 per cent, in the practice
of the late Dr. Paul F. Eve, whose records show
eight deaths in ninety cases, in the last forty-five
of which, however, only two deaths occurred.

The prerectal operation, according to Nelaton,
has for its main feature the avoidance of the ure-
thral bulb. The bugbear of excessive haemor-
rhage from division of the bulb has led to many
unnecessary and sometimes hurtful devices for
avoiding this bulb, which, in point of fact, is al-
most always cut, in perineal lithotomy, and sel-
dom bleeds excessively when it is freely divided ;
a slight wound being more likely to bleed pro-
fusely. To Mr. Skey lithotomists are indebted
for exposing this fallacj'. The results of the pre-
rectal are about the same as those of the bilateral
method, of which it is but a slight modification.

The medio-bilateral operation, proposed and
performed in 1829 by Civiale as an improvement
on the bilateral method, consists in making a
median external incision including the urethra,
and in using, for the deep incision, a straight-
bladed instead of the flatwise-curved-bladed dou-
ble lithotome. Civiale's advocacy of this valuable

292

TREATMENT OF URINARY CONCRETIONS.

[August 31,

method is owing, as he saj-s, to its easier execution
than the operation of Dupuytren, and to its occa-
sioning less haemorrhage. This operation has
been performed with great success by Dr. W. T.
Briggs and others. Dr. Briggs and the late Dr.
J. C. Hutchinson have employed a double litho-
tome similar to Amussat's. Others have cut with
a single-bladed lithotome, thus making a veritable
medio-lateral operation. Dr. Briggs has performed
the medio-bilateral operation upon 136 patients
with only three deaths.

The median (Berlinghierian) operation, sug-
gested by the Marianian, consists in making a
median perineal incision, in opening the urethra
at its bulbo-membranous junction, and in incising
the prostate and vesical neck in the median line.
Vacca Berlinghieri proposed it as a substitute for
the external urethrorecto-vesical operation of
Sanson. The liability of wounding with the
knife, or of lacerating during extraction, the rec-
tum or ejaculator\- ducts, renders this operation
verj' objectionable. It is, however, the only
method to which strictlj' the name of median
lithotomy can be applied.

The median (Allartonian) operation opens a
route to the bladder permitting the safe extrac-
tion of only small and medium-sized stones.
Large stones, of 2 or more than 2 inches in di-
ameter, have been easily extracted, during this
operation, from adults, and proportionately large
calculous masses from adolescents and children,
but only in cases of ver3' soft and extraordinarily
extensible prostates. Under ordinary circum-
stances forcible extraction is as hurtful in the me-
dian as in other perineal operations. On this ac-
count Mr. Allarton advises that the larger stones
be broken up and their fragments extracted.

This method of lithotomy is indicated in chil-
dren, in adolescents, and in adults whose bladders
do not require drainage. It is indicated also in
elderlj' men suffering from prostatic obstruction
due to urethro- vesical "bars" which need inci-
sion or exci-sion, and when the combined opera-
tions of lithotomy and prostatotomy or prostatec-
tomy may be advantageously performed.

The median operation is contraindicated when
the bladder requires drainage, and of course when
the indications for lithotrity are plain.

The desirable features of the Allartonian meth-
od are : the median incision, bj- which excessive
haemorrhage is avoided ; dilatation instead of in-
cision of the prostate and vesica! neck ; and little
if any liability to infiltration of urine. As ordi-
narily performed it is not so difficult as the other
methods, except in cases of very hard prostates,
and in verj' young children whose urethrae have
been torn acro.ss and even severed from the pros-
tate in the attempt to dilate the prostatic region
with the finger. It is therefore wise to substitute
for the finger a metallic dilator such as that de-
vised by Dolbeau, The mortality from the Allar-
tonian operation is about 10 per cent.

Lithoclastic trachoelo - cj'Stectasy, otherwise
known as perineal lithotomy, when stripped of
the details prescribed by Dolbeau for its perform-
ance, bears much resemblance to Allarton 's meth-
od except in the accomplishment of the dilatation
— to the extent of {j of an inch — which is made
with a specially constructed instrument much
safer in its application than the antero- posterior
digital dilatation of Allarton. Another difference
between Allarton's and Dolbeau's methods is that,
in the first, medium-sized stones are removed en-
tire and larger stones are fractured before extrac-
tion, while in the second case the operation is in-
tended only for large stones which are to be
fractured before extraction. Lik^ Allarton's
method, this operation is not applicable when the
bladder requires drainage.

The mortality from lithoclastic trachoelo-cj's-
tectasy in Dolbeau's hands was at the rate of
about 16 per cent. In view of the fact that Dol-
beau's cases were of large stones, this death-rate
may be regarded as small, since the mortality from
other methods of perineal lithotom)' without lith-
oclasty, for large stones, was formerly 30 per cent.

The external urethro- recto-vesical and the ex-
ternal recto- vesical operations of Sanson have long
ago been abandoned. The external wound, con-
tinuous with the urethra, prostate and rectum, in
one case, and the great liability to urinary fistula
in both cases, render them ver>- undesirable.

The internal recto-vesical method of Sleigh has
been advocated partly because no other than the
recto-vesical wound is inflicted. But even in this
case urinary fistula has ensued. Its alleged ad-
vantages are : the absence of inordinate haemor-
rhage, and the facility with which a large stone
is extracted. In later years the wound has been
successful!}' closed with silver sutures, and in one
instance with the aid of Bozeman's button suture.

The accidents of recto-vesical lithotomy are,
infiltration of urine, v^-ound of the ejaculatory
ducts, and wound of the peritoneum. The mor-
tality is computed at about 19 per cent.

Supra-pubic cysto-lithotomy, condemned bj-
Franco, its inventor, and urged by Rousset, who
never performed it, lingered for a century and a
half, when it was suggested by James and put
into practice by John Douglas ; performed for a
time by Cheselden and modified by Frere Come
and others, again abandoned, then revived by the
Souberbielles and by Amussat, was finally, on ac-
count of the mortality it occasioned, verj- excep-
tionally performed until these late years, when it
was reinstated with improvements that now ren-
der it comparatively safe.

The operation is indicated in 'cases of large-
compact stones too hard to t^e broken in perineal
cystotomy or cystectasy, in cases of such stones
complicated with prostatic "bars," or tumors re-
quiring incision or excision, in cases of stone with
tumors of the bladder, and in ca.ses of foreign

1889.]

TREATMENT OF URINARY CONCRETIONS.

293

bodies in the bladders of patients suffering from
prostatic obstruction, when these foreign bodies
cannot be extracted by the natural route. In
such cases the bladder must be ample, although
the supra-pubic operation has been successfully
performed when the capacity of the bladder has
been markedly diminished.

For supra-pubic intra-vesical prostatectomy^ a
rectangular instrument, constructed on the prin-
ciple of Skene's hawk-bill scissors, such as this
now exhibited, may be employed with advantage.
This intravesical prostatectome, made by Tie-
mann & Co., answers well the purpose of excising
a \'-shaped portion of the enlarged prostate. Mr.
Stohlmann has promised to make an instrument
of the same sort, capable of cutting a U-shaped
segment. Pedunculated tumors of the prostate
maj^ be excised with rectangular short-bladed
scissors adapted to the supra-pubic operation.
The intravesical operations upon the prostate will
be facilitated bj- electric illumination of the cavity
of the bladder.

Urethro-lithotomy is described by Celsus as
performed in the phallic region. This method of
removing urethral calculi continued to be em-
ployed until the invention of lithotrity, since
which time the cutting operation has been aban-
doned, except in cases of very large stones. Ure-
thro-lithotomj' is now generalh' performed in the
scrotal, perineal, membranous and prostatic re-
gions. It is indicated in cases nf urethral calculi
complicated with narrow undilatable strictures,"
and in cases of large stones lodged in these sev-
eral regions of the urethra when urethro-lithotrity
is not practicable.

Lithotrity, the reduction of stone to small frag-
ments, to a granular state, or to a powder, sug-
gested probabh^ by the observ^ation of spontaneous
fracture of stones in the bladder, by the lithotomy
of Ammonius, bj- the lithoclasty of Franco and
the Colots, and developed from the primitive con-
trivances of Pare, of Sanctorius, of Fabricius
Hildanus and of Gruithuisen, satisfactorily dem-
onstrated, in male patients, onl)* in the first quar-
ter of this century, could not at first be rightly
valued, as too much was promised for, and ex-
pected of, the new operation with its complicated
appliances. It over-zealous advocates endeavored
to grade it above all other modes of treatment,
and particularl}' to establish it in place of cutting
operations, but at length acknowledged that it
failed to supersede lithotomy and must be regard-
ed solelj- as an additional resource of surgery, to
be applied with proper discrimination in a partic-
ular class of cases. Nearly half a centurj' of ex-
perience was needed to gi\'« lithotriptic instru-
ments their present degree of simplicity and to
enable Civiale and others to formulate proper
rules for the guidance of those who undertake the
operation.

The operations of lithotrity comprise cysto- and
urethro-lithotrity.

Cysto-litholrity includes : lithotrity bj' the nat-
ural route to the bladder ; b}- an accidental route,
i. e., through a perineal fistula; and by an artifi-
cial route, /. ('., through a perineal incision.

Cysto-lithotrity consists of: lithotrity in multi-
ple short sittings : in one or two long sittings,
with extraction of the detritus by means of the
spoon lithotrite ; and in a single prolonged sitting,
with aspiration of the detritus.

Urethro-lithotrity includes : urethro-lithotrity
b}' the natural route; by an accidental route, /. e.,
j through a urethral fistula ; and by an artificial
[ route, I. c, through a urethral incision.

Cysto-lithotrity is indicated in cases where the
j stone is free, friable and of small or medium size.
i Under favorable circumstances stones of larger size
ma}' be crushed, and within certain limitations,
plurality of stones is not a contraindication. The
further requirements are, that the patient shall be
in an otherwise good physical state, that his ure-
thra shall be ample or susceptible of being safelj'
rendered so, and that his bladder shall tolerate
the necessan,' instruments.

The existence of stricture is not a contraindica-
tion of cysto-lithotrity provided the urethra can
be freely dilated or eveu enlarged by internal in-
cision, but a narrow stricture in the perineal re-
gion, especially if it be of traumatic origin, con-
traindicates lithotrity by the natural route and
generalli' demands a cutting operation.

Urethro- vesical obstruction, unless very exten-
sive, does not contraindicate lithotrity. Contrac-
ture of the vesical neck often subsides soon after
removal of the detritus. But in casee of thick
" bars " at the neck of the bladder and tumors of
the prostate, lithotrity is not alwa3's practicable
and cutting operations are sometimes required.

When the bladder walls are much thickened,
when this viscus is permanently contractured, when
its capacit}' is markedly diminished, or when it is
inordinately irritable, provided the kidneys be
not disea.sed, perineal cystotom}- is indicated and
lithotrit\' contraindicated.

Advanced disease of the bladder, ureters and
kidneys contraindicates both lithotomy and lith-
otrity.

The worst results of lithotrity, outside of France,
until about twenty j-ears ago, gave a mortality of
20 per cent., and the best results 9 per cent., the
average being about 10 per cent., in a total of 992
operations.

Up to the year 1884, vSir Henry Thompson's
own record shows a mortalit}- from lithotrity, in
a total of 672 cases, of " fort3--three, one death in
fifteen cases, or under 6.5 per cent.; " while the
deaths from lithotomy, also in his practice, were
" thirty-nine in no operations, or 35 per cent,"

To choose properly between cysto-lithotrity in
multiple short sittings, in one or two long sittings
with e-xtraction of the detritus by means of the
spoon lithotrite, and in a prolonged sitting with.

294

TREATMENT OF URINARY CONCRETIONS.

[August 31,

aspiration of the detritus, requires sound judg-
ment based not onlj- upon experience but upon
careful consideration of the peculiar circumstan-
ces of each case. Therefore only general rules
for guidance can be formulated, and these rules
are varied to suit particular cases.

As a general rule multiple short sittings, of
from one to three minutes, are applicable to pa-
tients whose bladders are only moderately tolerant
and do not fully respond to ordinary preparator}'
treatment. Three or four such sittings, each with
a single introduction of the lithotrite, four or five
days apart, being ordinarily sufficient to cause
the spontaneous expulsion of all the detritus of a
friable and granulable stone i inch in mean di-
ameter.

One or two long sittings, say ten or fifteen min-
utes each, with five or six introductions of the
spoon lithotrite, as recommended by Heurteloup
under the name of lithocenosis, sometimes suSice
to remove, from a tolerant bladder, the major part
of a friable stone i inch or i '4 inch in diameter ;
the remainder of the detritus being spontaneousl3-
expelled.

Cysto-lithotrity at one sitting with aspiration
of the detritus is said to be indicated when the
stone is large and when there exists urethro-vesi-
cal obstruction ; but it is often performed in vio-
lation of both of these indications. Note the many
reported operations of " litholapaxj' " for stones
capable of being destroyed at a single two minute
sitting. Another notable fact is that some of these
reported cases were not cured at one sitting, but
required two, three, and even four sittings, each
followed by aspiration. The operation is named
rapid lithotrity as well as ' ' litholapaxy , ' ' although
it lasts from fifteen minutes to two hours. The
sittings of ordinarj' cysto-lithotrity average two
minutes. If there be four sittings, only eight
minutes are consumed in all for the safe tritura-
tion of the stone. This is indeed a rapid process,
but prudence demands that there be intervals
averaging four daj-s between the sittings, or twelve
days in all to effect a cure. Manj' cases of stones
of f of an inch diameter are, however, cured at a
single sitting of three minutes without the aid of
anaesthesia or aspiration, and with scarcely any
pain.

Much may be said against the single sitting
with aspiration of the detritus, when this sitting
is prolonged one or two hours, as sugge.sted by
Dr. Bigelow. The urethral and vesical irritation
caused by the repeated pa.ssage of the lithotrite
and of the tubes for aspiration, the violence done
to the bladder by the beak of the lithotrite in the
many seizures of calculous fragments, the friction
and i)erhaps the erosion of the mucous membrane
by angular fragments during search for these
fragments, and the several aspirations with sud-
den and frequent distension of the bladder are, to
say the least, serious objections to the one pro-

longed sitting. The process of aspiration is itself
so much more painful than the crushing of the
stone and fragments (acting much of the time, in
the hands of the inexperienced, like a cupping
glass upon the vesical mucous membrane and
contusing it in many places), that anaesthesia is
rendered necessarj', and this also is a grave objec-
tion, considering the fact that anaesthesia is to be
prolonged one or two hours, particularly with the
aid of sulphuric ether, whose ill effects upon the
kidnej'S are now so well known. Is it not safer,
in cases of large stones, to replace prolonged
"litholapaxy" by suprapubic iithotom}- or by
lithoclastic cystotomy or cystectas}-, and thus
avoid exposing patients to the risks of general
cystitis and pyelo nephritis, or to acute parenchy-
matous nephritis from the elimination of a large
quantity of ether?

Aspirations of calculous detritus are often ad-
vantageous, particularly in cases of urethro-vesi-
cal obstruction, but need scarcely last longer than
two minutes. Such aspirations, practiced with
the utmost gentleness, can safely be made with
Dr. Bigelow's excellent and most ingenious in-
strument, immediately 'after each three minute
sitting at lithotritj', though the case require three
or four sittings in the course of two weeks.

Lithotrity at one prolonged sitting cannot with
prudence be generalized. The majorit}- of cases
of stone can be treated with greater safet3- to pa-
tients by other methods which leave behind no
untoward vesical trouble. The early writers on
" litholapaxy," allured by some brilliant results,
hastily recommended it, and had many followers
who, however, were soon disappointed by discov-
ering that the new method is more difficult and
more dangerous than the old, and that it requires
no less discrimination. There are surgeons who
still perform the operation at one prolonged sit-
ting, notwithstanding that the effects of one or two
hours' trituration of a stone and aspiration of its
fragments are known to be so injurious and to be
so much more, grave than the irritation caused by
fragments made in ordinary lithotrity, which has
for one of its objects the granulation and partly
the pulverization of the stone,

" Litholapaxy " is no longer a novel tj- ; it has
been performed several hundred times since the
year 1878, and may now be estimated at its right
value. The great expectations of its advocates
are not realized, for they have discovered that the
operation cannot always be terminated at one sit-
ting, that it is not suitable in a number of cases
of large stones, that it is not applicable in many
cases of stone complicated with prostatic obstruc-
tion, that it has been too often misapplied, by the
over-zealous, in cases of medium-sized and even
small stones amenable to ordinary lithotrity in one
or two .short sittings, that in too many cases the
injury inflicted upon the bladder has led to chronic
cystitis and to the formation of phosphatic stones,

i

1889.]

YELLOW FEVER.

295

and that ttie necessarily prolonged anaesthesia is I
too dangerous to be general!}' emploj-ed.

' ' Litholapaxy, ' ' applied to a very limited class
of cases, is a very good operation, in the hands of
skilled and experienced lithotritists, but too much
of an undertaking for beginners or for those who
are not constantl}- occupied with surgerj-.

Respecting lithotrity in children, only a few :
words will be said. !

Lithotritj' was successfully applied in 1827 by
Civiale to an iil-developed child 7 years of age
suffering from a large vesical stone. In 1834 Se-
galas reported a case of stone treated by lithotrit}' ;
in six sittings in a child aged 33 months, the stone '
measuring "11 lines. ' ' He subsequently record-
ed four additional cases in children aged respec- ;
tively : 40 months, stone lO lines, four sittings ; i
45 months, stone 13 lines, ten sittings ; 4'2 years,
stone I inch, six sittings; 5 years, stone 15 lines, !
twelve sittings in two months : and no deaths. In
1838, Nathan R. Smith performed lithotripsy suc-
cessfully upon four boys, of whom one was under
2 years of age, another 3 years, and the other two
7 years. In 1S39 John Randolph performed this
same operation upon two 'boys, one aged 4 years
and the other 1 1 years, both cases being successful.
In 1836, Lero}' also wrote of lithotrit}' in \-oung
children, and Guersant, who operated upon twen-
ty-one children, lost six. Mercier (1862), Bej'-
ran (1863) Fournier (1874), Gonzalez (1883),
and others, all spoke their word concerning lith-
otritj' in children, and the final conclusion of
those whose testimony carries the most weight
was that it should be reserved for cases of small
stones requiring onlj' one short sitting. Sir Hen-
ry Thompson, whose number of lithotriptic oper-
ations exceeds that of any other living surgeon,
records, up to the j'ear 1884, only three lithotrities
upon children.

Dr. Keegan's success with lithotrity and " lith-
olapaxy ' ' in children is likeh' to lead many young
surgeons to the wrong use of these operations, and
man}' will be the ill consequences of such a violent
procedure as " litholapaxy." In some of the chil-
dren subjected to "litholapaxy" b}- Dr. Keegan
the detritus weighed only a few grains and could
have been easih- expelled spontaneously after sim-
ple lithotrity, and he counts these cases among [
the triumphs of "litholapaxy;" and in other
cases the stones exceeded 200 grs. in weight. In
the first instance, simple lithotrity was clearly in-
dicated, while in the second, both lithotrity and
"litholapaxy" were clearly contraindicated. Of
Dr. Keegan's first seventeen cases of "lithola-
paxy," in children aged from 20 months to 12
years, only one patient died. This speaks well |
for the tolerance of the patients' bladders and for
the skill of the operator, but even if the percentage
of mortality should, in future, be no greater in
other cases of children Vjetween the ages of 20
months and 1 2 3'ears, it would not render the op- \

eration justifiable in children of 5 or under 5 years
of age.

Lithotrity would long ago have been largely
performed in such children if it had been found
generally safe. In cases where the stone is fria-
ble, small, weighing a few grains, lithotrity is not
only justifiable, but the proper operation, provided
the urethra easily admit a suitable lithotrite ; but
to combine aspiration with such an operation is,
to saj' the least, unnecessary'.

Lithotomy is assuredly the safer operation in
such children when the stone exceeds '2 inch in
diameter, but when it is too large to be extracted,
lithoclastic cystotomy is essential to success in the
majority of cases.

Sir Henrj' Thompson gives a table in which it
appears that of 473 lithotomies performed upon
children of from i to 5 years of age, thirty-three
died, or one in fourteen and one-third cases ; and
of 377 operations upon children of from 6 to 11
years of age, sixteen died, or one in twentj'-three
and one-half cases. Lithotrity in children has
not yet given such results on the same scale.

The general conclusion drawn from this study
is that a proper choice of treatment of urinary
concretions can only be made after careful consid-
eration of each method and each case, there being
no generalizable method.

YELLOW FEVER.

Read before the State Medical Society of Arkansas, Pine Bluff, Meet-
ing May SS, iS8g.

BY WOLFRED NELSON, CM., M.D.,

MEMBER OF THE COLLEGE OF PHYSICIANS AND SURGEONS, PROV-
INCE OF QUEBEC, CANADA; LATE STATE BOARD OF HEALTH,
PANAMA. SOUTH AMERICA, ETC.

With your kind permission I shall read a brief
paper on j'ellow fever, a theme at once interesting
to all students of medicine, and presumably of
marked interest to my confreres in the ' ' Sunnv
South."

In what follows I shall refer to mj' own expe-
rience of this dread disease at Panama on the Pa-
cific, Colon on the Atlantic, both ports of the
Isthmus of Panama. My studies and observations
on the west coast of Mexico, where in 1885 I
traced its epidemics of 1883 and 1884. My ex-
perience in the hospitals of Cuba, and finallj' my
visit to Florida, in the fall of 1887, when I delib-
erately forecast the epidemic that swept Jackson-
ville in 1888. My letter of warning to the people
of Florida was published in the Times-Union, of
Jacksonville, November 30, 1887, and was recalled
u'hcn the disease was upon them.

Now, to return to the Isthmus of Panama,
where I lived and practiced from 1880 to 1885.
I was back there twice in 1886 and twice in 1888,
thus, to use an expressive phrase, bringing my
knowledge down to date.

The yellow fever of the Isthmus of Panama I

296

YELLOW FEVER.

[August 31,

describe thus : It is an acute infectious disease, a
specific fever, ordinarily not contagious, but under
certain atmospheric conditions, not yet fully ex-
plained, the disease undoubtedly develops conta-
gious properties and epidemics result.

Yellow fever is ushered in in a variety of ways.
It ma}' be preceded by languor or malaise. The
invasion may be abrupt. Generally characterized
by a chill, often verj- severe, lasting one, two or
three hours ; the duration of the chill having a
marked significance, severe chills marking nearly
all fatal cases, Again, the disease may be ushered
in by sudden nausea and faintness, without any
warning, as in my own case during the Isthmian
epidemic of 1880. Headache is always met with.
I know of no exception to this statepient. Frontal
headache, a flushed face and gastric irritability in
newcomers within the yellow fever zone is always
very suspicious, a fact specially referred to in Dr.
Belot's admirable book. La Fievre Jaiine a la Ha-
vana. Generall}' the headache is frontal ; it may
be bi-parietal and occasionally' occipito frontal,
but, to repeat, marked headache always. In deal-
ing with specific yellow fever of the Isthmus of
Panama — of which, if respectability depends on
its antiquity, is the oldest, most respectable and
fatal variety known — a history of constipation
obtains in nearlj- all cases. I can recall but a
single case in mj- practice where the disease had
been preceded by malarial diarrhoea. No condi-
tion of health gives immunity. It aims at all, be
they healthy or unhealthy. It has a specific role.
From early youth to advanced age it pursues its
death-dealing mission. It is true that the mor-
tality among children is less than at puberty and
beyond. Pains in the legs and sacral region, the
latter often intense and agonizing. I shall never
forget my own experience. It seemed as if a le-
gion of fiends were trying to dig out — if I may
use the expression — va.y sacrum with red-hot pin-
cers. The pain is excruciating and indescribable.
In the majority of patients, the face was red, just
like the face in scarlet fever — the boiled lobster
color. The eyes at first were clear, providing
there had been no antecedent hepatic disease ;
later they became suffu.sed, injected. The skin
was hot and dry. In many cases a peculiar biting
heat was felt (like the calor mordax of pneumo-
nia). It produced a strange sensation, resembling
a current of electricity playing over the extended
palm. Pul.se hard and slow, varying from 65 to
80. Temperature, first stage 100° to 103°, where
the cases proved fatal in the first stage, rising to
104°, 106° and 107°, the latter being the highest
temperature noted by me in my practice. To fall
slightly just before death. In the second stage
or "period of calm," as it is termed, it fell, a
remission only. At the beginning of the third
stage or the stage of ' ' secondary fever ' ' it rises
again. Respiration, as one would expect during
the "hot stages," is hurried. At times a pecu-

liar moaning respiration of indescribable sadness.
It fills the room and the vicinity. The respira-
tions varied from 30 to 40 per minute, and at the
close of the third stage 50 to 60, becoming less
with the fall of the temperature just before death.
Great thirst, nothing appeases it. Restlessness,
no position giving any ease. Urine, at invasion,
normal but high-colored. In the majority of
cases on the Isthmus of Panama they died during
the first stage. Such was the blood-destroying
intensity of the disease, when all, or nearly all of
the symptoms detailed and to be detailed, ap-
peared. They do not appear in any stated order.

Within twenty-four hours of invasion, all the
symptoms are intensified. Sacral pain and head-
ache increasing. Gastric disturbances and epigas-
tric tenderness developing early in many cases,
the slightest pressure over the stomach causing
intense pain and eliciting sharp cries. In cases
where the brain symptoms were very marked, in
some where patients were unconscious, the slight-
est pressure produced a contortion of the face and
body. If deep-seated pressure was made they
writhed upon their beds, but the instant that it
was removed they bec5ame quiet again. Next,
nausea and vomiting, at first a clear fluid, well
named "white vomit" by Surgeon- General Blair,
of British Guinea, South America. Tongue at
first slightly coated. I am dealing with compli-
cated cases. In patients who had sufiered from
intermittentSj or bilious remittents, what is termed
the characteristic tongue of yellow fever was not
found. As stated, it was slightly furred. Later
the fur increases from behind forwards, the tips
and edges take on a deep red. Gums also become
a fiery red, also the mucous membrane of the
mouth and throat. The whole mucous tract suf-
fers. Later, in the majority of cases, sore throat
is complained of, due to stripping of the mucous
membrane. Blood oozes from the denuded tongue
and gums, giving an indescribable fetor to the
breath; at times it collects on the teeth. In some
cases a peculiar and characteristic odor is exhaled
from the patient's body. Once recognized, it
never will be forgotten. It somewhat resembles
iodeur dii radar/r, of French authors. The late
Dr. Stone, of Louisiana, was the first American
writer, I believe, to recognize it. As he states, it
is a very bad omen.

When patients die in the first stage, the urine
always shows a large amount of albumen. The

temperature remains high, 104^ to 107

Deliri-

um, often quiet, marks the latter temperature. In
some cases extending over more time — beyond the
fourth or fifth day — the albumen does not appear
until the close of the .second or the beginning of
the third stage. Albumen is a s/'/u- qua no//. I
know of no yellow fever without it, nor do any of
my many friends practicing within the tropics.
It never was absent in Isthmus cases. I never
have seen or heard of a case of specific yellow

1889.]

YELLOW FEVER.

297

fever without it ; never, either in the practice of
Dr. L. Girerd, late Surgeon-in- Chief Panama
Canal Company, in that of Dr. Didier, of the
same service, or in the cases seen by my brother,
the late Dr. George W. Nelson, at one time my
partner, and later Resident Surgeon at the Canal
Hospitals, Huerta Galla, Panama, giving a com-
bined experience of hundreds and hundreds of
cases. During an epidemic at Colon in the fall
of 1883, it swept the shipping, over 150 cases,
nearly all fatal. Again albumen in all cases.
Suppression of urine is a late, and generally
among the last symptoms. Where it is marked,
the)- seldom recover. The bowels, if freel}- acted
upon by the sulphate of soda, to be referred to,
may not furnish any earlj^ information, diarrhoeal
motions produced by the soda being followed by
"black vomit motions" in many fatal cases.
These motions may precede or follow black vomit.
No rule is absolute, or such material, well named,
may only be seen at the autopsy. Black vomit
follows the constant retchings and the "white
vomit " of Blair. Black vomit is happily named,
and shows innumerable fine particles or flocculi
named black vomit or " coffee ground vomit,"
or the marc de cafe of the French writers, whose
books on yellow fever are among the latest and
very best. Frequently patients, without the slight-
est warning, commence violent vomiting. It
pours forth from mouth and nostrils, often threat-
ening to choke them. I have seen a patient rest-
ing quietly on his back after the subsidence of the
gnawing sacral pain, when a perfect flood of black
vomit has spurted from his mouth and nostrils up
into the air, over bedding, mosquito curtains and
the nurse. An old and intelligent writer on yel-
low fever, Dr. Dowell, has been singularly happy
in his remark, that it \s per saltern. So it is.

Here, I must pause and divide my yellow fever
cases into two classes, and shall state that such
are met on the Isthmus of Panama. One class, I
took the liberty of naming " uncomplicated," the
other " complicated." By uncomplicated, I mean
the disease occurring in new comers. In the.se,
brain symptoms and delirium were common.
Such, almost without the classic exception, died,
I never knew one to recover. The possession of
full health meant rich blood, and a better culture
fluid for the germs, that destro)^ it ; the absolute
destruction of the blood being but a matter of
three or four days. I can best illustrate this by
a case in the practice of my valued friend. Dr. L.
Girerd, to-day a retired practitioner living in
Paris. In the case referred to, on the fourth day
of the disease, he failed to get a single red cor-
puscle in the blood — not one. The heart was
driving a fluid through the vessels — one incapa-
ble of nourishing the brain and tissues. A fluid
wholly devoid of the life sustaining oxj-gen car-
riers, the red corpuscles. His crucial microscopic
work revealed a fluid, and in it the debris of cor-

puscles ; or, to use the old time word that I have
applied to this condition in yellow fever, a necre-
mia, or death of the blood. His patient, a titled
I foreigner, a magnificent specimen of manhood,
I who stood 6 feet 4 inches in his stockings, died a
few hours later. The "complicated" occurred
in those who had been on the Isthmus from six
months to sixteen }'ears, and of course were pro-
foundly malarious. I say of course, as no man,
woman or child there escapes intense paludal poi-
soning. Sixteen years had failed to give the so-
called acclimation to an American, Captain Dean.
Specific yellow fever cut him off". He was my pa-
tient. An elderh' Italian, M. Georgetti, after
thirty-seven years' residence at Panama, died of
specific yellow fever. I personally know a French
gentleman in Guaymas, Mexico, who has spent
over forty years on both coasts of Mexico. He
went through epidemic after epidemic unscathed,
but in the thirty-sixth year of residence, after
passing through the Guaymas epidemic of 1883,
he came down with the disease in 1884, when a
few cases appeared, as is usual following all epi-
demics 'cvithin the tropics, and just escaped dj-ing.
He in person related his experience to me. Ac-
climation is only so-called; it is a myth, but quite
in keeping with much of our gross ignorance re-
garding yellow fever. Nothing, absolutely noth-
ing, protects against yellow fever — except having
had the disease, a fact well known to all close stu-
dents of the disease within the tropics.

With this digression as a preparatory statement,
I shall next consider the second stage, or " period
of calm," as it is termed. There is a marked fall
of temperature, but merely a remission, and most
deceptive and dangerous it is. I can best illus-
trate this by actual cases. In two cases, both
mine, during the epidemic of 1880; new arrivals,
just married ; he a Frenchman and Consul for
France; she a Portuguese, aged 17. They had
passed the first stage. His temperature had run
up to 106°, hers to 105°. Then came the decep-
tive " period of calrii." They felt so well that,
despite my emphatic orders, they got up and
walked about. He was in one room and she in
another. In the woman's case, the secondarj'
fever came on that night, together with a copious
"vaginal haemorrhage," practically, the equiva-
lent of black vomit. She died within twelve
hours of her walking about her rooms. His tem-
perature again ran up ; he died the next day.
She, poor girl, was laid out in her wedding finery.
They occupy a single grave in the foreign ceme-
tery at Panama. Such, gentlemen, is malignant
yellow fever as I know it.

As I have stated, yellow fever may be a disease
of a single " access " or paroxj'sm. When it is
so, the patient dies or enters on convalescence —
such being the milder cases at Panama. Thus,
it resolves itself into a sharp, clearlj- defined
fever of a single paroxysm, or " access," as the

298

YELLOW FEVER.

[August 31,

French so expressively term it. As nearly all
attacked died, the milder cases were the excep-
tions. In the great majorit}' the " period of calm"
was deceptive, the slightest imprudence on the part
of the patient ending in death later. The remission
— I have seen the temperature as low as 99° — last-
ing from twenty-four to thirty-six hours, in cases
marked by long chills, but twenty-four hours, to
merge into the third stage of the disease, or that
of ' ' secondary' fever. ' ' I have faced three epi-
demics of small-pox, one at home in Montreal and
two at Panama. The severe chills in that dis-
ease, initiating the severe and confluent cases,
the high primary- fever, the second stage, to merge
into the high temperature of the secondarj^ fever,
consequent blood changes and death. These
cases, so familiar to me, have caused much think-
ing in connection with my studies in 5'ellow fever
and its blood changes. In a fatal case of confluent
small-pox, wi-thout the slightest warning, I have
seen a fluid, that to the eyes was indentical with
black vomit, spout from the mouth, high in air,
over even,'thing, staining the bedding just like
black vomit ; \\. was per saltern. To our life-cur-
rents we must look for information.

In the "third stage" the albumen appears,
that is, if absent at close of "period of calm,"
it is invariably met here. Black vomit, and black
vomit motions, suppression of urine, brain symp-
toms, etc., in cases ending fatally in this stage,
all the symptoms crowd each other, and death
closes the scene.

In "uncomplicated" cases, or where violent de-
lirium may be met, many painful scenes result. A
young Englishman, a picture of health, as attested
by his magnificent physique and rosy cheeks, was
stricken on landing. He was my patient. The
case closed with furious delirium. Four men had
to take turns in holding him, until death closed
one of the saddest of sights.

A few words regarding the " fever of acclima-
tion " of some writers. This, mark 3'ou, is gen-
erall}' preceded by a slight chill, a rapid pulse, a
flushed face, suffused eyes, with a trace of albu-
men in the urine — in a word, it is a verj% very
mild form of yellow fever — the febrile movement
lasting twenty-four to thirty-six hours, the mild-
est form of an " access." Failing a trace of albu-
men— it is not a fever of acclimation, that is to a
tropical physician — and the other symptoms, no
subsequent protection may be expected. In fact,
some profound students of the di.sease within the
tropics, consider it but a temporary protection,
that in seasons of epidemic, while such are ex-
posed in a lesser degree, still they are liable to
contract the severe type.

Such, briefly told, is yellow fever on the
Isthmus of Panama. I have seen and attended
it in both cities. Colon and Panama. I wish to
add, that it and other tropical di.seases have caused,
at a low estimate, fully 20,000 deaths on the line

of the Panama canal. The N'ezv York World, of
May 18, 1889, credits the French Consul at Colon
with saying that 15,000 Frenchmen have died.
This probably is a mistake. I believe 20,000 all
told, will be a generous estimate. The heaviest
dying known to me was in November, 1884, dur-
that epidemic at Colon, in the shipping and on
the Isthmus. In an article in Harper s Weekly of
July 4, 1885, I placed the death-rate for that month
at 653 ofiicers and men of the Canal Company.
I obtained the figures from an inside source. The
Canal Company's statements, as published in Le
Bulletin die Canal Interoeeanique, were as menda-
cious as they were misleading. DeLesseps' last
ditch, that absurd creation of a man in his second
childhood, has cost 20,000 lives, over $200,000,000
in gold, has ruined hundreds of thousands of petty
investors in France. Up to the hour of the crash,
DeLesseps, in person, while knowing the whole
truth, unblushingly told his fictions. Since 1884
he has known the whole truth. He is a wicked old
man, who should be buried alive under his fictions.
Manj- of our confreres have fallen on the Isthmus.
Some noble fellows are buried there — yellow fever,
dj-senterj- and pernicious fever. Yellow fever
must be seen and studied in its own habitats.
The Isthmus is one of the earliest.

My visit to Tampa, in November, 18S7, im-
pressed me in many ways, but what greatly inter-
ested me was to hear of cases of non-albuminuric
yellow fever. These cases of so-called yellow
fever, I believe, furnish that class of people who
have had yellow fever two and three times. As
may be inferred, I have no faith in any yellow
fever without the invariable presence of albumen
in the in-ine. I have yet to meet with or read of
a well authenticated case of secondary' yellow
fever. Nor do I know of a single physician who
has seen one.

Now I come to the subject of treatment ; and
here I most emphatically state that yellow fever
has no treatment properly so-called. The host of
so-called treatments justify my statements. How
can a disease, according to the old view, charac-
terized by the symptoms described by me, have
one ? Four centuries seem to have taught the
profession nothing, or next to nothing. All that
was known with absolute certainty was that peo-
ple got yellow fever and died : the world heard
of the dying, and that from Cuba it makes peri-
1 odic invasions of the Sunny South. The treat-
[ ment of yellow fever is purely symptomatic, my
early treatment, up to 1884, was that of the "Old
[School." May God forgive it for its ignorance
and charlatanism I Many authors have made a
reeliauff'e, or re-hash, of the experience of others,
they never having seen a case themselves. They
are responsible for much ignorance, ;/' not 7corse.
Having tried all the so-called orthodox treat-
ments, I, previous to the fall of 18S4, settled on
the following :

1889.]

YELI^OW FEVER.

299

On being called to see a patient at the outset, I
plaj-ed a trump card and made quinine a diag-
nostic agent. We must bear in mind that a few
hours in such cases maj- mean a life saved or lost.
The following was the mixture :

R

Ouin. Sulph 5j

Acid. Sulph., Dil. B. Phar gij

Soda Sulph ^ij

Tinct. Card Co 3ij

Water, add ^viij

"K fiat mistura.
Sig. : Take a quarter at ouce aud repeat in two hour.s.

This mixture, given French fashion, in potions,
or portions, well diluted with water, made a per-
fect solution and was readily absorbed. It was
ray " multicharge gun." It gave me the best
results. Hot baths. Pilocarpine in one case,
aconite, etc., were in order, to produce free action
of the skin. If the ca.ses were purely malarial
the quinine and sulphate of soda met all the indi-
cations. The sulphate of soda acts like a charm,
free, bilious motions following. Ever>' dose con-
tained 15 grains of quinine and '2 ounce of sul-
phate of soda. If after two doses the temperature
remained high, 100° and upwards, with the usual
s}-mptoms, yellow fever was the verdict. Valu-
able time had been saved, the bowels freely acted
upon — a most important indication. Later, I
added to this treatment the following : A phos-
phoric acid mixture everj' hour or two, largely
diluted with water ; gave it and it onlj', purposely
to bring about an acid condition of the blood.
In a few words, to make it wholly uninhabitable

as far back as 1884. I have the notes on those
cases. I took full notes on all my cases, as I had
been taught to do, while a student at the Montreal
General Hospital, 1868-72.

The blood is the habitat of the germ of yellow
fever. When my first case in the series of three
demanded my attention, alas, I could not procure
a reliable phosphoric acid, when I had to fall back
on a formula published on page 93 United States
Dispensatorj', being that proposed by Mr. James
T. Shinn, American Journal of P/iannacv, Octo-
ber, 1880, thus: '' Ligitor Acidi P/iosp/iorici. A
similar preparation under the name of Horsford's
Acid Phosphate has a large use in this country.
The formula is as follows : Liquor addi phospho-
rici (without iron) : Calcii phosphat., 384 grains ;
magnesii phosphat., 256 grains; potassii phos-
phat., 192 grains ; acidi phosphorici (60 per cent.),
640 minims ; aq., q. s. to make a pint." As
stated, not being able to secure a reliable phos-
phoric acid, I was forced to use Horsford's Acid
Phosphate. It, as I knew, was a standard pre-
paration of uniform strength and excellence. I
strongly object to employing a patent preparation,
so to speak. Its contents or make up was known
and it was " Hobson's choice." The preparation
did all that I anticipated, and I give its formula
as found in the United States Dispensatorj'. I
know what I used. It is essentially a strong acid
mixture.

To repeat, having given my quinine and sul-
phate of soda mixture, thus securing free motions
from the bowels. The malarial element being

to the germs. I adopted this course, only after , eliminated by the non-effect of the quinine, I
serious thought, and said to a medical friend, then treated for yellow fever, thus : To bring
" My next patient with yellow fever gets well or 1 about free action of the hot and burning skin was
dies on phosphoric acid." I explained it to two , absolutely necessarj-. As stated at first, I tried
friends. Dr. L,. Girerd and Dr. Arthur Gore, who hot baths, aconite, etc., and abandoned them,

using a simpler and more effective means, in a

saw my cases. Also, to Dr. Bransford, United
States Navy, who crossed the Isthmus on his way
to Nicaragua. Previous to my adopting this
purely acid treatment, following the quinine and
soda mixture, mj- patients kept on dying in a way
that was simply appalling. Not that I lost more
than my confreres. Our helplessness dazed me.
As stated, after mature deliberation, I settled on
phosphoric acid, well diluted, for life or death.
Three cases so treated, all in succession, got well,
an absolutely unheard of thing there. I had

vapor bath, named in Peru " Dr. Wilson's treat-
ment," being that of an English physician, who
used it with great success during an epidemic
there in 1854 and later. The patient was placed
on a chair — one with a wooden seat — all clothing
being removed ; he was covered with blankets
tucked in closel}^ under the chin. A spirit lamp
was lit and placed under the chair, thus giving
heat and vapor. To Dr. Wilson's vapor bath, I
added a foot bath, all under the blankets, the

friends see them — knowing as I do, what unbelief I water as hot as the patient could bear it. Finally
and professional jealousy will do. My reasoning ! I grafted on some Jamaican treatment, giving a
was sound. The acid did not destroy the oxygen- ; pint of hot lemonade or orange-leaf tea. Under
bearing function of the red corpuscles, while the ' this triad a profuse perspiration followed, usually
germs of yellow fever did, and so killed my pa- 1 within ten minutes, it fairly ran off them. As
tients. By rendering the blood acid these germs soon as it was freely established they felt better,
could not live and reproduce. They were de- i The scarlet hue of the face faded. The hard

stroyed in situ, and the blood ceased to be a cul-
ture fluid. Any student of medicine familiar
■with bacilli and their cultures knows full well,
that even faintly acid solutions are fatal to the

pulse became softer. If the bath caused any
tendenc)' to faintness, that was guarded against
by a shorter exposure. With this I had no un-
pleasant symptoms, but with nitrate of pilocar-

propagation of bacilli. Such was my reasoning | pine profound pallor and faintness in a well nour

300

YELLOW FEVER.

[August 31,

ished man caused me alarm. I tried it in but a
single case, and that was previous to my knowing
of Wilson's vapor bath. The necessary exposure
being made, ten to fifteen or twenty minutes, the
patient stood up, the chair was slipped from below 1
the blankets and he was lifted into bed oi )iiasse
to prevent any escape of heat or moisture. More
blankets were put over him. In some cases the
perspiring lasted one or two hours, to the marked
relief of the patient and the lessening of all the
symptoms. After a variable time the skin again
became hot and dry, when the same procedure was
repeated as often as necessary. Thus two highly-
important indications were met at the verj' outset.
First, under the quinine and soda, free motions
from the bowels were secured. Remember the
marked constipation in these cases, often extend-
ing over three or four days, while the man had
been eating as usual. Secondlj', full and free
action of the skin. According to my way of
thinking and reasoning, the patient was placed
under the most favorable conditions for fighting
the disease. Generally large quantities of foecal
matter were voided, and the pores were thor-
oughly opened. Next, the rest of the treatment
was in order. It was of the simplest. A tea-
spoonful of the acid phosphate in a half-tumbler
of water every hour or two, day and night, for
the first twenty-four hours. It never caused
nausea. I continued it for two or three days,
according to temperature and .symptoms. The
bowels continue to act freely — bilious motions.
Later they became very dark under the acid.
Previously I had used sinapisms and a lot of
things recommended by the books, and those
supposed to be experienced in treating the disease.
The sinapisms were placed over the stomach to
try and check the distressing vomiting, at times
they were beneficial ; again, useless. Diet in
these cases is a matter of very small importance.
They are too busy with the disease. I fail to re-
call a single case where food of any kind was
asked for. The highly irritable stomach must be
remembered. Iced milk and beef broth in very
small quantities at frequent intervals, //' the stom-
ach tolerates them. Iced lemonade and pure soda-
water. Small pieces of ice allowed to dissolve in
the mouth. I gave champagne a fair trial and
abandoned it. I am satisfied that the purely acid
treatment is ample. The simpler the treatment
the better. The quinine and sulphate of soda
mixture, vapor baths, a la Wilson, and the acid
meets all requirements. I abandoned the old-time
treatment. As I have already informed you, I
had three recoveries, one after the other, all in
infected premises where the previously attacked
had died. These recoveries were in the fall of 1 884.
Early in the spring of 1885 — March — I left for my
annual holiday, visiting Nicaragua, when L re-
turned to the Isthmus, to leave it, April 25th, for
New York City.

Three swallows do not make a summer, nor do
I claim that three successive recoveries are every-
thing, but as nearly all attacked died, I do eam-
estlj' claim that three successive cases getting well
furnish food for thought. Personally I am satisfied
that bj' persistently acidulating the life-currents
they ceased to be blood-heat culture fluids for the
germsof yellow fever. I sa}- germs. The following
facts will I believe strengthen my claim that three
successive recoveries were absoluteh- unheard of
at Panama. A few words regarding the dying
from j-ellow fever thereaway. I can recall twentj'-
seven admissions to the yellow fever ward of the
Canal Hospitals, Panama, with but a single recov-
ery. My brother, the late Dr. George W. Nelson,
then Resident Surgeon, furnished me with the
figures. Of 42 cases sent to the Charit)- Hospital,
Panama, during the epidemic of 18S0, when I
had the disease, not a single recover}-. As a con-
cluding statement, I could amplify them to any
extent — the Dingier Expedition and its experi-
ence will be ample. Mr. and Mrs. Dingier, ac-
companied by Mr. and Miss Dingier and a part}'
of Canal Engineers, all told, a party of thirty-three,
arrived at Colon in October, 1883, Mr. Dingier
being the new Director- General of the Canal
Works. Within six weeks of landing Count de
Cuerno and Mr. Zimmerman were dead — specific
yellow fever. Within fifteen months of the land-
ing of that party of thirty-three, fourteen had had
yellow fever and but one recovered (Mr. Dingier
losing his wife, son and daughter), he was a pa-
tient of mine, a Canal Officer, and had been on
the Isthmus previously. His reg-ular life no
doubt was the factor that saved him. Contrast
three successive recoveries with the above — my
cases were specific yellow fever.

As previously intimated, yellow fever spares
none. While it is quite true that total abstainers
have been swept away by it, it is equally true
that even in the severest cases, they have recov-
ered, where the moderate drinker was lost from
the start. Time and again my own experience
has confirmed this. The regular life, particularlj-
within the tropics, is its own reward. In Ziems-
sen's Encyclopaedia, \(A. 11, in the article on yel-
low fever much valuable information will be
found on this subject, the value of total absti-
nence— "Panama in 1855," Harper Bros., New
York. Dr. Otis' work, "The Handbook of the
Panama Railway," i860. Harper Bros. Dr. L.
Girerd's work on Panama, published in 1883, in
French, in Paris, all contain much information
regarding that land of pestilence and death, as well
as " Five Years in Panama," 1889, Belford, Clark
& Co., New York.

In reference to the inestimable benefits of total
abstinence within the tropics, it simply confirms
the opinion of a valued friend at Panama. The
Consul-General of the I'nited States, who, when
asked, " How do you live in the tropics ? ' wittily

1889.]

YELLOW FEVER.

301

replied, "It all depends on the liver," So it
does. An alcoholic liver in yellow fever means
death.

The time allowed for the reading of this paper
necessitates my leaving out much that I should
like to discuss. I must ignore the interesting
history of the disease and hasten on.

A few words or points on the after-treatment.
The treatment during convalescence calls for con-
stant watchfulness. It is here, that malarial
svmptoms crop up, in the cases of those who had
been at Panama a few months. Dr. L. Girerd
examined the blood of hundreds on arrival, and
found it normal, in no case showing the malarial
bacillus. After the first month he re-examined
scores of them ; the blood of all showed it, simply
confirming the statements to be found in Dr.
Tomes' work, " Panama in 1855," statement am-
plified in Dr. L. Girerd's work.

To return to the stage of convalescence, I have
known a beefsteak to cause death on the tenth
day. During convalescence such patients are
simply ravenous. Well do I recall my own in-
tense hunger. Slops are in order, fluid food, given
at short intervals, not to overload the stomach. !
Its irritability lasts for weeks and weeks. Bathing, '
a thorough washing of the patient's body and
hair daily in a weak carbolic bath, the thorough \
disinfection of the patient's effects and room. i

The majority of cases were fatal on or before
the fifth daj-, closing with the black vomit, sup-
pression of the urine, etc. In such patients it was
fever of a single " access," or paroxysm. Other
cases passed through the " period of calm,'' and
died in the third stage, or that of "secondary-
fever," from the sixth to the ninth day. Cases
of tj'phoid character were rare. I saw but one,
being that of my friend Dr. Arthur Gore, now in
San Francisco, California.

The sequalae : boils, pimples, parotid swellings,
and intermittent fever, jaundice — I was of a rich
canarj- color. It lasted a whole month. People
were never curious about it or anxious to ask me
questions — not any.

Now for a very brief reference to post-mortem
appearances. My small experience under this
heading simply confirms what an old and clear-
headed American writer has stated, "Yellow
fever has no pathology." I refer to Dr. Grenville
Dowell, whose little broclmre contains a mine of
information, or what the great French Undertaker,
M. DeLesseps, calls " an arsenal of facts."

The. post- uiorfrm findings are so variable in pa-
tients cut off by the same symptoms, that no re-
liance can be placed upon them. I deem it a
blood disease, pure and simple, and, if mj- view
is accepted, the absence of any marked pathologi-
cal change, save in the blood itself, cannot cause
surprise.

The liver : It presents a variety of conditions.
I have found it fattj' ; again, fatty on section,

showing an immense quantity of oil globules ;
again, perfectly normal in size and color. The
chamois-colored liver is supposed to be the char-
acteristic liver. I never saw but one, and that
was the onh- one in nearly one hundred autopsies
made at the Canal Hospitals, Panama, by Dr. S.
Didier, a gentleman profoundl}^ versed in j^ellow
fever. He was born in one of its habitats, the
island of Martinique, French West Indies.

The kidneys : Nothing constant. I met them
large and small ; again, perfectly normal to the eye.

The stomach : This organ presents signs of
acute inflammation. Generally its coats were
thickened : it contained more or less black vomit;
I saw nearly a pint in one case ; its inner surface
showing innumerable pink points or foci of con-
gestion, and small deposits of blood. Dr. Castel-
lanos, a physician of the Charity Hospital, Pan-
ama, a Spaniard, told me that it was the only
constant condition found by him, and he, while
living in Cuba, had made nearh- 150 autopsies.

The brain I have never examined. Dr. L. Di-
dier found nothing worthy of remark in his large
experience. Nothing.

The blood : I have always found it in a per-
fectly fluid condition. Remember the destruction
of the blood and the great amount of albumen
eliminated by the kidneys. Its specific gravit}'
taken by me two hours after death, was nearly
normal. To this fluid we must direct our whole
attention. To repeat, I consider it a blood disease,
pure and simple, and have held this view since
1884. Death in these cases is due to a true necre-
mia. If this view, which I believe is peculiar to
myself, be proven, we have an explanation of a
majority of the sj-mptoms of j-ellow fever, and
as already stated, it explains the absence of any
characteristic pathological changes, save in the
blood.

The brain symptoms are due purely and simply
to the destruction of our oxygen-carriers, the red
corpuscles. The great Virchow attributes loss of
consciousness to their failure to carrj- oxj'gen. By
rendering the blood uninhabitable to the germs
that prej- upon and destroy the corpuscles, we tri-
umph. Much remains to be explained about yel-
low fever. Many honest and patient toilers are at
work on this great problem. I believe that with
the discovery of the specific germ by Dr. Domiu-
gos Freire, of Rio de Janeiro, Brazil, b}' Dr. L.
Girerd, at Panama, and its discovery by Dr. Car-
los Findlay in Havana — to his and the work of
his friend Dr. Delgado, of that city— add to this,
our knowledge of the truh^ wonderful strides
made by these gentlemen in their bacteriological
studies and inoculations — to the above, by acid-
ulating the blood, as I have done, where it has
invaded the system — with such factors, the future
seems full of hope to me. Ma}- it prove so. Hav-
ing digressed, I must go back to the post mortem
findings

302

INFANTILE HEMIPLEGIA.

[August 31,

The bladder: Generallj- a few drachms of high-
\y albuminous urine were found, Remember the
suppression.

Black vomit has a peculiar odor, and is slightlj'
acid to the taste. To clear up a vexed point in
mj' mind, I collected some in one of my cases and
tasted it. It required a little courage, but I was
in earnest and working for results. I may state
mfer alia that it will never compete favorably
with other beverages. The "vomit," on settling,
deposits coffee-ground ' ' particles, ' ' the fluid above
being the color of weak black tea. Black vomit
is not bilious vomit. I tasted it to clear up this
verj- point. Black vomit as a symptom is of grave
import.

It indicates blood changes — the beginning of
■the necremia. While at Panama I sent my friends
specimens of my late patients. My rooms were
miniature graveyards. Some " black vomit " sent
to my old classmate. Dr. \Vm. Osier, then Profes-
sor of Clinical Medicine in the University of Penn-
sylvania, with other materials l\\.xm.i\i.^A. pabulum
for a lecture on vomited matters. To-day, he is
Professor of Practice of Medicine in the Johns
Hopkins University, Baltimore, Md., and Ph3-si-
cian-in-Chief to the magnificent hospital of the
same name.

To recapitulate : Now that Drs. Freire, Girerd,
Findlay and Delgado have found the same germ.
Dr. Domingos Freire being the first investigator,
and its discoverer, to him the honor and credit are
due. He caused others to work. Now that this
has been accomplished, I firmly believe a new era
is at hand, and that soon, this constant reproach
to our profession, and much vaunted modern civ-
ilization, the sway of yellosv fever, is about to
receive its coup de grace. Inoculations will pro-
tect man against this awful disease as vaccine
does against small-pox. Dr. L. Girerd proved
his good faith in such a vaccine, if the term is
permissible, by making attenuated cultures of the
microbes of specific yellow fever, and by inocu-
lating himself and without carrs'ing it to its full
protective influence, he allowed himself to be bit-
ten by mosquitos (Dr. Carlos Findlay 's discoverj-)
that had been feeding on a man in the yellow fever
ward of the Canal Hospital, a case of specific yel-
low fever, the fifth day, the mosquitos were dis-
turbed and allowed to bite him. The result was
a mild yellow fever. I translated his report, and
it was published in the Canada Medical Record,
Montreal, in the fall of 1886, together with an
editorial.

With inoculations to protect and prevent, and
the purely acid treatment where the germs have
invaded the system — with these, and a strictly
scientific quarantine, a la Dr. Joseph Holt, our
profession can save the lives of hundreds of
thousands in the future, who but for such means
would die like rotten sheep. The acid, I be-
lieve, is a germicide in these cases. I like the

term and make no apologj- for using it. Inter-
mittent fever, as we well know, thanks to the
crucial work of Leveran, Girerd and Osier, has
its bacillus malariiv: quinine is its germicide.

When these things are thoroughly understood
and put in practice, travel in the tropics will be
divested of its terrors. People ere visiting them
for business or pleasure will be inoculated, and
with quarantines, a la Dr. Joseph Holt, the com-
merce of nations will be almost free and nntram-
meled.

Here, gentlemen, I must say farewell. I have
to thank you for your kind attention and patience.
In the near future, I trust that you will recall these
statements made in the presence of the Members
of the State Medical Societj' of Arkansas, on this,
the 28th of May, 1889.

Articles extensively quoted in preceding, from
author's papers as under:

' ' Yellow Fever Considered in its Relation to the
State of California." Ninth Biennial Report of
the State Board of Health, 1886. Sacramento.

" Cuba in its Relation to the Southern United
State ; its Danger as a Disease-producing and Dis-
tributing Centre." Tenth Biennial Report of the
State Board of Health, California, 1888. Sacra-
mento.

' ' The Present Tendency to Epidemics." Tenth
Biennial Report State Board of Health. Califor-
nia, 1888. Sacramento.

' ' The Isthmus of Panama Considered as a Dis-
ease-producing and Distributing Centre." Tenth
Biennial Report of the State Board of Health,
California, 1888. Sacramento.

"The Holt System of Maritime Sanitation, or
an Ideal Quarantine." Tenth Biennial Report of
the State Board of Health, 18S8. Sacramento.

CASES OF INFANTILE HEMIPLEGIA.

BY WILLI.-VM L. WORCESTER, M.D.,

.\SSIST.\NT PHYSICI.iN TO THE ARKANSAS STATE LrXATIC
ASVLV.M, LITTLE ROCK.

The following fourteen cases of infantile hemi-
plegia have come under my observation in this
institution, all but one being under treatment at
the same time, in a total population of 419 pa-
tients. Thej' exemplify most of the s\-mptoms
usually found in such cases, and are, perhaps, of
suflicient interest to be put on record, although I
cannot lay claim to any original discoveries in
connection with them. The histories furnished
at the admission of the patients are, I regret to
say, so imperfect as to be worthless for the pur-
poses of this article.

Case I. — Margaret B., aged 30. Said to have
become paralyzed at the age of eight months.
The left side of the face is smaller than the right,
and less strongly innervated. Left arm shorter
and smaller than right ; good movement of elbow,

1889.]

INFANTILE HEMIPLEGIA.

303

shoulder and wrist joints ; imperfect abduction of
fingers, movements of hand somewhat awkward
and weak. Has occasional sudden choreiform
twitchings of arm and hand. Left lower extrem-
ity not shortened and but slightly smaller than
its fellow. She limps and drags the toe slightly
in walking. Knee-jerk much exaggerated in left
leg. She has frequent and severe epileptic con-
vulsions, which begin by extension of the left
hand and arm and conjugate deviation of head
and eyes to left, before consciousness is lost. Fre-
quency of convulsions much diminished by use of
bromides. Her skin presents a deep bluish dis-
coloration, doubtless from the effects of nitrate of
silver.

Case 2. — Ellen B., aged 28. Says she became
paralyzed in infancy. Left side of face better in-
nervated than right. Right elbow and wrist
flexed nearly at a right angle and capable of but
little movement ; fingers extended. All parts of
the extremity shorter and smaller than that of
its fellow. Hand practically useless. No de-
cided difference in dimensions or mobility of lower
extremities. Knee-jerks somewhat more active
than usual on both sides. She has occasional
general convulsions, which she says begin with
cramping in the right arm.

Case J. — Ellen B., aged 29. Says the right
side has always been paralyzed. Face unaffected.
Right upper extremity shorter and smaller than
left ; forearm pronated ; wrist strongly flexed ;
hand closed with thumb outside. She cannot lift
the arm to the level of the shoulder : flexion and
extension of elbow-joint all good but supination
is imperfect ; can move the wrist but slightly.
There are constant slow, slight, involuntary move-
ments of the wrist and fingers. The right lower
extremity is proportionately more atrophied than
the upper ; it is shortened three-fourths of an
inch, and the thigh is three inches and the calf
two inches smaller than its fellow. It is partially
flexed at hip and knee, and there is marked
talipes equino- varus. The foot is dragged in
walking. There are involuntary movements of
the ankle and toes, similar to those of the upper
extremity. Has general convulsions, not ver}^
frequent. Order in which muscles are affected
unascertained. I

Case 4. — Georgiana G., aged 15. Left side of j
face slightly smaller than right ; inner^'ation not !
sensibly different. Left eye deviates upward and
outward. Arms of equal length ; left slightly
smaller. Extension of left elbow and wrist in-
complete. Both little fingers somewhat contract-
ed. She has pretty fair use of the left hand, 1
Left calf is one- half inch larger than right, thighs
equal ; no shortening. Left ankle cannot be (dor-
sally) flexed ; attempts to do so result in adduc-
tion. She is not known to have had any convul-
sions since her admission, "in 1887, until October,
1888, when she had one. On Januarj' 15, i

she had four severe convulsions, and since then
has dragged the left foot, which previously had
not been very noticeabh- lame.

Case 3. — Mary J., aged 42. Right side of face
smaller than left ; tongue deviates to right when
protruded ; nystagmus ; convergent squint of left
eye. Elbow slightly flexed ; forearm pronated.
Cannot raise arm above the level of shoulder,
fully extend elbow, or hj'per-extend wrist. Can
execute all the ordinary movements of the fingers,
but only by making the same movements with the
left hand. The right extremitj' is smaller than
the left in all its parts and dimensions.

The right lower extremity is also much smaller
than the left, especially the calf, which onlj' meas-
ures 9-= K inches against 1 2 '/( on the left side The
hip and knee-joints are somewhat limited in move-
ment, and there is complete talipes varus, the pa-
tient walking on the outside of the foot. Knee-
jerk exaggerated, right side. She says that the
paralysis is congenital. Has epileptic convul-
sions, which are stated to have begun at the age

of 37-

Case 6. — Kate T., aged 27. Says her paralysis
is due to an injur>' to the head from a fall at the
age of one year. No scar or evidence of fracture
can be found. Left side of face smaller than the
right, but seems equally well inner\-ated. The
left upper extremity' is shorter and smaller than
the right. Movements of elbow and wrist are
free, but those of the shoulder are limited, and
the fingers cannot be completely closed or ab-
ducted. The left lower extremity is shorter and
smaller than the right ; movements good, except
that dorsal flexion of the ankle is imperfect ; knee-
jerk exaggerated. Convulsions pretty frequent ;
she says she first has a ' ' nervous ' ' feeling in her
head, and then tremor in the left hand and foot,
which sometimes passes off without loss of con-
sciousness.

Case 7. — Georgiana H., aged 15. Says paral-
ysis dates from an illness at two years of age.
Left side of face smaller than right ; innervation
equal. Arms equal in size ; movements in all
joints free, but she is awkward and clumsy in the
use of the left hand, and there are constant, slow,
irregular movements of the fingers, especially
marked when the hand is open. There is slight
talipes equino-varus of the left foot, and the toe
is dragged in walking. Has frequent epileptic
convulsions, beginning with cramp in the left
arm and hand. The bromides, which hold the
convulsions in check to some extent, seem to ag-
gravate the spastic character of the gait.

Case S. — Martha T. , aged 22. Left side of face
smaller than right ; no marked difference in in-
nervation. The left arm is one- fourth inch smaller
than the right : the fore-arm, on the contrary,
one-half inch larger. The forearm is pronated,
and the wrist flexed to a right angle, with little
mobility. Voluntary movernents of fingers very

304

INFANTILE HEMIPLEGIA.

[August 31,

imperfect. There are constant slow involuntary^
movements of the thumb and fingers, which prob-
ably account for the hj-pertrophy of the forearm.
There is no atrophy of the lower extremitj', and
no impairment of movement except in the ankle,
which cannot be flexed beyond a right angle.
She has frequent attacks of convulsions, which
begin by strong flexion of the left hand and
forearm.

Case Q. — Louisa M., aged 27. Says she be-
came paralyzed at the age of three months. Left
side of face smaller than right, no paralysis. Left
arm shorter and smaller than right ; cannot be
lifted above a right angle at the shoulder. Move-
ments of elbow good ; wrist cannot be hyper- ex-
tended : closure of hand imperfect. Right lower
extremity longer and larger than left. Dorsal flex-
ion of left ankle imperfect ; knee-jerk exagger-
ated on left side. Feels premonitions of convul-
sions in her head, and has tremor of left hand
and foot before losing consciousness.

Case 10. — Thomas M., aged 15. Left side of
face smaller than right ; innervation equal. Up-
per extremities equal in size. The fingers of the
left hand tend to take the position characteristic
of paralysis of the iuterossei, and the use of the
hand is imperfect. When he opens or closes the
left hand slight movements of the same character
take place in the right. The left lower extremity
is one-half inch shorter than the right ; the knee
cannot be completely extended, and there is slight
talipes equino-varus. When he stands the toes
are strongly flexed. When the weight is taken
from the foot they are in constant, slow move-
ment. He has frequent convulsions, beginning
in the left upper extremity. j

Case II. — Riley T,, aged 29. Says he became'
paralyzed in infancy. Right side of face smaller
than left. Right arm not materiall}- smaller than
left : movement of fingers clumsy and imperfect.
The arm jerks when he attempts voluntan,- move- 1
ments with it, and there are slight movements of
athetosis in the fingers. The right calf is three-
eighths inch smaller than the left, and the right
knee-jerk is exaggerated. There is tendency to
hyper-extension of toes. He walks without no-
ticeable limp. His convulsions, which are very
frequent and severe, occur suddenly and without
warning ; he drops as if .shot.

Case 12. — Edward H., aged 18. Says a rail
fell on his head when he was two 3'ears old ; at- [
tributes convulsions and paralysis to the injury.
Has a depression in the frontal bone, about one
inch from median line, three-fourths of an inch
in diameter, and extending a little beyond the
coronal suture. The left side of the face is .slight-
ly smaller than the right. The left arm is not
shortened, but is slightly smaller than its fellow;
the wrist cannot be fully hyper-extended, and the
movements of the fingers are imperfect. When
the hand is at rest there are constant slight move- 1

ments of the fingers, most marked in thumb and
forefinger. Left lower extremity slightlj- smaller
than right ; foot cannot be extended without ad-
duction, nor flexed (dorsally) beyond a right
angle. There are constant slow movements of
flexion, extension, adduction and abduction in
the toes ; the great toe is often raised almost to
a vertical position. Says he has warnings of his
convulsions, which are frequent, but cannot de-
scribe them. His attendant saj's the}' begin with
contraction of the left arm and hand.

Case I J — William McV., aged 28. Origin ot
paralysis unknown. Said to have been epileptic
for seventeen years. There is no very marked
asymmetr}- of the face, but innervation is rather
better on the left side than the right. Slight di-
vergent strabismus of right eye. There is no
material difference in the length of the upper ex-
tremities. The left biceps measures 2 "4 inches
and the left forearm 2 inches more in circumfer-
ence than the right. The right elbow and wrist
cannot be fully extended ; the hand can only be
incompletely closed, and is of little use. Lower
extremities of equal length, but the right thigh
Is 1 1 i and the calf i '4 inches smaller than the
left. Cannot flex (dorsally) right ankle ; foot
deviates inward slightly when extended. Knee
and hip slightly flexed. Patient walks with a
limp, but does not drag foot. No involuntary-
movements of either extremitj- at time of exami-
nation. He has rather infrequent convulsions,
which he says always begin with cramping in
right hand and arm before he loses consciousness.

Case i^. — Susan B.,- aged 42. Said to have
become parah'zed at the age of 7 months, and to
have suffered from convulsions ever since. The
face is much distorted b}- cicatrices from an exten-
sive burn. The right upper extremity is i inch
shorter than the left, but the circumference of the
arms is equal, and the right forearm is only %
inch smaller than the left. There is free mobility
of all the joints, but voluntary movements are
clumsy and feeble, and there are almost constant
irregular movements of the thumb and fingers
more extensive than in anj' other of the cases.
The right foot is in the position of equino-varus ;
the knee- and hip-joints are slightly flexed and
cannot be fully extended, and locomotion is
greatlj' impeded in consequence. There are
athetoid movements of the toes. The patient has
been received since this paper was begun, and
there has not been, thus far, opportunity to ob-
serve the mode of on.set of the convulsions.
Mentally she is alinost idiotic.

AN.'VLV.SIS OK THE FORKGOING C.\SES.

Sex. — Four of the patients are males and ten
females. Most observers have found girls were
more frequently affected than boys, but so great a
predominance of one .sex must probably be con-
sidered fortuitous. Gowers' states that of 80

1889.

INFANTILE HEMIPLEGIA.

305

cases 35 were boys and 45 girls. Of 1 20 reported
by Osier 63 were girls.

Sfdt- Affected. — In 8 cases the left side was
affected, in 6 the right. Gowers" says he found
the left side paralyzed in 37 out of 80 cases, the
left in 33, which leaves 10 unaccounted for. He
considers that the two sides are affected with
about equal frequency-.

Atrophy. — It is, of course, the rule in hemi-
plegia that there is some shrinking of the para-
lyzed muscles. It has, however, frequenth' been
observed in infantile cases that the bones of the
affected side are less developed than those of the
sound side. In my cases the bones of the face
were as frequently affected as those of the
extremities, being distinctly smaller on the para-
Ij'zedside in 10 cases. This is the more remark-
able as in most of these cases there was no very
noticeable difference in the activity of the mus-
cles, though I found in several of them that the
patients could not close the eye on the affected
side while holding the other open. There was
shortening of one or both paralyzed extremities
in 10 cases.

Exirctnitj Principally A/fceted. — In most of mj'
cases the paralysis follows the general rule in af-
fecting the upper more than the lower extremity.
In case 2 the power and mobility of the leg are
very slightly impaired, and the case should per-
haps be considered one of brachial monoplegia.
In cases 5, 10, and 14, on the contrary, the paral-
j-sis, atroph}' and contracture are all in excess in
the lower extremity, and in cases 3 and 4 it can
hardly be said that either predominates.

Athetosis and Chorea. — -In three cases there
were slow, involuntarj', irregular movements
(athetosis) of the fingers, in one similar move-
ments of the toes, and in three both fingers and
toes were involved. In one case there were sud-
den, irregular movements of the paralyzed hand,
which were not, however, very extensive or vio-
lent. In one case the muscles of the affected
forearm were more developed than those of the
sound side — doubtless on account of their con-
tinual activity. Osier' onl}- found athetosis in
six of his cases.

Coiiviilsiotis. — All of these patients are epilep-
tics. The frequency with which cases of infantile
hemiplegia are afflicted with epilepsy is in strik-
ing contrast with its comparative rarity in con-
nection with hemiplegia occurring in adult life.
The frequencj' with which this complication
occurs has varied very greatly in different collec-
tions of reported cases, and no conclusions on
this head can be drawn from these cases, as it is
probable that the mental symptoms which occa-
sioned their committal to this institution were less
the direct effect of the cerebral lesions than of

the resulting epilepsy. All are subjects of the

grand mat, but several of them have attacks, at
times, confined to the paralyzed side, without loss
of consciousness. In eight of the cases the con-
vulsions begin with spasm of the paralyzed side ;
two fall suddenly and pass at once into general
convulsions, and in four I have not been able to
ascertain the mode of onset.

Strabismus. — Three of the fourteen patients
have strabismus. The proportion seems large if
it is merely a coincidence, and none of the patients
present errors of refraction which seem to account
for the state of the ocular muscles. Two of them
(cases 4 and 5) were examined by Dr. T. E. Mur-
rell, of this city. He found a considerable degree
of hyperopia in the former case — a condition
which is one of the principal causes of convergent
squint, but would not seem to throw anj^ light on
the condition present. The other case was found
to be emmetropic. In case 13, also, the only
anomaly of refraction discovered is a moderate
degree of astigmatism. On the other hand, the
connection of the strabismus with the cerebral
lesion is not easily made out. The muscles of the
e^-e are not usually affected in paralysis from that
cause, and in two of the three cases the eye affect-
ed is on the sound side.

Mental Symptoms. — It is probably impossible
to say how much of the mental impairment no-
ticable in these cases is the direct effect of the
damage to the brain and how much to the epi-
lepsj^ from which all the patients suffer. Imbe-
cility, amounting in some of the cases to almost
complete idiocy, is a marked feature of all, and
most of them manifest the selfish, irritable and
quarrelsome disposition so common in epilepsy.
The religious sentimentality so often observed in
that disease is absent, and delusions are a promi-
nent symptom in only one case.

I have not had, either here or elsewhere, an
opportunity to make post-mortem examinations
in cases of this kind. A full discussion of what
is known in regard to their pathological anatomy'
can be found in the exhaustive paper of Dr. Osier,
already referred to.

ISSS.

Nervous Diseases, p. S40.

Cerebral Palsies of Children. Medical News. July lo-Aug 11,

The American Association of Obstetricians
and Gynecologists will hold its next annual meet-
ing at the Burnet House, Cincinnati, O., in the
rooms lately occupied by the Military Order of
the Loyal Legion, on Tuesday, Wednesday, and
Thursday, September, 17, 18 and 19, 1889. No
formal invitations will be issued to non-members,
but the Association extends a cordial invitation
to such members of the profession wherever resi-
dent as ma^- feel interested, to attend the meeting
and participate in the proceedings. The papers
and discussions will embrace sujects pertaining to
obstetrics, gynecology and abdominal surgery.

3o6

MEDICAL PROGRESS.

[August 31,

MEDICAL PROGRESS.

Mixed Infection in Gonorrhcea. — Anala-
gous to the definite sequelae which are observed
in various affections and which, as proved bj' bac-
teriological investigations, are caused by the en-
trance of various microorganisms into the tissues
at the same time, are the various complications of
gonorrhcea, such as inflammation of the erectile
tissues, peri-urethral abscess, bubo, prostatitis,
vesical catarrh, gonorrhoeal rheumatism, peri- and
parametritis, inflammation of the Fallopian tubes,
bartholinitis and endocarditis. These are mixed
infections produced by the gonococcus together
with other pathogenic microorganisms. The
author adduces, in substantiation of this state-
ment, the assertion of Bumm that the gonococci
develop only in cylindrical epithelium, or in tis-
sues which, in their histological structure, are
closely related to cylindrical epithelium, and the
fact, as experimentalh' demonstrated by Rinecker,
that when gonococci are injected into the con-
nective tissues they disappear without leaving a
trace behind them. Throughout the entire course
of gonorrhcea, however, opportunity is afforded
for the entrance of other pathogenic organisms
through the ulcerations of the mucous membrane.
These find, in the profuse secretion present, the
very best conditions for their propagation and
further advance into the lymph and blood chan-
nels, whereby the complications of gonorrhoea
arise. Were it not that gonorrhoea is a purely
local affection of a mucous membrane provided
with cylindrical epithelium, these complications
would be obser\-ed ver}' much oftener. The rela-
tive frequency' of these complications, however,
is explained bj' the readiness with which micro-
organisms other than those of the gonorrhoeal
variety find their way from the diseased mucous
membrane of the genitalia into the tissues and
lymph channels.

Bumm has discovered a yellowish-white diplo-
coccus which, as well as the staphylococcus aureus
and albus ( which are often found in gonorhoeal
complications together with the gonococcus) may
easily be confused with the gonococcus and thus
mislead one into the belief that the pathological
process is a uniform one, whereas, in point of
fact, it is a question of mixed infection. — Ger-
HEIM, Centralblatt fur Gynakoloi^ic.

Treatment of Abscess of the Liver. By
MoN. Chauvel.' — I have had opportunity to ob-
serve four cases of abscess of the liver in militan,-
hospitals. These ab.scesses occurred in soldiers
returning from Tonquin and Algiers, all of whom
were markedly ancemic as the result of dysentery.
The air of their native country had at first ame-
liorated their condition, but soon the attacks of

' Read in the Academic dt- MCdicine, Paris, May 7, 1889.

dysentery and diarrhoea recurred, with febrile

exacerbations, quotidian fever, intercostal pains,
either vague or localized in the hepatic region,
pain about the scapula, and absolute anorexia.
Abscess of the liver was diagnosticated, the diag-
nosis being verified by means of an exploratorj^
puncture. The development of these various
SN'mptoms was much more sudden in the cases of
the soldiers from Tonquin than in the single in-
stance of the one from Afi-ica.

In two of the cases the abscess occupied the
right lobe, in the other two the left lobe ; these
latter cases terminated fatally.

Incision with the bistoury- presented no serious
difficulties ; it corresponded with the seat of swell-
ing, at which point the puncture had been made
with the trocar.

The following are the conclusions derived firom
a stud}' of these four cases :

1 . Immediate, direct incision of abscess of the
liver by means of the bistourj' presents no danger
as regards the development of peritonitis, if it
be made antiseptically.

2. The opening should be large and lead di-
rectly into the abscess cavity. On account of the
retraction of the liver after the evacuation of the
fluid, it is well to make it as high up as possible :
if it retract upon the collapse of the ribs, resection
of the latter may be indicated.

3. It is useless and perhaps dangerous to su-
ture the liver to the edges of the parietal wound.

4. The large opening should be made early,
and the exploratory' punctures are clearly indi-
cated as soon as there is a suspicion of pus.

5. It is almost always impossible to recognize
the existence of multiple foci with sufficient ac-
curac}' to reject the possible intervention of an
accessible tumor. In these perplexing cases the
large incision in the principal focus causes the
disappearance of one of the sources of fever ; it
favors the opening of the secondary' foci into the
principal cavity, already emptied, and if it does
not arrest the progress of the affection at least it
exerts no unfavorable influence upon its course.

6. Abscesses of the left lobe appear to be the
more seriou.s, a fact which may. perhaps, be ex-
plained b}' the possibility of a pericarditis by ex-
tension, and by the probability of other collec-
tions of pus in the large right lobe. — Le Bulletin
Medical.

Rupture of the Liver with a Large Per-
itoneal Effusion of Blood Simulating a
Right H.EMOTHOR.\x. — Fkvrier and Ch.wier,
{Centralblatt fi'(r Gyii., January 19, 1889). A
soldier was violently hurled from a falling horse
in such a manner as to strike a tree with the left
side of the thorax. The horse fell so heavily as
to be instantly killed. The man was rendered
unconscious ; when first seen his face was pale,
there was marked dyspnoea, a small pulse and

I889.J

MEDICAL PROGRESS.

307

grating of the teeth. He had passed urine. Sen-
sibilit}^ was normal. There was a fracture of the
middle portion of the 3d, 4th and 5th ribs. There
was no superficial injurs- of the abdomen appar-
ent and no where sensitiveness upon pressure.
The liver dulness was normal, the abdomen soft.
There was an area of dulness two fingers breadth
in extent in the postero- inferior part of the right
thorax. Respiratory- movements were feeble.
Rupture of the lung from indirect force, and a
consequent hemothorax, was diagnosticated.
During the next few da^s the bowels and bladder
acted normally : the belly was soft and painless ;
the area of dulness on the right side gradually
increased until it reached the angle of the scapu-
la. The right inferior portion of the thorax ex-
panded, dyspnoea and bodily temperature increas-
ed, and the patient died on the fourth day after
the injurj-. The liver dulness had alwaj-s re-
mained normal. An autopsy revealed little wor-
thy of note in the left lung ; in the right pleural
cavity there was about one-half a litre of fluid ;
the diaphragm was pu.shed up so high that the
pleural cavity was encroached upon to one-half
its extent. There was a great deal of blood in
the abdomen. In the right lobe of the liver, 2
cm. from the suspensory ligament, there was a
rupture through the entire thickness of the organ,
13 cm. in length. At the posterior border of this
rupture there was a cavitj' of large size filled with
fragments of liver substance. It may easily be
understood why the above described symptoms
gave the impression of a right-sided haemothorax.

On Creoline in Dysentery. — N. P. Sossow-
SKY {Vratch, No. 14, i8Sg) used in sixteen cases
of dj'sentery cly.sters of a solution of ^2 per cent,
of creoline. The clyster (from 2 to 3 and even
3^2 litres) w-as generally given twice a da}', some-
times three and even four times. No disagreeable
secondar}' sj-mptoms. The patients did not com-
plain of either smarting or abdominal pain. The
results obtained were as follows : In two cases
the disease was broken up after two injections ; in
nine cases the blood}- stools disappeared on the
third day, in two on the fifth, in one on the sixth,
and in another on the ninth. In the last case the
appearance of putrid matter in the stools was not
checked, but the patient recovered nevertheless.
Not one of these patients died, although there
were a great manj- cases with fatal termination
reported in the cit}-. From these observations
the author draws the following conclusions :

1. Clysters of a ' 2 percent, solution of creoline
possess antiseptic qualities and seem to be less
dangerous and toxic than the clysters of sublimate
or phenol.

2. Clysters of creoline check the blood without
irritating the intestinal channels.

3. Cases acute from the beginning, with fre-
quent tenesmus and copious bloody stools, take

a more favorable course and are cured more rap-
idly than cases insidious at the beginning, char-
acterized by catarrhal stools.

4. In cases where the creoline clj-sters do not
stop the development of the intestinal catarrh, cly-
sters of tepid water and subsequently of a solution
of acetate of lead ' _> per cent., or of tannin of 1-2
per cent., should he prescribed; at the same time
a decoction of the bark of quinquina should be
taken internalh' with sulphate of soda.

The author has successfull}- used the same
treatment in two children, one 11 and the other
9 months old. Dr. Kolokoloif has also prescribed
creoline clysters (i per cent.) in twelve cases of
dysentery ; all the patients recovered without
showing at any time alarming secondar}- symp-
toms.— Les N^ouz'eaiix Rimcdcs,'iiio. 11, 1889.

The Diagnostic Tampon and its Value in
THE Recognition of Chronic Endometritis.
— B. S. Schultze (Centra/hi. fin- Gyn., Mar. 11,
1889). In 1880 Schultze described a method
which he had been employing for several years
as furnishing a means for the earh- diagnosis of
endometritis. He now reaSirms all that he then
said of the value of his method, and expresses
much surprise that it has not attracted a greater
amount of attention. The diagnostic tampon is
made of absorbent cotton soaked in a 20-25 per
cent, solution of tannin in glycerine. This, after
careful cleansing of the vagina, is pressed firmly
against the cervix so as to fully cover the os and
portio vaginalis. The gh-cerine solution absorbs
water from the surrounding tissues and allows it
to escape, together with the water\- part of the
secretions, the remainder of which is arrested by
the cotton. After 24 or 48 hours the tampon is
removed, whereupon, if the uterus be healthy, a
lump of vitreous cervical mucus is found. If, on
the other hand, any portion of the mucous mem-
brane above the tampon is secreting pus, the se-
cretion will be found on the tampon. It is not
the quantity and watery character of the secre-
tion that proves the presence of endometritis, but
the pus therein contained. The quantity of the
secretion is often so moderate that patients do
not complain of it, and indeed if the cervix and
vagina are not affected a ver}' considerable degree
of endometritis may occasion so small a discharge
that patients assure their physician in good faith
that there is none.

Schultze claims that too much stress is laid
upon abnormal discharge of blood as the diag-
nostic feature of endometritis, and that there is a
much larger class of cases in which haemorrhage
has not appeared or does not tend to appear, and
that these verj' cases of beginning endometritis
are easily recognized b\- means of his tampon.

On Compensatory Hypertrophy .\nd the
Phvsiologicai, Growth of the Kidney. — Th.

3o8

MEDICAL PROGRESS.

[August 31,

ECKARD reports, in Virchozv' s Archiv, No. 2, vol.
cxiv, the result of careful comparative measuring
and counting of the constituents of eight normal
kidne5-s from different ages (i day to 48 years),
as follows :

I. \\'ith the cessation of embryonic growth new
glomeruli no longer develop. The physiological
growth of the kidney as far as the glomeruli are
concerned is, therefore, purely hypertrophic. 2.
The tubuli contorti increase considerablj' during
the first j'ears of the life of the individual, in
thickness as well as in length. Subsequently
growth is limited to increase in length, but the
author is unable to decide whether it consists in
hyperplasia or in hN'pertrophy of the epithelium.
The examination of the intact hypertrophic kid-
nej's in three interesting cases of congenital defect
in the kidney' showed that the compensatory hy-
pertrophy of a kidney as result of an innate defect
is caused primarih^ by a hj^perplasia (an augmen-
tation) of the glomeruli as well as of the urine
channels, but that at the same time a hypertrophy
of the Malpighian bodies and of the tubuli con-
torti is going on. Compensatory hypertrophy of
a kidne}- as result of an acquired defect, however,
is alwaj's caused by hypertrophy of its constitu-
ents.— Centralblatt fiW Klinische Medicm , No. 22,
i88q.

Contribution to Electrother.\py in Gyn-
ECOtOGY.- — Orthmann reports the results ob-
tained in 95 cases treated in Martin's clinic in
Berlin. Among these, most of which were chronic
cases of inflammation of the uterus and the sur-
rounding parts, there were 36 ca.ses of perimetri-
tis : in one case there was a ^•ery favorable re-
sult, in 24 cases marked improvement, and in the
remaining 11 no appreciable change. In cases
where there was great sensitiveness, the faradic
current or the positive pole of the galvanic cur-
rent was employed ; in cases of moderate .sensi-
tiveness the negative pole : this was introduced
in the form of a ball electrode into the posterior
cul-de-sac, while a flat electrode applied to the
abdomen was made the other pole. The current
varied in strength between 50 and 100 ma. The
number of seances varied from six to eighteen,
the length of each seance averaged five minutes.
At most there were two seances per week.

In similar manner twelve cases of parametritis
were treated ; in eight of the.se there was improve-
ment, in the others none. In five cases of para-
and perimetritis, exudate of greater or 'less ex-
tent, there was improvement in three, no change
in one, and retrogre.ssion in the last.

The most favorable results were obtained in
the treatment of severe dysnienorrhoea and amen-
orrhoea. In twenty-six cases of dysmenorrhea
dependent upon metritis, endometritis, retroflex-
ion of the uterus, and stenosis of the cervical
canal, six were cured, while the others were mark-

edly improved. In like manner of four cases of
amenorrhoea three were cured, while the fourth
remains under treatment. In the treatment of
dysmenorrhoea and amenorrhoea the negative
electrode was used especialh-, being introduced
into the uterus while a current of from 50-75 ma.
was employed.

As a result of these experiments, the writer
believes that additional information is required,
especially as regards the treatment of dysmenor-
rhoea and amenorrhoea. — Centralbl. fur Gyn.

The Injection of Cocaine in Spastic Cox-
traction OF the Joints. — In primary inflam-
matory contraction of the joints, that is, in those
cases where a contraction of the joint results from
an inflammatory irritation or from an inflamma-
tion of any of the constituents of the joint, Lorenz
recommends ( W'kiicr klin. Wochcnschrift, No. 9,
1889) as the simplest and surest treatment for the
removal of the muscle-spasm, injections of co-
caine into the respective space of the joint. He
uses for this purpose a common Pravaz s^'ringe
with a somewhat longer needle, and injects with
antiseptic precaution one-half or a whole of a
syringe of a 10 per cent, solution of cocaine into
the joint. Immediateh- after the injection the
pain disappears, and a few minutes later the joint
may be put into the correct position and fixed, or
extended. This mode of treatment is especiallj-
recommended for the correction of spastic club-
foot. Children bear cocaine very well ; in adults
more caution is necessary, a few centigr. often
being sufficient to produce the desired effect. In
Albert's clinic a general narcosis is no longer
used for primarj- inflammatory contractions. —
Centralblatt fiir Chinirgie, No. 23, 1889.

Sulphate of Eserine in Chorea. — Reiss
{Phanit. Joiini. and TransacL, No. 2, March,
1889) recommends subcutaneous injections of sul-
phate of eserine for chorea ; dose o.ooi gr., twice
daily. He claims to have effected a cure in many
cases after five or six days of treatment, although
in acute cases of chorea in adults success was not
so very brilliant. He obtained also satisfactory'
results with this drug in tetanus, paralysis agitans,
spinal sclerosis, and in one case of hysteria in a
man, accompanied b}- extreme excitement and a
remarkable exaggeration of the reflex move-
ments.— Journal de Mt'dicinc dc Paris, No. 21,
1889.

On Ini-wntile Leuc.emia. — Prof. Jaksch
lost a patient some time ago, a little boy 20
months old who was suffering from genuine lym-
phatic leucaemia. This di.sease is extremely rare
at this age, and consequently this case is quite
interesting. The diagnosis was verified by the
autopsy, \l. Jaksch finding the typical lesions of
the di.sease in the inte-stines, the liver and the kid-
neys.— Lc Bulletin Medical, No. 45, 1889.

1889.]

EDITORIAL.

309

THE

Journal of the American Medical Association

PUBLISHED WEEKLY.

Subscription Price. iNCLnDixG Postage.

Per Annum, in Advance $5.00

Single Copies 10 cents.

Subscription may begin at any time. The safest mode of remit-
tance is by bank check or postal money order, drawn to the order
of The Jot"RN.\L. When neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
letters.
Address

Journal of the American Medical Association,

No. 68 Wabash Ave.,

Chicago, Illinois.
A1! members of the Association should send their Annual Dues
to the Treasurer, Richard J. Dunglison. M.D., Lock Box 1274, Phila
delphia, Pa.

London Office, 57 and 59 Ludgate Hill.
SATURDAY, AUGUST 31, 1889.

PROGRESSIVE NEUROTIC MUSCULAR
ATROPHY.

J. Hoffman bestows the above name on an
affection of which he reports an original case,
with further observations on three cases which
had been previous!}' described by F. Schultze,
and an abstract of the literature of the subject.
The disease seems to be a rare one, but he finds
obser\-ations by Eulenburg, Eichhorst, Hammond,
Charcot and Marie, Herringham, Tooth and Osier.
It is in a marked degree hereditary, usually affect-
ing several members of a family, and descending,
in some of the recorded cases, to the sixth gener-
ation. Males are more frequently affected than
females, and healthy females, in families subject
to the disease, maj' bequeath it to their male
offspring.

It ma}- appear in infancy, and usually develops
in early life, but cases are recorded in which the
first symptoms were observed after thirty years of
age. It probably begins with atrophy of the
small muscles of the feet, but is apt to escape
attention until the muscles of the legs become
involved. Next in order, the small muscles of
the hands are attacked, and subsequently the
forearms, the thighs, and, in some cases the mus-
cles of the trunk are invaded. Deformities result,
varying according to the degree in which the
different muscles are affected. The feet assume
the position of talipes equinus, varus or equino-
varus, the hands that of " main en griffe." These
deformities, with the striking differences which
usually exists between the degree of atrophy of
the distal and the proximal segments of the
limbs, impart a very characteristic appearance to

the patients. The affection is symmetrical, and
proceeds from the most remote segments of the
limbs toward the trunk. Although there is a
tendency to anchylosis of the joints there are no
contractures. Fibrillar twitchings of muscles has
been observed in some cases. Tendon reflexes
and mechanical excitability gradually disappear.
The same is true of the electrical reactions ; at a
certain stage of atrophy the " reaction of degen-
eration" is present; ultimately all response to
both faradic and galvanic currents ceases. Sensi-
bility is impaired in less degree than the motor
functions, and there is no uniform relation be-
tween the two.

Two autopsies are on record, one by \'irchow
j and one by Friedreich. In both the muscles and
ner%'es of the parts involved were found to pre-
sent the changes characteristic of the degenera-
tive atrophy of the nerves. Sclerosis of the col-
umns of Goll was found in the spinal cord. From
the course of the disease and the post-mortem
appearances the author concludes that it is pri-
marily an affection of the peripheral ner\'es. The
prognosis, as to recover}-, he considers entirely
unfavorable, although the disease may be arrested
for an indefinite period, and is not incompatible
with long life. No cases are on record in which
it proved directly fatal, but the possibility of such
a result cannot be excluded. No remedies, thus
far, have seemed to be of any avail.'

THE ERRORS OF STATISTICS.
It is unfortunate that in an era when many
conclusions are necessarily dependent upon sta-
tistical computations, a neglect of technical mathe-
matical training often vitiates both a writer's de-
ductions and his reader's apprehension of them.
So common is this sort of ignorance, even in
otherwise educated circles, that, outside of a
comparatively small coterie of cautious, and
especially cultivated algebraists, the civilized
population is about equally divided between
those who sneeringly remark that ' ' figures can
be made to prove anything," and those who
overconfidently derive preposterous fallacies from
insufiBcient data. In no pursuit is unintention-
ally false logic more mischievous in its results
than in that of medicine, and we therefore offer
no apolog}' for presenting certain facts which, if

Archiv. fUr Psychiatric, xx, 3.

3IO

GERMICIDAL ACTION OF BLOOD.

[August 31,

they be tediously familiar to a choice few of our
readers, ma)- be useful to the majority.

Despite the popular proverb, figures will not
lie if the3^ be properly interrogated ; but the ac-
curacy of their response will be proportional to
their multitude, and the interpretation of their
oracles must be guided bj^ a knowledge of the
law of such proportion. Argument is hardly
needed to show the unreliability of percentages
drawn from a verj- small number of data : No
sane person, having seen but four cases of a rare
disease, two of which were fatal, would assume
that the average mortalitj- of the malady would
alwaj's be 50 per cent., but many people fail to
consider that a similar, though constantly di-
minishing, margin of uncertainty- pertains to in-
creasingly numerous groups of figures.

To determine this "possible limit of error,"
several formulae — all leading to the same result —
are given in treatises on statistics ; the simplest
being that of Poison, namely : If q represent
the total number of observed cases, and p the
number of the particular class of which it is de-
sired to calculate the proportion as a clue to the
probable general average, the " limit of error "

geon perform a novel operation on forty patients,
of whom thirty-two recover, he is apt to announce
— and to believe — that his procedure reduces the
mortality of such-or-such a grave disease to 20
per cent., unconscious that his own figures inti-
mate that of his next series of forty, fifteen may
die, or all survive. Estimates of the movement
of population in minor communities; "experi-
ence tables ' ' of life assurance companies ; in
short, all prognostications of averages based on
finite numbers, require correction according to
the rule above defined, and only he who knows
just how many " grains of salt " to season them
wherewith can profitably digest them.

•11 i_ -A =p[^-p]
will be 2 \ or

\ a>

what is the same thing,
Applj'ing this rule, and adhering

for the present to rates of mortalitj', it will be
found that if our record comprise 100 persons,
with 10 deaths, the error-margin is 8:48, so that,
instead of 10 per cent., successive groups of 100
may yield as much as 18. 48, or as little as 1.5
per cent. ; if our total be 200, with 20 deaths, the
possible error is 6, and the general average may
varj- between 16 and 4 per cent. ; with 500 persons
and 50 deaths, the allowance is 3.8, and the pos-
sible variation of subsequent percentages from
13.8 to 6.2 ; if we have as many as 1,000, with
10 per cent, of deaths, a second thousand may
give a rate of 12.7 or 7.3 ; and it is not until we
reach a total of 10,000 that the limit of error is
reduced to less than i. Of course, the extent of
the possible error will var>- with the value p in
the equation, even when q remains constant.
Ne.science in this respect renders worse than
worthless— because misleading — many painstak-
ing contributions to medical literature, and in-
validates, a large part of the work industriously
done in the domain of vital statistics. If a sur-

THE GERMICIDAL ACTION OF BLOOD.
The explorations in science are carried on with
the greatest vigor in diSerent directions at differ-
ent times. It is now over three years since
Metschnikoff promulgated his phagocj'te theorj-.
During this time it has met with the greatest op-
posion. NuTTAL and Buchner' have added ma-
terially to our knowledge of the germicidal action
of blood. Both defibrinated and freshly-drawn
blood manifest a decidedh- deadlj- action upon
bacteria for more than four hours after it has been
drawn from the body. This is most marked
toward the pathogenic bacteria. For example,
the number of anthrax bacilli in a g^ven quantity
of material was reduced in two hours from 4,800
to 56 by being mixed in a test-tube with defibrin-

j ated blood ; and three hours later onh- three
living bacilli remained. Almost as remarkable a
germicidal influence was manifested toward other

j pathogenic bacteria. The destruction of putre-

I factive bacteria is, however, much less marked,
and against some of them, at least, the blood
manifested little germicidal influence. This is

I in accord with the latest ideas of the origin of

: parasitism.

These investigations open up a new field of
inquiry' and thought which promises a reorgan-
ization of our ideas of infection. We are brought

\ back to consider the animal body a colony of in-

I dividual cells, the integritj- of which when at-
tacked by parasitic bacteria depends upon the
issue of the struggle for existence between indi-
viduals of the invading parasites and the indi-
vidual cells of the body.

I ' I'eber <lie bnkterientodtende Wirkung des zellenfreien Bliit-
I ser\iiiis. Ceiitralblatl fur Bakteriolgic mid rarasiteiikuiide. V.
1 Band, No. 25, page S17, et seq.

1889.]

EDITORIAL NOTES.

3"

EDITORIAL NOTES.
HOME.
Faculty Changes. — The Toledo Medical Col-
lege have elected Dr. J. T. Woods, formerly Pro-
fessor of Physiology in the Cleveland Medical
College, to the chair of Orthopjedic Surgery ; Dr.
F. B. Robinson, of Grand Rapids, Wis., to the
chair of Anatomy ; and Dr. H. G. Blaine, Editor
of The Medical Compend, lecturer on Diseases of
the Nervous System.

C.A.NADIAN Medical Association.— The an-
nual meeting of this Association recentl}' held at
Banff, was a very successful one. The work was
good and the papers creditable. Dr. James Ross,
of Toronto, was elected President, and the next
meeting will be held in the latter city.

Columbus Medical College. — The Secretary
of this College, Dr. J. M. Dunham, writes us that
the}- require and make examinations of students,
before entrance, in literary attainments. It was
not so stated in the table in our Special Edition
of May 25.

Transactions of the American Medical
Association. — Any member of the Association
desirous of procuring volumes of the Transac-
tions from 1844-82 at a reduced price, can do so
by addressing the Business Department of The
Jour'^al.

The American Dental Association. — This
Association concluded its sessions at Saratoga on
the 9th inst. after electing the following officers :
President, Dr. M. W. Foster, of Baltimore, Md.;
first Vice-President, Dr. A. W. Harlan, of Chi-
cago ; second Vice-President, Dr. J. D. Patterson,
of Kansas City, Mo.; Recording Secretary, Dr.
George H, Gushing; Corresponding Secretary, Dr.
Fred Levy, of Newark, N. J, ; Treasurer, Dr. A.
H. Fuller, of St. Louis, Mo. The Association
will meet at Excelsior Springs, near Kansas City,
next year.

A Note of Warning. — Dr. R. Harvey Reed,
Health Officer at Mansfield, O., has communicated
the following to the Mansfield Daily Nezi's: " In
view of the fact that the use of the so-called ' Elixir
of Life ' (which consists in injecting under the
skin the raw liquid obtained from crushing and
expressing the juice of the fresh testicles of the
lamb or other animalj has developed a marked
case of erysipelas in our city, which disease was

clearly traceable to the use of this liquid, and de-
veloped from the punctures where said liquid was
injected, until almost the whole of both forearms
were involved, which was accompanied by a chill,
vomiting, fever and a rapid pulse, with marked
redness and swelling of both forearms; and in
view of the fact that numerous other cases of erj--
sipelas and blood-poisoning have been reported
occurring from the use of this liquid, saying noth-
ing of several deaths occurring from its use, which
clearly demonstrate that its use is attended with
danger to the public health, it therefore becomes
our duty to warn the public of the danger attend-
ing its use "

We learn that, since the issue of the above, the
man has an abscess at each of the punctures, three
on the right and two on the left arm, and one on
the right leg. Dr. Reed lanced them and thej-
yielded from Vj to i oz. each of unhealthy pus,
and after all giving no relief whatever for his
chronic troubles.

American P.ediatric Society. — The meet-
ings of this Society are announced to take place
at the Army Museum Building, Washington,
D. C, September 20 and 21. One of the after-
noon meetings will be held in the Johns Hopkins
Hospital, Baltimore, Md., by invitation of the
Director of that Hospital. A large number of
papers have been promised. Dr. A. Jacobi is the
President, and Dr. Thos. L- Latimer, Chairman
of Committee of Arrangements.

Prevention of Typhoid Fever. — The State
Board of Health of Kentucky has issued a circu-
lar to the health officials and people of the State
impressing upon them the necessity of preventive
measures to , stop the gradually increasing preva-
lence of, and mortality from, typhoid fever. The
circular goes on to say :

Two methods of prevention, having the same
general object in view, are to be recommended.
The first involves the thorough disinfection of
all discharges from the bowels of typhoid fever
patients. This is best done by the use of a solu-
tion of chloride of lime, 8 ozs. to the gallon of
water, using a quart of this solution for each dis-
charge, and allowing it to stand in the vessel at
least one hour before emptying. A solution of
corrosive sublimate, 2 drachms to the gallon of
water, will answer the same purpose, but requires
to remain longer in contact with the material to be

312

EDITORIAL NOTES.

[August 31,

disinfected. Bed and body linen soiled by such
patients should be disinfected by the use of the
same solution or by boiling.

The second method relates to avoiding the use
of suspicious water, and especiallj- well water,
and where this cannot be done, to boil such water
before it is used for drinking purposes. In the
absence of a pure and well guarded public water
suppl}', properly stored cistern water is probably
open to least objection.

The effectual practice of these methods will re-
quire intelligent care and some expense, but it is
confidently believed that their general adoption
would result in the practical disappearance of a
disease which is not only a disgrace to our civili-
zation, but an annual scourge and tax upon the
people of Kentucky, in comparison with which
yellow fever and cholera sink into insignificance.

The Mississippi Valley Medical Associa-
tion.— The annual meeting of this Association
will be held in Evansville, Ind., on the loth, i ith
and 12th of September. The officers for this year
are: President, Dr. Geo. J. Cook, Indianapolis;
Vice-Presidents, Dr. J. A. I,arrabee, lyouisville,
and Dr. J. D. Griffiths, Kansas City ; Secretarj%
Dr. R. L. Thompson, St. L,ouis ; Treasurer, C.
W. Chapman, Toledo, O. ; Committee of Arrange-
ments, Dr. Edwin Walker, Dr. Lud Worsham,
Dr. Charles Knap, with Dr. A. M. Owen, Chair-
man ; Dr. C. P. Bacon, Chairman Committee of
Arrangements, and Dr. Geo, P. Hodson, Chair-
man of the Committee on Exhibits.

•Trafi5c Manager J. G. Grammer, who is Chair-
man of the Committee on Transportation, has
succeeded in securing a one and one-third rate on
all the roads in the Ohio and Mississippi valleys,
which insures a large attendance.

This organization is the outgrowth of what
was formerly the Tri-State Medical Association,
which at first only included Indiana, Illinois and
Kentucky, but its usefulness to the profession has
become so great that it was found necessary to
enlarge its territor}', and as it is now constituted,
is second only in importance and numbers to the
American Medical Association, to which it is
auxiliary' and subordinate.

This Association is rapidly attaining the object
of its formation — a thorough organization of the
members of the regular profession of the entire
Mississippi Valley, thus to foster, advance and

disseminate medical knowledge, to uphold the
honor, and to maintain the dignity of the medical
profession.

Last year members in the Gulf States were
unable to attend on account of the yellow fever
quarantine. This year nothing will hinder a full
attendance from all sections of the country, as
questions of importance to the entire profession
of the South and West will be before the Associ-
ation for consideration.

The importance of this Association in bringing
together the members of the profession within
this territorj- must be apparent to everj-one, as
there are many interests in common and individual
welfare that can best be promoted by the advance-
ment of the interests of all.

The preliminar}' programme contains a list of
ninety-seven papers, It is expected about 800
members will be in attendance.

The Address of Claudius G. Wheelhouse,
F.R.C.S., President of the British Medi-
cal Associ.vTiON — B}^ special courtesj- we were
able to present to our readers in The Journal of
August 24 the address of the President of the
British Medical Association, which was delivered
at its annual meeting, August 13, 18S9. We are
confident that it has been read with special inter-
est. We only regret that the limited spaje at
command did not permit us to publish it entire.
His able review of the progress of medicine during
I the last centurv is alike interesting to its readers
in Europe and America.

Omission. — In the report of the Section of
Ophthalmology, it omitted to state that the paper
submitted by Dr. F. C. Hotz, of Chicago, was read
b}' title and referred for publication. It will appeal
in its order in The Journ.\l.

The American Public Health Associa-
tion will hold its seventeenth Annual Meeting at
Brooklyn, N. Y., on Oct. 22, 23, 24 and 25, 18S9.

Dr. J. Solis-Cohen, of Philadelphia, was
recentl}' elected Honorary Fellow of the British
Larj-ngological and Rhinological Association.

The Sanitary Nczcs draws attention to the fact
that silk thread is soaked in acetate of lead to in-
crease its weight, and persons who pass it
through the mouth in threading needles, and then
biting it off with the teeth, have suffered from lead
poisoning.

1889.]

TOPICS OF THE WEEK.

313

TOPICS OF THE WEEK.

MEDICAL JURISPRUDENCE. CASES RECENTLY ADJUDGED.

Drunkenness. — Voluntary drunkenness which pre-
cludes a comprehension of the nature of the act, or rec-
ognition of the person killed, is uo excuse for murder ;
but mania a polu, or any insanity or permanent unsound-
ness of mind resulting from the use of intoxicating
liquors, will exempt one who commits a murder from
punishment therefor. Beck v. Slate, 76, Ga. 452.

Employment. — .4. physician employed by the conductor
of a train to care for a man injured by the train can re-
cover against the railroad company for his services if,
after knowledge or his employment b\- the conductor,
the company failed to notify hjm that it would not be
responsible. Terre Haute <sr I. R. Co. v. Stockivell
(Ind.) 20 N. East. 650.

Expert. — When a medical expert is asked to give his
professional opinion to a jury, not upon matters within
his own knowledge, but upon an hypothetical case
founded upon the testimony of witnesses previously ex-
amined in the case, the questions to him must be so
shaped as to give him no occasion to mentally draw his
conclusion from the whole evidence, or a part thereof,
and from these conclusions, so drawn, express his opin-
ion, or to decide as to the weight of evidence or the
credibility of witnesses ; and his answers must be such
as not to involve any such conclusion so drawn, or any
opinion of the expert as to the weight of the evidence or
the credibility of witnesses. Kerr v. Luns/ord (W. Va. )
2 L. R. \. 668, 8 S. E. 493.

The opinion of medical experts, founded on testimon}-
already in the case, can only be given on an hypothetical
case ; and the hypothesis must be clearl}- stated, so that
the jury may know with certainty upon precisel}- what
state of assumed facts the expert bases his opinion. Id.

In putting hypothetical questions to expert witnesses,
counsel may assume the facts in accordance with their
theory of them. It is not essential that he state the facts
as they exist, but the hypothesis should be based on a
state of facts which the evidence in the cause tends to
prove. Id.

The opinion of an expert witness as to the nature and
extent of an injury to a person is not inadmissible be-
cause based in part on the statements of the injured
person. Louisville, N. A. &■ C. H. Co. v. Snider (Ind).
20, N. East. 284.

Insanity. — Insanitj- is a fact that cannot be proven by
reputation, or by a witness who is not an expert, unless
he first gives the facts upon which his opinion is based.
Griibb V. State (Ind.) 20 N. East. 257.

Where there is an issue made as to sanit}-, and evidence
is introduced under it tending to show insanity, there is
no presumption to be indulged one way or the other.
Missouri Pac. R. Co. v. Brazil (Tex.) 10 S. W. 403.

A defendant in a criminal case who raises the defense
of insanity must prove it by a preponderance of evidence;
and this applies as well to the causal connection between
the fact of insanity and the crime committed as to the
insanity itself. Cunter v. State, 83 Ala. 96.

Pi. person, though of weak mind, but with sufficient
capacity to distinguish right from wrong in respect to the
particular acts charged, is accountable for his acts, and
the plea of insanity will be unavailing as a defence for
crime. Anderson v. State (Neb.) 41 N. W. 357.

An instruction as follows : "If you believe from the
evidence that defendant fired the shot that caused the
death of the deceased, and that, at the time of the con-
troversy, defendant was in such a mental condition as to
distinguish the difference between right and wrong, then
he was responsible for his act, and you must convict," is-
erroneous, as it does not, standing alone, state a correct
legal proposition. Kearney v. People, 11 Colo. 258.

Moral insanity, as distinguished from mental derange-
ments, is not an excuse for crime, and does not exempt
from punishment therefor. People z: Kerrigan, 73
Cal. 222.

Malpractice. — In an action against a physician, based
on his lack of care or skill, the burden of proof to show
such lack is on the plaintiflT. State Jenney v. House-
keeper (Md.) 2 L. R. A. 5S7, 19 Md. L. J. 917, 16 Atl. 382.

The party who allows a surgical operation to be per-
formed is presumed to have employed the surgeon for
that purpose, and the burden of proof to show lack of
consent is on the party alleging it. Id.

If physicians attending a woman deem it necessary, for
the preservation and prolongation of her life, to perform
an operation, they are justified in doing so if she con-
sents, whether her husband consents or not. Id.

The degree of care and skill required of physicians is
that reasonable degree of care and skill which physicians
ordinarily exercise in the treatment of their patients. Id.
— EwELL in Xorth American Practitioner

SPLENECTOMY.

\ successful case of splenectomy for enlargement and
displacement of the organ is reported by Sir Spencer
Wells. The patient was a young married woman, aged
21, who had suffered from ague when a child. Soon after
her marriage, an abdominal tumor which she had had for
several years began to enlarge, and was thought to be
connected with the left ovary. It continued to increase
in size till it lay in front of the uterus, extending from
the pubes to the umbilicus, and measuring 9 inches trans-
versely. Sir Spencer Wells diagnosed it to be an enlarged
displaced spleen. After an attack of peritonitis, which
was judged to be due to haemorrhage into the spleen sub-
stance, the tumor was aspirated, 10 pints of thick reddish-
brown fluid being drawn off. Microscopically this was
found to contain mainly broken-down red blood corpus,
cles and numerous leucocytes. As the fluid quickly re-
accumulated, and the patient's condition became critical,
Sir Spencer removed the tumor on Ma}' 13, 1888. During
the operation the cyst wall ruptured, and a large quantity
of fluid, similar to that withdrawn by aspiration, rushed
out. The solid part of the tumor, consisting of hyper-
trophied spleen tissue, weighed 4 lbs. There were ex-
tensive adhesions to intestines, uterus, etc. One part in
front was so firmly adherent that it was decided to leave
a portion of the cyst wall, measuring 3 to 4 inches from
above downwards, 2 to 3 from side to side, and (4 inch

314

TOPICS OF THE WEEK.

[August 31,

in thickness. Sir Spencer Wells decided not to drain,
and after securing the splenic vessels with silk ligatures
stitched up the wound with fine silk, including sac wall,
peritoneum and integument. The operation, which lasted
fifty minutes, was performed under carbolic spray, and the
wound was dressed antiseptically; scarceU' any blood was
lost from the splenic pulp, but the patient was much ex-
hausted after the operation. The wound had to be parth-
reopened a week later to give exit to pent-up discharge.
The pus-forming cavity did not communicate with the
peritoneum. Strict antiseptic precautions were employed
and the sac gradually contracted into a sinus. On July
22 she was perfectly well and only a small superficial sore
remained. A year after the operation she continued well,
and could exert herself in any way as well as ever. The
abdominal cicatrix was firm and nothing abnormal could
be discovered either in the abdomen or the pelvis. A re-
port by Dr. Dreschfeld on the blood, dated June 21, 18S9,
more than a year after the operation, states that on mi-
croscopical examination it appeared perfectly normal.
The red corpuscles were of normal size and appearance;
the leucocytes were of normal size and were present in
normal proportion. The quantity of hemoglobin was
between 75 and So per cent. — Londoti Medical Recorder.

ON SUPRA-VAGINAL AMPUTATION OF THE UTERUS.

Dr. Petr. A. Rakuza, of Odessa, Russia, has made the
operation in twelve cases. In nine it was resorted to
on account of uterine fibro-myomata ; in a tenth case
on account of haematometra with haemoatsalpinx and
hitmatocolpus ; in an eleventh the amputation became
necessary in the course of an unusually difficult double
ovariotomy, where there were met with extensive and
extremely dense adhesions of cysts with the broad liga-
ments and womb ; in the remaining case, Porro's Caesa-
rean section for osteo-sarcoma of the pelvis and femur
was performed. In seven cases the operation was made
after an extra-peritoneal method (first described by Kle-
berg in 1 8751, all the patients making good recovery. In
the other five cases, an intra-peritoneal operation was
performed, with three recoveries and two deaths from
peritonitis. Dr. Rakuza's general deductions are these :
I. The extra-peritoneal method gives by far better results
than the intra-peritoneal. 2. Even under strictest anti-
septic precautions the intra-peritoneal amputation is
always associated with the danger of a secondary infec-
tion (through the cervical canal). 3. The operation is
justified only in cases of pedunculated fibroids and in
such ones where the stump is very short. — Transactions
of the Third General Meeting of Russian Medical Men
at St. Petersburg, 1S89, No. 10.

CHINESE DOCTORS.

Tcheng-Ki-Tong, a high military mandarin, has been
edifying the world with some remarkable illustrations of
the esteem in which native physicians are held in China.
One of them having advertised that he had an infallible
remedy for curvature of the spine, a hunchback applied
to him and asked if he could straighten his back. The
doctor undertook to do so, an<l placed the unfortunate
patient on his back on a flat Ijoard. He then placed a

similar board on his chest and abdomen, and loaded it
with heavy weights and stones. The result of this novel
orthopaedic surgery was that the patient was straightened
out so effectually that he died on the spot. The quack
claimed his fees on the ground that he had kept his
promise ; the bargain was that he should straighten his
patient's back, but nothing had been said about his life !
In China, it appears, the distinction between physicians
and surgeons is more sharply defined than with us, and
every man is expected to stick to his own branch of the
profession. A rich merchant was struck by an arrow,
which remained in the wound. The principal surgeon of
the place was sent for, and after insisting on pocketing
his fee in advance cut off the projecting end of the arrow,
leaving the point buried in the patient's body. On being
asked to extract it, he said medical etiquette would not
allow him to trespass on a brother practitioner's province;
the arrow being inside the body, the case was clearly one
for a physician ! An old Chinaman gave the following
practical advice as to how to find the most eminent doc-
tor in a strange place; "Count the number of ghosts
crouching about the doctor's doorsteps ; the one most in
vogue has always the largest number. ' ' — Londoti Medical
Recorder.

TO PUNISH DRUNKARDS.

The Legislature of Minnesota at its last session, appa-
rently realizing the failure of its high license enactment '
of a few years ago, ostensibly for the prevention of drunk-
enness, but in realit}' authorizing the means by which it
may be privileged, passed a law to punish drunkards.
The new law provides a fine of not less than $10, nor
more than ;?30, or b}' imprisonment for not less than ten,
nor more than forty days.- For the second offense, by
imprisonment for not less than thirty, nor more than
sixty days, or by a fine of not less than f 20. nor more
than I50. For the third or all subsequent oflfenses, by
imprisonment for not less than sixty days nor more than
ninety daj-s.

It is to be hoped that this law will be vigorously en-
forced. The Sanitarian has constauth' maintained that
the true criminal is he who gets drunk; and that it is no
more reasonable to hold the liquor seller guilty of pro-
moting drunkenness than it would be to hold the grocer
guilty of promoting theft because his goods are some-
times stolen. Make drunkards odious and cease pam-
pering them as unfortunates and encouraging them to
hold other persons responsible for their sins, and drunk-
enness will speedily go out of fashion. — The Sanitarian.

A SECOND EDITION OF THE SIAMESE TWINS.

77/1? Weekly Medical Rci'iezi' says: " F'rom Wabash,
Ind., is reported the birth of female twins inseparably
connected at the hips and lower part of the abdomen.
There is a head for each of the two bodies, and enough
legs to go around; these protrude from each side of the
body where the trunks are connected at the hips. The
spinal column is coutinous throughout, but no other vital
organs are connected. Each child breathes, pulsates,
and is nourished independently of the other. Both have
free use of their respective limbs. Their joint weight is
12 lbs., and they are plump and hearty."

1889.]

SOCIETY PROCEEDINGS.

315

SOCIETY PROCEEDINGS.

Medical Society of the District of Columbia.

Stated Meefitig, February ij, 188 g.

Thomas E. McArdle, Vice-President, M.D.,
IN THE Chair.

REPORT OF MICROSCOPICAL COMMITTEE.

The Committee on Microscop}^ reported that
the supposed gall stones presented by Dr. Hoeh-
ling were examined chemicalh^ and microscopic-
ally, and found with one exception to be true
gall stones.

The growths of the uterus presented bj^ Dr. J.
T. Johnson, January 16, were myofibroma. The
ovarj- presented at the same meeting was in a
state of cystic degeneration. The portion of
uterus presented b}' him Februar}* 6, can be de-
scribed as a fibromyoma. The part projecting
into the cavitj- of the uterus was in a state of in-
flammation and ulceration.

Dr. George N. Acker presented the following
case and specimen :

HYDRONEPHROSIS IN A CHILD.

Willie Smith, set. 5, colored ; father and mother
living. Child has never been well since birth,
has always been small for age, and emaciated.
About one month ago was taken with a bad cold,
and cough. The cough has continued up to the
time of admission, and the child has gradually
become more emaciated.

Present condition January 23 : . General ap-
pearance, very much emaciated, looks as if he
might be 3 years old instead of 5. Has a marked
phimosis. Temperature 97.4°. Has a dry hack-
ing cough, no expectoration. Diminished reso-
nance over both lungs anteriorly, more particu-
larly on left. Large and small moist rales over
both lungs anteriorly and posteriorl^^ Tongue
coated white, great thirst, ravenous appetite,
seems to be somewhat constipated. Abdomen
pendulous and tympanitic.

24th. Temperature at 11 a.m., 103°. Feet
swollen and oedematous.

25th. Vomited undigested milk, temperature
ranges from 99° to 102.5°.

26th. Oedema of feet and legs diminished, ab-
domen less distended.

27th. Temperature ranges from 100.5° to 102.5°.

29th. Abdomen much more distended, has
vomited milk three times in last twelve hours.
Temp, at 9 a.m. 104.2°.

30th. At 10 30 A.M., temperature 106.

31st. Has vomited twice in last twentj'-four
hours. Has been passing for past three or four
days, an unu.sually large quantity of urine.
Chemical and microscopical tests show it to be
normal. Also has slight diarrhoea.

February, ist. Temperature ranges from 101°
to 102.2° ; three passages from bowels to-day.

2d. Temperature ranges from 100° to 101°.

3d. Very weak, temperature ranges from 99.5°
to 102.8°, pulse too weak to be counted.

4th. Died at 3 a.m. from exhaustion.

Necropsy held eight hours after death. Rigor
mortis, slight. General appearance verj- much
emaciated, abdomen enormously distended. On
opening the chest a considerable quantity of sero-
purulent fluid escaped from the pleural cavity,
left side. The left lung was thicklj^ studded
throughout with tuberculous masses, the upper
lobe being entirely consolidated. A few tubercles
were found in the right lung ; the right lung was
also in a state of chronic hyperasmia. An ab-
normal quantity of fluid was found in the peri-
cardium. The liver was uniformily enlarged,
small caseous masses were discovered at the junc-
tion of pancreatic duct with the duodenum. Both
ureters were dilated, and contained a considera-
ble quantity of urine. Numerous tubercular
masses were found over external surface of spleen.

Up to within four days of patient's death, he
seemed to be verj' bright, and free from pain.
During his entire stay in hospital he passed a
large amount of urine. During the last four
days of his illness he seemed to be in great pain.

Dr. Bermann did not think that this was a
\ case of hydronephrosis as there were no symp-
1 toms recognized during life indicating disease of
the kidneys, and the microscopic appearances
would not indicate degeneration of these organs.
The child died of tuberculosis, the post-mortem
revealed a dilatation of the ureters and hydro-
nephrosis is diagnosticated. Is the name justified
by the dilated condition of the ureters ? He did
not think so, although Dr. Acker accepted the
diagnosis on the authority of Dr. Lamb.

Dr. Thompson : Was there any cause in the
bladder or urethra to account for the dilatation of
the ureters.

Dr. Lamb had presented about a year ago a
specimen of dilatation of the ureter in a new-
born child. Dr. Acker's case was undoubtedly
congenital hydronephrosis. The opening in the
bladder was normal, and the bladder itself was
thick but not diseased. The trouble was above
the bladder. There was a constriction of either
ureter just below the kidney, but no obstruction.
The pelvis of the kidney was dilated and the
pyramids flattened. This is what the books call
hj'dronephrosis. This was the second case he
had .seen.

Dr. Thompson : Would there not be a cause
for a congenital condition of this kind ?

Dr. Lamb : As a rule, no obstruction is found.
None was found in either of the two cases he had
seen.

Dr. Thompson: Congenital deformity ex-
presses a fact but not a pathological fact. There

3i6

SOCIETY PROCEEDINGS.

[August 31,

must be a cause for such conditions. He gave
the case of a man, ast. 50, whose ureter was dis-
tended to the size of the large intestine. He had
examined the opening into the bladder, but the
probe passed through it. He concluded that
there must have been a valvular opening of the
ureter into the bladder causing backward press-
ure. After death a probe may pass through
many such openings, although there may have
been an obstruction during life.

Dr. a. F. a. King : How are we to know that
there was not a congenital stricture of the urethra
since that canal was not examined ? The blad-
der has ruptured from congenital stricture of the
urethra. If there had been a stricture of the
urethra the dilatation of the ureters could be
easily accounted for by the backward pressure of
the urine.

Dr. Bermann objected to the term used, but
would ask Dr. Lamb, assuming that there was
no hydronephrosis, what he would call a case
with such a dilatation of the ureters ?

Dr. L.\mb : This is what the books call hydro-
nephrosis.

Dr. Bermann would call it dilatation of the
ureters.

Dr. King : The post-mortem appearances
show no evidences of obstruction of the ureter
below the dilatation. There may have been some
pressure exerted during fcetal life causing obstruc-
tion and dilatation ; after birth, the pressure be-
ing removed, the obstruction would disappear
and the ureters remain dilated.

Dr. Lovejoy : If we accepted Dr. King's be-
lief that the obstruction existed at the neck of the
bladder or in the upper part of the urethra, how
could we account for the dilatation of the ureters
as far as one inch from the kidneys at the seat of
the constriction ? The dilatation should be above
the obstruction and not below it.

Dr. King : One part of the ureter may be
more dilatable than another.

Dr. Acker accepted the diagnosis of hydro-
nephrosis because the kidneys were softened and
the ureters were distended to the size of the colon.

Dr. D. S. L,amb presented two cases of

INTRA-CRANIAL H.EMORRHAGE,

specimens.

WITH

This specimen consists of the lower half of the
brain, showing a dark blood clot under the arach-
noid membrane covering the pons varolii and me-
dulla oblongata, and extending forwards over crura
cereljri, iiitercrural parts and posterior portion of
orbital lobes.

The patient was a white woman, single, set.
19, who was .said to have been struck on the back
of the head with the blunt end of an axe. Some
time afterwards she was admitted to hospital with
double phlyctenular keratitis and conjunctivitis;
marked headache, photophobia ; the headache

was frontal, intense at times, but thought to be
due to the disease of the eyes. She had also hip-
joint disease, not however, requiring treatment.
She recovered from the disease of the e5'es and
wa.s discharged. Had had no symptom suggest-
ing disease of brain. She then went into the
Women's Christian Association Home, and made
no particular complaint till December 3. When
after a few hours' nausea, faintness and stagger-
ing movements, she died. Attended by Dr.
Mary Parsons.

The post-mortem examination by Dr. Lamb
showed the condition described in the specimens ;
also the following : Face pale ; no scar on scalp ;
no injury to bone ; adhesion of dura mater to
skull only ordinary ; but there were several long
bands of adhesion of pia mater to tentorium
cerebelli on right side ; and the pia mater was
congested. The blood described extended into
the 4th ventricle and down the spinal canal as far
as could be seen from the cavity of the skull.
There was bloody serum in the lateral ventricles.
Both lungs contained bloody serum. The heart
was somewhat enlarged ; the aortic and mitral
valves slightly thickened. Ascending aorta
showed a large atheromatous patch. Liver con-
gested, spleen, stomach and intestines normal,
kidneys normal and bladder full. The inner sur-
face of the mouth of the uterus showed a fringe-
like growth, and the cavity contained muco-pus.
Ovaries enlarged ; in the right was a large cavitj'
containing blood ; its inner surface ridged ; the
wall very thin and ruptured in handling. The
left ovary was thickened ; cortex contained niany
large cysts filled with white granular matter.

The next specimen consists of the lower half
of the brain showing large clots in the right
cerebral hemisphere ; the haemorrhage has caused
extensive laceration, involving the frontal, par-
! ietal and occipital lobes, corpus striatum and
thalamus opticus ; but opening into the lateral
ventricle only through the anterior part of the
corpus striatum ; the blood thence finding its way
into the left ventricle through the foramen of
] Monro.

The patient was a colored man, set. 52 ; had
been a widower, but was married just a week be-
fore he had a stroke of paralysis. He was a
large muscular man with thick neck ; medium
height and about 180 lbs. weight. He had eaten
heartily on the evening of December 5. The
next morning he was found in a stupor, from
which he was arou.sed with difficulty ; respiration
stertorous ; there were spasmodic movements of
the right arm ; right side of face paralyzed ; left
side of body also ; pupils dilated and insensible
to light ; dysphagia ; unable to iirotrude his
tongue ; tenderness on right side of neck aggra-
vated by movement of head ; urination involun-
tary ; constipation ; speech thick. Pulse at first
i full and quick ; afterwards weak and frequent.

1889.]

SOCIETY PROCEEDINGS.

317

He died eight days after seizure. His mother
had died of apoplexy ; a sister from softening of
brain. He was an inveterate smoker ; used
stimulants in moderation. Attended by Dr. S.
R. Watts.

These typical specimens are presented for con-
trast. The haemorrhage into the substance of the
brain in the one case, that of the old man ; and
into the membranes in the other, that of the
young woman. In both cases the accident was
caused doubtless by rupture of a diseased blood-
vessel. But the cause of the disease of the blood-
vessel was probably different in the two cases.

In that of cerebral haemorrhage, there is a
history which seems to show a hereditary ten-
dency to disease of blood-vessels ; the mother
died of apoplex3-, a daughter, of softening of
brain. Probabl}' also we should give some credit
to the man's plethoric habit as a predisposing
cause, although .such a cause is disputed. How
far an inveterate habit of smoking maj^ produce
disease of blood-vessels of the brain is an in-
teresting question. The absence of symptoms
suggesting disease of thoracic or abdominal vis-
cera was the reason for not including these in the
examination ; it is possible that there was some
disease of heart or blood-vessels of those cavities.
It seems altogether likely that the rupture of the
diseased vessel in the brain was induced by the
sudden fulness and pressure following a hearty
meal, especially as the man went to sleep soon
afterwards. It is worthy of note that the hrem-
orrhage took place into the brain substance just
outside the corpus striatum, the usual situation.
To the naked ej'e the large vessels appear normal;
the degeneration, probably fatty, I presume in-
volves only the minute vessels.

In the case of the young woman, there is to
the naked eye also no appearance of disease of
blood-vessels ; but we can hardly doubt that
there is disease. There is no history of heredi-
tary tendency, either positive or negative. But
there was marked atheroma of the ascending
aorta ; and the heart was somewhat enlarged and
its valves thickened ; there was also old hip-joint
disease. It is easy to believe, therefore, that
there v^as some disease of the blood-\'essels of the
brain and membranes, possibly cerebral aneurism,
which is said to occur oftener in children between
10 and 20 years of age that at any other period
of life. I am unable to trace any connection be-
tween the reputed injury received and this haem-
orrhage, although quite readj- to believe that
there may have been some connection.

I did not mutilate the specimens to ascertain
the particular ves.sel involved in each case, be-
cause it is so seldom that the vessel can be found
even with the greatest painstaking.

Dr. Thompson was surprised that one of these
cases did not have paralysis, and could only ac-
count for the absence of such symptoms by the

fact that the patient did not live long enough for
them to be recognized.

Dr. Mary P.\rson.s : The patient screamed
and staggered to the bath room, and then lost the
use of her limbs. She was conscious and talked
rationally up to five minutes of her death.

Dr. a. a. Hoehling, U. S. N., presented a
specimen of

tape-worm.

The patient, a marine, aged 24 j^ears, native of
Chicago, 111., enlisted last November ; so that he
probabl}' had the worm before he entered the ser-
vice. First passed segments of the worm about
Januarjf 21, 1889, and has never felt a bad symp-
tom from its presence. On Februar}^ 6, after
breakfast, he was told to eat nothing more until
his treatment should have taken place. That
night he was given 10 grains of blue mass. At
1 1 o'clock on February' 7 he took 15 grains of the
oleo- resin of male fern every 15 minutes until he
had taken eight doses; in all 3 ij. In an hour
after the last dose of male fern he was given one
ounce of castor oil. That afternoon he had four
stools, and passed this worm in divided sections.
A good deal of the smallest .section, near the neck,
has been found ; but the slender inch of real neck
and the pin-head sized head have not been dis-
covered. Flint tells us that the head is rarely
found after treatment for tape-worm, but that if
the worm breaks off very near the head there is
not enough body left to nourish the remainder,
and a cure is accomplished. Striimpel saj's that
in attempts to pull the worm away from the bowel
where the head fastens itself to the mucous mem-
brane, there is usually a separation caused near
the neck and the head remains clinging to the '
spot of its attachment. I have treated about six
men for this complaint, and have not seen the
head of the worm yet. This specimen I believe
to be of the variety known as the ttznia solium.
As I have usually been the shipmate of my pa-
tients for two or three years, I have had the op-
portunity to observe that tape-worm has a decid-
ed tendency to reappear, even after two or three
lots of segments have been gotten rid of by treat-
ment in the course of a cruise.

Dr. a. a. Hoehling, U. S. N., read a paper on

THE olive oil treatment OF HEPATIC COLIC.

Prof. H. W. Wiley, of this city, tells us in The
Medical Ne-a's, of July 28, 1888, that " Dastre, in
a recent study of the action of the bile in fat di-
gestion {Comples Re?idus, tome 106, p. 217) has
shown that the pancreatic juice alone is not capa-
ble of digesting fats;" also that "these conclu-
sions of Dastre have just been confirmed by the
experiments of Prevost and Binet {Coviptes Rcn-
(//«, June 11, 1888, p. 1690). These investiga-
tors find that in dogs, when the bile is prevented
from taking part in digestion, fat foods are voided
unchanged."

3i8

SOCIETY PROCEEDINGS.

[August 31,

In " Dalton's Treatise on Human Physiologj', "
seventh edition, pages 181 and 182, it is stated
that "the bile passes into the duodenum in much
the largest quantitj- immediately after feeding.
During the intervals of digestion it accumulates
in the gall-bladder ; and in animals which have
been for some time without food the gall-bladder
is usually distended with bile, while in those
killed immediately or soon after feeding it is com-
paratively empty. At the commencement of di-
gestion it is excited to contraction, causing a sud-
den flow of bile into the duodenum. After that
time the discharge remains nearly constant."

Admitting all of the statements just quoted to
be proven, we can formulate an explanation of
the modus operandi of large doses of bland oils
in removing gall-stones from the ducts in which
they have been arrested. Physiological action
causes the removal of the obstruction. What is
more likely than that the ingestion of a large
amouut of one of the food oils should furnish a
stimulus for the secretion of a proportion of bile
relatively equal to the amount .of oil to be di-
gested? And would not this increased quantit}'
of bile aid in the propulsion of the engaged gall-
stone, firstly by lubricating it thoroughly, as well
as bj- moistening completelj- the walls of the- ducts
which maj' be partiallj' dry from occlusion of
their lumen by the impacted gall-stone ; and sec-
ondly, by the force of hydrostatic pressure from
the proper direction for the expulsion of the cal- i
cuius? Is it not probable that the contraction of
the gall-bladder mentioned \>\ Dalton, also adds
to this hydrostatic pressure, both being called into
play when the digestion of a large dose of oil ;
begins? |

We have then a force pushing the calculus from
behind, the latter freshly moistened, and the ducts
made more distensible by the new access of bile :
and thus the stone reaches the duodenum. I
might add that when, as is frequently the case,
castor oil is given in these seizures there is no
reason why the physiological actions just spokeu
of should not be called into plaj', and aid the ther-
apeutical or purgative efiects of the castor oil.
We know that infants digest this oil very fre-
quentlj', and therefore require a relatively large
dose ; and it is reasonable to .suppose that adults
also digest some of its bland portion.

We have empirical knowledge that attacks of
hepatic colic have often been relieved by large
doses of olive oil, and that in such cases .solids
have been voided that were regarded as true
gall-stones. Dr. T. H. Streets, U. S. N., reports
such a ca.se in the Medical Record oi April 14,
1888; in the Medical Neu's of May 26, 188S, I
reported a case in which prompt relief was af-
forded by olive oil, but no stone was found, nor
was a clo.se search made. On the other hand.
Prof. D. W. Prentiss reports a case in the Medical
News of May 12, 1888, in which relief was given

the patient, but the particles removed after large
doses of cotton-seed oil were found to be soap, on
examination by Dr. H. W. Wiley, as described
in his article heretofore quoted.

Prof. R. T. Edes, in his text-book on " Mate-
ria Medica and Therapeutics," 1887, p. 287, speaks
of the same sort of masses as "lumps of soap
formed b}' the oil with the alkalies of the intes-
tinal secretions." In conversation with Drs.
Edes and Prentiss I learned that they do not deny
that true gall-stones maj' be discharged during
the treatment under consideration : but they take
the position that semi-solid saponified masses of
injested oil are sometimes passed, and that such
substances have been mistaken for gall-stones.

Dr. Hoehling presented a case of

GALL-STONE COLIC TREATED BY THIS METHOD.

Henry T. , marine, aged 46 years, native of
Italy, was the patient who passed the gall- stones
exhibited to the Societ}', and I am indebted to
Dr. A. F. Magruder, U. S. N., for the notes of
his case. He had his first attack of gall-stone
colic Nov. 12. His bowels were opened by pur-
gatives, and jaundioe relieved in about two days,
and he passed the two smaller gall-stones. No
oil was given during this attack. On Januarj' 9
he had another acute attack of the same nature,
lasting five hours, which was followed for several
days b}^ nausea and vomiting, with pain on pres-
sure over the gall-bladder, abdominal tenderness
and distension, and steadily increasing jaundice.
Unable to procure a movement of his bowels un-
til January 14, on which day he took about one
quart of olive oil in divided doses, some of which
he vomited up again, and in the afternoon his
bowels were moved, attended by the passage of
the two largest gall-stones that have been shown
to the Society by me. His urine had become as
dark as porter, and his skin looked a dark green.
He had partaken of no food of any kind in four
days, and had been troubled with singultus for
twelve hours before his bowels were moved.

After the passage of the gall-stones he com-
menced to improve steadily, and he continues to
do so. His wife states that during the olive-oil
treatment he had a stool composed of "thick bile"
after he had passed the calculi. She describes it
as a gruel-like mass which would about fill a tea
cup. We may well regard this grumous dejec-
tion as being a portion of the olive oil emulsified,
or partially .saponified, and discolored by biliarj-
and faecal additions.

It is interesting to note that no semi-solid sap-
onified lumps were found in this case, though a
very large quantity of oil was taken. We might
inquire how is the soap formed in those cases
where it occurs. As many of the.se patients are
early put upon an alkaline treatment I supposed
that might account for the .saponification ; but
experiments with a solution of bicarbonate of

1889.]

FOREIGN CORRESPONDENCE.

319

soda added to olive oil in a vial, at the tempera-
ture of a warm room, did nothing to confirm this
view. The alkalies found in the bowels never
produce lumps of soap in a state of healthy di-
gestion, so far as I am aware.

FOREIGN CORRESPONDENCE.

LETTER FROM PARIS.

(FROM OUR REGULAR CORRESPONDENT.)

The International Congress on Dermatology and
Syphilogi-aphy — The International Congress on
Hypnotism — The International Congress on Men-
tal Medicine.

Among the numerous International Congresses
that are being held in Paris since the opening, in
May last, of the Universal Exhibition, one of the
most important is that on Dermatology and Syph-
ilography. The meetings, which will extend from
the 5th to the 9th of August, will be held at the
Museum of the Hopital St. Louis, than which, a
more appropriate place could hardly have been
selected for the purpose. The first meeting took
place on the morning of the 5th inst., when more
than 220 members, composed of French and for-
eigners, were present. Among the latter were
the most dinguished dermatologists of their re-
spective countries. This may be seen b}- citing
the following names: Kaposi, Hans, Hebra, Neu-
mann of Vienna, Malcolm, Morris, Hutchinson,
Crocker of London, Duncan Bulklej' of New York,
Duhring of Philadelphia, Tarnowsky of St. Peters-
burg, Olavide of Madrid, Manassei of Rome, Zam-
baco of Constantinople. Besides Dr. Unna, other
distinguished dermatologists of Germanj- sent in
their adhesion to the Congress but, at the last mo-
ment, they all withdrew, wh}' and wherefore, re-
mains a mystery. This of course has been severe-
ly commented on by the French, and not without
reason, as it cannot be said that such a proceeding
on the part of the German savants was in good
taste. However, in spite of this unpleasant inci-
dent, it is anticipated that the Congress will be a
great success. The first meeting was presided
over by M. Ricord, the illustrious syphilographer
and octogenarian, who, notwithstanding his ad-
vanced age, expressed himself willing to preside,
and in ver}' suitable terms welcomed the foreign
members of the Congress. He was naturally the
object of a veritable ovation, M. Peyron, the
Director- General of Public Assistance, retraced
the histor}^ and origin of the museum from De-
vergie, its founder, to the present time, which he
said was the finest museum of its kind in the
world, and where dermatology' may be studied as
on the living subject. This is due to the consum-
mate skill of M. Baretta, the eminent modellist,
who is the author of the incomparable collection

now to be seen in this museum. The bureau was
next constituted, and Dr. Hardy, the well-known
dermatologist, was elected the actual President
of the Congress.

Another Congress, not less interesting, is that
on Hypnotism, which has been organized under
the auspices of Drs. Dumontpallier of Paris, Gras-
set of Montpellier, Liegeois of Nancy, and Beril-
lon of Paris. The Congress has for Presidents of
Honor Drs. Charcot, Brown-Sequard, Azam, Brou-
ardel, Charles Richet, vSombroso. The Congress
is International, and will be devoted to experi-
mental and therapeutic hypnotism. The first
meeting took place on Thursday the 8th inst.,
and the Congress will continue in session until
Monday the 12th inst. The meeting was well
attended, and presided over by Dr. Dumontpal-
lier. The following subjects will be discussed at
the meetings : i . Necessity for forbidding public
exhibitions of hypnotism, hy Dr. Ladame, of
Geneva. 2. Relative value of the different pro-
cesses intended to produce h}'pnotism and to in-
crease suggestibility from a therapeutic point of
view, by Professor Bornheim, of Nancy. 3. In-
dications of hypnotism and suggestion in the
treatment of mental disease, bj' Dr. Voisin, of
Paris. 4. Application of suggestion in the men-
tal education of vicious or depraved children, by
Dr. Berillon, of Paris. 5. Relations of sugges-
tion and somnambulism to the law and to medi-
cal jurisprudence. Responsibility of those in
hypnotic conditions, by Professor Liegeois, of
Nancy. It will be seen that the programme is
sufficiently interesting, but it is impossible to
give even the summary of the discussions in an
ordinary letter.

On Monday the 5th inst. the International Con-
gress of Mental Medicine was opened in the large
amphitheatre of the College of France, under the
Presidency of Dr. Falret. Drs. Ball, of Paris,
and Morel, of Brussels, were elected Vice-Presi-
dents, and Dr. Ritti General Secretary. Dr. Fal-
ret read a report on the first question of the
programme : Obsessions with consciousness (in-
tellectual, emotive and instinctive). He said that
it is not very long ago that the consciousness of
a patient's state excluded the idea of a mental
malady. However, Esquirol and Baillarger had
already published observations of insanity with
consciousness. Now-a-days, all physicians admit
these singular morbid forms. Certain ideas, cer-
tain emotions, certain impulsions, take hold of a
patient in an irresistible manner. He knows that
they are false, deceiving and not natural, which
he wishes to repel. He combats them, but they
impose themselves on him in spite of himself.
One patient cannot see a razor without wishing
to cut his throat, another is beset with the idea
of stealing ; the latter is at the same time beset
with the idea of homicide. These troubles, though
varied, have the same character of being recog-

320

DOMESTIC CORRESPONDENCE.

[August 31,

nized so far as concerns the consciousness of the
patient and the domination of his will. Heredity
here plaj'S a role so essential that Magnan desig-
nated this form of insanitj- under the name of
hereditarj- insanity. Others have named it in-
sanity of degenerated subjects. It is remittent,
with intervals of appeasement sufficiently long to
lead one to believe in a permanent cure. It is
never altogether isolated in its sj^mpto raatic man-
ifestation, but it is accompanied with anguish,
with doubt and varied emotive symptoms. On
the contrar)', it is never associated with halluci-
nations, it is not transformed into any other vari-
ety of mental aberration, it never ends in de-
mentia, and it is onlj- exceptionally that it is
accompanied with the delirium of persecution or
that of melancholy. The members of the Con-
gress listened with great interest to the report of
Dr. Morel, on the works of the delegates to the
Internationa"! Commission to establish the bases
of a good International statistic of mental dis-
eases. Dr. Morel proposed the following classi-
fication: I, mania; 2, melancholia ; 3, periodi-
cal insanity (a double form, etc.) ; 4, progressive
systematized insani.ty ; 5, insane dementia ; 6,
organic and senile dementia ; 7, general paral-
ysis ; S, neurotic insanity (hystero-epilepsy, hy-
pochondriasis, etc.) ; 9, toxic insanity ; 10, moral
and impulsive insanity; 11, idiocy. a. b.

DOMESTIC CORRESPONDENCE.

Yello-sv Fever.

Audi Alteram Partem.

To the Editor. — I have just read a letter in
The Journ.\l for July 27, last, from S. Paulo,
Brazil, about the yellow fever in Santas, Cam-
pinas, and other smaller places in the same
Province, with a great deal of interest and atten-
tion, as I am in the position to bear testimony to
its correctness, having been all the time of the
late epidemic practicing in Rio de Janeiro, which
also suffered at the same period ; so much so that
the fatal year, 1889, will not soon be forgotten
there. I was in correspondence with a medical
friend in S. Paulo who gave me a very graphic
picture of the state of affairs there, and I shrewdly
suspect that he is the author of the letter in The
Journal ; and as I know and esteem him as a
competent observer of rigid impartiality, I think
he will be obliged to me for explaining away an
erroneous impression he seems to have imbibed
from the defenders of Freire's preventive inocu-
lation (or vaccinations, as he himself calls them)
against yellow fever.

The paragraph I allude to is as follows : " It is
to be regretted that the gentleman who was sent
out here by our Government to investigate Dr.

Freire and his method could not have selected
this season of the year for his studies, when
yellow fever can always be found and Dr. Freire
is always at home."

Now Dr. Sternberg was not sent to study yellow
fever clinically, he having had ample experience
of the disease in question during several epidem-
ics. He went as an expert in bacteriologj-, and
under definite orders, signed by the President of
the United States, to studj- the results of the in-
oculations made by Dr. Freire, and it i*; the
opinion of all impartial people who are familiar
with this affair that he did it in a most thorough
manner. Besides, one t5-pical case of yellow fever
would be enough to furnish material for Dr.
Sternberg's investigations as to the universal ex-
istence of the pathogenic germ of Dr. Freire, and
no one will deny that such a case can, unfortun-
ately, be found at all seasons of the year in Rio
de Janeiro, and that Dr. Sternberg found more
than one case during his sta}- in Rio, and that he
worked jointlj^ with Freire in his laboratory. I,
myself, was with him one day in Dr. F^'reire's
laboratory, where I was shown a micrococcus
said to be the germ in question, and once again
at an apothecar\-'s in Rua Conde d'Eu, when Dr.
Freire inoculated three persons in our presence.

That is all, and I think I have said enough to
stay opinions on Dr. Sternberg's proceedings until
the publication of his forthcoming report, which
will be ample and conclusive enough to set at rest
this unhappy dispute, v.hich up to to day has ex-
hibited more violence than is admissible in a
scientific discussion.

R. Cleary, A.m., M.D.

Washington, D. C, August 19, 1889.

Ovarian Cyst, wltli Extensive Adlieslons, in
a Patient SO Tears of Age— neeovery.

To the Editor: — I send you the report of a case
which I thiiik will be of interest to the readers of
The Journ.\l, and hope it maj' be of use to
others in similar cases in forming a favorable
prognosis where age seems to contradict any op-
erative procedure that may give the patient a
chance of prolonging life.

Mrs. H., 80 years old, native of South Caro-
lina, resident of Edisto Island. First seen by me
July 2, 1889. Her weight at that time was 85
lbs., her general health bad. She insisted on my
operating at once, strongly against my desire and
advice — said life was a burden to her, a.ssmned
all the responsibility and preferred death under
the operation, rather than to live any longer in
her present condition. Four days later I made
an exploratory incision in the mediati line, as
usual, and about 6 inches in length. During the
progress of the operation this incision was extend-
ed to the umbilicus. The entire peritoneal cavity
was of a dark crimson hue, but there was no

1889.]

BOOK REVIEWS.

321

lymph, pus, or ascitic fluid. The tumor, which
was about the size of a foetal head at full term,
was found to be firmly adherent to the intestines
everywhere, except its upper surface. Not even
the slightest space between the tumor and intes-
tines could anywhere be discovered. There was
no attachment to the uterus, bladder, or other
abdominal viscera. Its enucleation was at once
considered: but after separating a portion, in area
equal to the surface of the palm of the hand, with-
out discovering anj- lamination, but with the feel-
ing that I was digging into solid tissues, instead
of separating layers, I became alarmed lest I
should make matters worse, and desisted. Dur-
ing the progress of the operation the abdominal
viscera were protected b)- frequent applications of
soft, warm cloths, wrung out in hot carbolized
water. The natural heat of the body was main-
tained by keeping the temperature of the room at
80° F. , and during the latter part of the operation,
by also applying bottles of hot water to the pa-
tient's extremities. The patient was under chlo-
roform sixty-five minutes.

The shock was great and left her in almost a
dying condition ; under hypodermatic injections
of ether and atropin she rallied. The spray used
was listerine i to 8, the instruments, sponges,
etc., were kept immersed in a hot 2 per cent, so-
lution of carbolic acid. The highest temperature
reached was 101.5°, on the third day. The pa-
tient on the third night was given a suppository
of I4 gr. of morphia, after that she slept naturally
without opiates. The day following the opera-
tion, a small quantity of milk was taken and read-
ily assimilated. Nothing but milk and beef-tea
was given till the eighth day, when chopped beef
and cracker was allowed and well borne. The
abdominal sutures, which were of silk, were re-
moved on the sixth day, primary union being
perfect, and on the following day the bowels
moved naturally.

The patient has recovered and at the present
time, August 10, 1889, writes me that she eats
and sleeps well and is in good health, weighing
now I ig lbs.

In presenting this contribution to the profession
I give no exciise, as the case seems to me, at least,
of great importance, first as to the extreme age of
the patient, and secondly to the almost fatal shock
sustained, which as bj' a miracle she slowly rallied
from and ultimately recovered. Re.spectfull}-,

Thos. Legare, M.D.

Charleston, S. C, August 19, 1SS9.

The Pekin University and its Medical
Department.

To the Editor: — I obser\-e in a recent number
of The Journal a statement that a University
under British tuition has been established at Pe-

kin, China, with a medical department in work-
ing order.

The Pekin University has been organized in
that city for a number of years, under the direc-
tion of the Rev. Dr. L. W. Pilcher. The medi-
cal department has been in active operation for
several years and is doing excellent work. This
institution, however, is under American control,
and the majority of its faculty are Americans.
jAs. E. Pilcher, Asst Surg. U. S. Army.

Governor's Island, New York City, August 22, 1889.

NECROLOGY.

Death of Dr. Turner.

Dr. J. Edward Turner, the Founder of the New
York State Inebriate Asylum, at Binghamton,
N. Y., died at his home in Wilton, Conn., on
the 24th of July, at the age of 67 years, after a
short but painful illness.

Thoroughly impressed with the idea that
inebriety is a disease needing medical treatment,
he gave his life to the work of winning over
public opinion, and the cooperation of scientists
and the thoughtful philanthropists of his age, to
the treatment of the inebriate as a sick man,
and not as a criminal.

The Binghamton Asylum was founded as the
result of his individual effort, and though for a
while diverted to other uses at the time of his
death, he was its sole proprietor, and had he
lived it would doubtless been the ambition of his
life to restore it to its arigiual purpose.

He was in its fullest sense a philanthropist,
and only recently is the medical profession ready
to accept and utilize many of the tenets which he
began to promulgate nearly fifty years ago.

BOOK REVIEWS.

The Diagnosis and Treatment of Extra-
uterine Pregnancy. By John Strahan,
M.D., M.Ch., M.A.O. (Royal University of
Ireland). Jenks' Prize Essay of the College of
Physicians of Philadelphia. Philadelphia : P.
Blakiston, Son & Co. 1889.

This is a valuable contribution to our knowl-
edge of a very interesting subject, and well merits
the prize which has been awarded it. The ques-
tion of diagnosis before rupture, at the time of
rupture, during the first three months, and at or
about the viable period are very- fully discu.ssed.
Considerable space is also devoted to the question
of differential diagnosis. Among the concluding
remarks on diagnosis the author saj-s, ' ' Those

322

BOOK REVIEWS.

[August 31,

who diagnose or fancy they diagnose early extra-
uterine pregnancies depend on two things, prin-
cipall3% viz., the presence of all the most impor-
tant signs of ordinary pregnancy and the
interruption of menstruation, if onl}' for a period
or two, of course with the presence of an extra-
uterine tumor. Now the ordinary signs of preg-
nancy and menstrual suspension may both be
absent, in which case thej^ are apt to fail most
disgracefully."

The results of rupture are one of two things,
either an intra- or an f.v/ra-peritoneal haemato-
cele. In the latter case the rupture is so situated
that the blood is poured out between the layers
of the broad ligament and the effusion is confined
in some degree ; while in the intra- variety the
bleeding, which is limited only by the peritoneal
cavity, is sure to be fatal, if not immediately, at
least after a very short time.

The killing of the fcetus by electrical methods
or by injections of drugs, etc., suggests an inter-
esting consideration, and the author observes
that, " As in intra-uterine pregnancy the death
of the ovum is the great cause of abortion, may
not our killing the foetus bring on efforts at its
expulsion, the false abortion which ends in rup-
ture of the tube ? In fact, may not the killing
of the foetus promote the very accident we are so
anxious to guard against?" Among other con-
siderations which the destruction of the foetus
gives rise to, is, whether or no the placenta con-
tinues to grow after the foetal death. This is a
controverted point, though Tait and others do
believe in the continued growth of the placenta.

In cases of doubtful diagnosis, the foetus being
dead, a trocar or aspirator may be used to draw
off some of the liquor amnii, both to confirm the
diagnosis and relieve the pressure within the
tumor, though "unless it has been decided to'
operate immediately for the removal of the fcetus,
the use of the trocar is utterlj- unjustifiable. But
very few women have long survived its u.se."

In the forty-two operations Tait has done for
haemorrhage and abdominal collapse, a name in-
troduced by Barnes to denote that group of symp-
toms which follow rupture, he has had only two
deaths, a mortality of 4.7 per cent.; and it is safe
to say that every one of these would have died
under any other treatment.

A bibliograghy of the subject is appended to
the volume, making it very convenient for those
who wish to study further.

A Manual of Instruction for giving Swed- j
isH Movement and Massage Treatment. \
By Pkof. Hartvig Nissen. Philadelphia
and London ; F. A. Davis, Publisher. 1889.
A small work of 128 pages, illustrated by 28
woodcuts. According to the author this is prob-
ably the only manual on this subject in the Eng-
lish language which gives any information how

to apply the treatment in different diseases. It
is the object of the handbook to give directions
sufficient to enable the physician, or an operator
under his direction, to apply the " movements "
in the sick-room without the aid of apparatus.

The value of this mode of treatment should be
recognized and neither prejudice nor ignorance
should stand in the way of its adoption when it
can be beneficial.

The Physician Himself and things that
CONCERN His Reputation and Success. By
D. W. Cathell, M.D. Ninth Edition, Re-
vised and Enlarged. Philadelphia and London:
F. A. Davis, Publisher. i88g.

If the change from the old-fashioned preceptor-
ship had its immense advantages to medical edu-
cation they were not, however, wholly unqualified ;
where much has been gained by the modern system,
still something has been lost. What that loss is
the present volume indicates better than any
brief work can. That peculiar gift of professional
tact and talent the author has tried to make con-
ceivable to the reader. It is these qualities, emi-
nently essential to the successful practice of medi-
cine, and usually best acquired by associating
with and obser\nng those who possess them, that
the preceptor of former times conveyed to the
student under him by a power of personality and
dignity of bearing which we venture to say few
schools are capable of exerting over their students.
The success of this work has been such that a
ninth edition is before us. The author has in
fact made accessible to the young graduate many
valuable rules of conduct and words of advice,
which as the custom is now-a-days remain un-
taught, because in the verj' nature of things we
cannot endow a corporate body (a medical faculty)
with that personality which will enable it to
: teach a philosophy of conduct that shall give a
distinguishing dignity to all who acquire their
knowledge under it.

Such principles the young physician of to-day
must acquire for himself, guided by his own
natural instinct, observing where he can and read-
ing where he can. An opportunity for such to
read with profit is here given.

Wood's Medical and Surgical Monographs,
August, 1889. William Wood & Co., Pub-
lishers.

This number contains monographs upon : "The
Treatment of Syphilis at the Present Time," by
Dr. Maximilian von Zeissl. "The Treatment of
Inebriety in the Higher and Educated Classes,"
by James Stewart, B.A., and a " Manual of Hy-
podermic Medication," by Drs. Bourneville and
Ikicon. The latter is the most extensive work of
the kind which we have seen. It contains more
than 125 different drugs whose administration

1889.]

BOOK REVIEWS.

323

and therapeutics are taken up from the hypoder- ',
mic standpoint, and arranged aphabetically. For
instance, mercurial medication b\' the hypodermic ]
method receives about 15 pages. The mode of
preparing and using the albuminate and pepton-
ate of mercurj' for injection is fully given. Qui-
nine occupies 1 1 pages, and the discussion of the
other more important drugs is taken up under
the heads of Physiological Effects, Local Effects
and Therapeutics. There are included many new
drugs which are commonly not employed hypo-
dermicall}', and of which even the therapeutics is
not well known, .:'. ^., arbutin, hypnom, kairin,
solanim, sparteine, arseniate of strj'chnine, thallin,
urethan, and others. While many unusual drugs,
and ones of qviestionable value, are given a place
in this manual, those of well-recognized value
receive full and satisfactory treatment.

Transactions of the American Orthopedic
Association. Vol. I, Published by the As-
sociation. 1889.

The first volume of this society is a promising
one, containing as it does, some twenty-four
papers and the discussions which follow each.
It will be read with interest b}- surgeons, and
particularly those who devote themselves to this
department.

Dr. E. H. Bradford has a valuable communi-
cation on the "Treatment of Club-Foot," to
which is appended a tabular record of 10 1 cases,
giving results and detailed notes in illustration.
A studj' of these cases is used in the attempt to
substantiate the following statements :

1. " That the cases of infantile club-foot can,
as a rule, be thoroughly and efficiently treated
without tenotomy b}' mechanical correction, and
mechanical retention alone. Tenotomy, however,
is an aid even in infantile cases,"

2. " That in older cases tenotomy aids the cor-
rection, and is not injurious in the permanent
result."

3. "That, as a rule, resistant cases of the
severest type can be corrected without tarsal
osteotomy, by forcible rectification."

4. " That in exceptional cases of resistant club-
foot, tarsal osteotomy may be needed for perfect
rectification, and is not only justified, but may be
indicated in exceptional instances."

Some interesting points were developed in an
essay entitled, "An Experimental Study of Fix-
ation and Traction in the Treatment of Hip-Joint
Disease, with the Description of a Splint," by
Robert W. Lovitt. American orthopedic sur-
geons generally agree that the best results are to
be obtained by the continued use of the long
traction splint. While on the other hand,
English surgeons do not take the same view,
holding that it is impossible to maintain exten-
sion with such splints as those described by
Davis, Taylor, Sayre and others ; also that they

do not furnish adequate fixation of the joint. A
series of experiments were undertaken to de-
termine how much fixation is afforded by the
ordinarj- Taylor hip splint using one perineal
band, when walking is attempted ; and also how
much fixation was dependent upon extension.
A pencil attached to the apparatus registered
mechanically any motion of the joint and a
dynameter measured the number of pounds ex-
erted in extension. The apparatus was first tried
in an anchylosed hip, and of course, showed no
motion, then upon those who had hip disease,
and those who were sound. An amount of mo-
tion equal to from 15° to 40° was recorded, and
this seemed neither increased nor diminished b)-
altering the extending force. The author does not
under\'alue extension, but his experiments seem
to show that it does not contribute to fixation in
any perceptible degree. Former investigations
have shown that the articular surfaces are not
in the least separated by any ordinary amount of
traction, therefore the only explanation of the
benefit to be derived from extension rests upon
the fact that force thus applied overcomes mus-
cular spasm, and thus diminishes the pressure at
the points of contact within the articular capsule.
At least the modus operandi of this agent is
open to further study.

We might cite portions of many other papers
which deal minutely and scientifically with their
various subjects, but those who are interested can
more profitably consult for themselves.

Surgical Tre.atment of Diseases of the

Brain. By Professor E. v. Bergmann.

1889. Published by A. Hirschwald, Berlin.

Review in Berliner Klinische Wochcnschrift,

July 8, 1889, by W. Koerte.

The author advises to operate only in cases in
which a definite diagnosis can be made. In cases
of hernia of the cerebrum he advises tying of the
pedicle and removing the tumor. No great harm
IS noticed from the loss of brain tissue in these
cases. There is less danger in the operation for
cenencephalocele than in that for hydroencephal-
ocele, because in the latter the danger from hy-
drops ventriculorum continues after the operation.
In the occipital region cephaloceles are amenable
to surgical operation only if they are small or if
they are pure meningoceles. Deeply seated ab-
sce,sses are considered at length. They should
be opened and drained whenever positively diag-
nosed. The diagnosis depends chiefly upon the
etiology. The following causes are given : trau-
matic injury to the hard or soft covering of the
brain, or suppurative inflammation of some skull
bone, usually the temporal, in connection with
otitis media purulenta. Extensive suppuration,
notably of the lungs, may be followed by metas-
tasic abscesses of the brain. They may also de-
pend upon tuberculosis. In these two instances

324

MISCELLANY.

[August 31, 1889.

nothing can be hoped from surgical aid. In the
other much depends upon an early diagnosis.

The important symptoms are: i, those caused
bj' the accumulation of pus (temperature, general
condition) ; 2, compression caused b\- the growth
of the abscess ; 3, regional affection, this is espe-
ciallj- marked if the abscess is near the motor re-
gion of the cortex, but the absence of regional
affection has no absolute weight if the other sj-mp-
toms exist. Von Bergmann reports eight cases
of successful diagnosis and treatment. All of
these cases followed chronic purulent inflamma-
tion of the middle ear. He warns very strongly
against opening the skull unless a definite diag-
nosis has been made.

The author is much less hopeful regarding sur-
gical relief for tumors of the brain. The tumor
may be diagnosed but it may be difficult to locate
it definitely. It is also impossible to determine
whether it can be enucleated and, if this is possi-
ble, whether or not it will recur. V. Bergmann
quotes the ver},- important collection of cases by
H. White, which shows that of the 100 cases nine
might have been relieved by surgical operations,
but of these seven could not have been diagnosed
on account of their location.

In cases in which a tumor cannot be located
definitely, exploratory trephining is not justifia-
ble. Aside from the possibility of not finding the
tumor there are two great dangers, viz. : haemor-
rhage and secondary oedema. All of these prin-
ciples are confirmed by clinical histories of cases
observed by himself and others. In seven cases
intracranial tumors were diagnosed, located and
removed. Three cases died after the operation,
one from recurrence after three months, and three
cases recovered permanently. Of eighteen cases
eight died after the operation, two from recur-
rence, and eight recovered. In epilepsy opera-
tions are allowable only in clearly marked ca-ses
of Jacksonian, /. t\, epilepsy due to cortical irri-
tation. In these cases v. Bergmann advises exci-
sion of the diseased portion by Horsley's method.

In the last chapter puncture and aspiration of
the ventricles for relief of intracranial pressure is
considered. A patient suffering from long con-
tinued headache after a fall was relieved by v.
Bergmann by the aspiration of blood from the
ventricle. In a case of tubercular meningitis
only symptomatic benefit was achieved. The
book is complete and a valuable addition to the
literature.

meeting some vears ago, expressed his unqualified belief
in the feasibilit\- of Mr. Chadwick's proposition. If this
is true, and it comes from very high authority, the respon-
sibility of municipal authorities and boards of health is
measured through a wider range than is generally sup-
posed. With a death-rate ranging about twenty-five per
1,000, health officials should raultiplj- their diligence by
about five to secure the minimum death-rate. — TAe Sani-
tary Xews.

The faith-cure doctor took the hand of his patient,
and looking into his eyes, said : " I can cure you."
Patient — " kre you sure?" " Verj- sure. All you've
got to do is to believe. Just believe vou're cured. That's
all." "All right ; I'll try it. Good' day." " Hold on a
minute, my man. Didn't you forget something?"
" What ?" ■' The fee, I charge a dollar a visit." " Oh,
yes. Well, believe. All you've got to do is to believe
I've paid you and it'll be all right."

MISCELLANY.

Edward Chadwick, a distinguished sanitarian, has
said that he could construct a city which would give any
desired death-rate from five, or possibly less, to fifty or
more in 1,000 inhabitants annually. This has the en-
dorsement of the President of the Health Department of
the British Social Science Association, who, at an annual

LETTERS RECEIVED.
Dr. H. M. JIcKenzie, Elwood, la.; Societe Medico-
Chirurgicale de Liege, Liege, Belgium; Dr. G. H. Gib-
son, Dr. J. M. Bessey, Denver, Col.; Dr. Philip C. Knapp,
Boston; Dr. L. C. Moore, Muscatine, la.; O. H. Burbridge,
Chicago; Dr. H. L. Jenks, Hazel Green, Wis.; Dr. Wm.
B. Atkinson, Dr. R. J. Dunglison, Philadelphia; I. Hald-
enstein. New York; Dr. R. W. Ramsay, St. Thomas, Pa.;
Dr. N. Senn, Milwaukee. Wis.; Rees Printing Co., Oma-
ha, Neb.; Subscription News Co., Chicago; Dr. L. C.
Manchester, Pittsburgh, Pa.; Dr. E. Mcllhenny, New
Iberia, La.; Dr. Alice T. Hall, Baltimore, Md.; Dr. J. M.
Emmert, Atlantic, la.; Dr. J. H. Kellogg, Battle Creek,
Mich.; J. H. Bates, New York; Scott S: Bowne, New
York; Dr. Marv F. Lovett, Westminster, Conu.; Dr. J.
Priest, Toledo, 'O.; Dr. W. S. Hall, Cambridge, Mass.;
Dr. John S. Sundberg, San Francisco, Cal.; DeWoife, Fisk
& Co., Boston, Mass.; Dr. H. G. Critzman, Welsh Run,
Pa.; Munn S: Co., New York; Dr. L. O. Bowen, East-
ford, Conn.; Peacock Chemical Co., St. Louis, Mo.; One-
ita Springs Co., Utica, N. Y. ; Dr. Geo. E. Frothingham,
Ann Arbor, Mich.; Post Surgeon, Fort Leavenworth,
Kan.; Dr. E. W. Cross, Rochester, Minn.; Dr. J. L. Mc-
Comas, Oakland, Md.; R. W. Gardner, New York; Dr.
Frank S. Billings, Dr. Frank Billings, Chicago; Dr. R.
Harvev Reed, Mansfield, O.; Dr. A. M. Owen, Evans-
ville, ind.; Parke, Davis & Co., Detroit, Mich.; Dr. T. J.
Hutton, Chicago; The Lancet, London, Eng. ; Dr. Alex.
Boggs, Paris, France; Dr. John S. Marshall, Green
Spring, O.

Official List of Changes in the Stations and Duties of
Officers Serinng in the Medical Department, U. S.
Army , from August tj, iSSg, to August 22, /SSg.
Lieut. -Col. Joseph C. Baily, Surgeon U. S. .\rmy. Medi-
cal Director, Hdqrs. Dept. ofTexas, San -Antonio, Tex.,
.\ugust 14, 1SS9, is granted leave of absence for one
month. S. O. 54, Hdqrs. Dept. of Texas.
Commanding officer at Jackson Bks. La., telegraphs the
.Adjutant General of the .Army, that Major Harney E.
Brown, Surgeon U. S. Army, died at Jackson Bks. to-
day, at 1:40 o'clock P.M. Jackson Bks., New Orleans,
La., August 20, 18S9.
1 Official List of Changes in the Medical Corps of the U. S.
I Navy for the Week Ending August 2^, iSSg.

Medical Inspector W. K. Scofield and P. A. Surgeon C.

T. Hibbelt, detached from the "Lancaster."
Medical Inspector C. H. White and P. .A. Surgeon F. -A.
1 Heslcr, ordered to the " Pensacola."
I P. -A. Surgeon L. W. Curtis, ordered to the " New Hamp-
shire."
Surgeon W. H. Jones, detached from the "Pensacola"

and placed on waiting orders.
Asst. Surgeon L. von Wedekind, detached from the
" New Hampshire," and ordered to the "Pensacola."

THE

J ournal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.
PUBLISHED WEEKLY.

Vol. XIII.

CHICAGO, SEPTEMBER 7, 1889.

No. 10.

ADDRESSES.

RECENT ADVANCES IN THE TREAT-
MENT OF DISEASES OF THE
SKIN.

Read in the Section on Dermatology and Syphilographv at the Fortieth

Annual Meeting of the American Medical Association held

at Newport, R. I., June, iSSg.

BY L. DUNCAN BULKLEY, M.D.,

OF NEW YORK,
CHAIRMAN OF SECTION.

Gentlemen : — In opening the Second Session of
the Section of Dermatology and S3'philograph)' of
the American Medical Association, I must first
express my thanks publicly to the gentlemen who
at the last session so kindly called me the second
time to preside over your deliberations, an honor
which was as unexpected as it was gratifying. I
must also congratulate you, and, I believe, the
profession at large, upon the interest which the
Section has developed, and express the hope that
by its means the large and important field of
study and practice which is here represented may
be simplified, so that diseases of the skin may no
longer represent the terra ineognita which they
have sometimes been considered by those inexpe-
rienced therein.

As was remarked last j'ear, on opening the
session, the Section is organized for work in the
line of practical dermatology, and as a Section of
the American Medical Association it should be
attended by members who are not dermatologists,
and subjects should be presented which are of
general and practical interest and value to the
general practitioner if we would seek to give the
widest usefulness to our Section.

With this aim in view we have this year, as
well as last, prepared a "question box" into
which any one may drop a written slip regarding
any subject upon which he would like aid or in-
formation from those present, or on which may be
proposed subjects for future discussion. It is
earnestly requested that this method of securing an
interchange of ideas be utilized to as great a de-
gree as possible ; an hour has been set apart on
the second day for answering such questions, and
further time can be taken later if necessary ; if
freely used this plan might be made the means of

developing verj' interesting practical matter which
would not otherwise be reached.

The general topics assigned for discussion at
this session, namely, " The Treatment of Tinea
Tonsurans," and "The Indications for and Dura-
tion of the Treatment of Syphilis," are, it is
thought, subjects which are of very considerable
practical and general interest. While pathologi-
cal considerations, and those relating to rare and
peculiar diseases of the .skin may be of a certain
advantage here, and may more or less find a place
in this Section, it is hoped that more common
matters, which shall be of use in general practice,
may in the main be presented, while the more
abstruse and difficult subjects shall be left for the
consideration of those whose attention is wholly
or largely given to this branch, in the American
Dematological Association.

By the rules of the American Medical Associa-
tion it is the duty of the Chairmen of the various
Sections to give an address upon the advances
which have been made in the departments of
medicine represented by the Sections, and to
bring to their attention such matters as may be
considered of interest and profit. In accordance
with this rule I beg now to direct your attention
for a short time to the subject of " Recent Ad-
vances in the Treatment of Diseases of the Skin."
Inasmuch as this is the first time that this subject
has been presented before the Section, we have
no date from which we may reckon the recent ad-
vances in the treatment of diseases of the skin ;
I have thought it best, therefore, not to confine
our considerations to any specified time, but to
look over the field a little broadly, and to take
account of stock, as it were, endeavoring to dis-
criminate between the good, bad, and indifferent
of the more recent so-called "advances " in this
department.

It is a constant remark among those acquainted
with the subject, that the need is not so much for
new remedies, in dermatology, or indeed in any
department of medicine, as it is of a better knowl-
edge of the true value and mode of application
of those means of combatting disease which we
now possess. While the question is repeatedly
put to one occupied in any special branch, "What
is the newest or best remedy for this or that com-
plaint," he is obliged just as frequently to reply

326

DISEASES OF THE SKIN.

[September 7,

that there is no one remedy or plan of treatment
which is wholly satisfactory in any particular dis-
ease, or which will reach everj- case ; and if, per-
chance, a suggestion is made of an}- particular
drug or method he feels that the chances are very-
great that there will be some error or some failure
to use the remedy correctl}-, and that the ultimate
result is very doubtful. In no department of
medicine is this true to a greater extent than in
diseases of the skin, and yet nowhere can we see
more brilliant results, the accuracy and truthful-
ness of which cannot be denied, because plainly
visible to all, than in the department of derma-
tology.

The first advance, therefore, to which I would
call attention in the treatment of diseases of the
skin is the recognition of the fact on the part of
those acquainted with the subject that accuracy
of diagnosis is essential to success in the treat-
ment of this" class of affections, and intelligence
in the application of remedies can alone insure
results which are not disappointing. I would
feel like apologizing for such an apparently self-
evident statement, were it not that a considerable
experience in consultations with other physicians
has made me think that too little care is often
spent in studying this class of cases, and in recog-
nizing all the features requiring attention, both
as regards the local affection and the constitu-
tional condition of the patient. If the same care
and thought were expended upon certain cases of
skin disease which are readily given to obstinate
or obscure diseases of other organs there would
be less difficulty in their management. The time
has passed when a patient afflicted with an affec-
tion of the skin should at once be given arsenic
internally and zinc ointment externally ; and
then, in the event of probable failure, that he
should be given mercury or iodide of potassium,
under the suspicion that perhaps there may be
some " taint ;" and then in the further event of a
failure of these plans, that he should be either left
to suffer, or be informed that it would be danger-
ous to cure the skin trouble lest "the disease
might strike in." There is much in the practice
of dermatology which the general practitioner
may readily grasp and use, if only sufficient care
and thought be given, and, in my judgment, as
remarked before, there is much less need of new
remedies than there is of a careful, proper and
widespread knowledge of the means already
known, and their intelligent use.

The second point to which I would call your
attention is, that while accuracy of diagnosis is
the first essential to success, it is almost equally
important to consider well and appreciate thor-
oughly the particular condition or stage of the
eruption under consideration, and, knowing the
action and effect of each remedy to use it accord-
ingly. The same measure advised for a certain dis-
ease will act entirely different under different con-

ditions and at various stages of the complaint, so
that one constanth- sees harm done from harsh
remedies when those of a soothing nature were
required, and mild measures are often uselessly
employed when those of a stimulating character
were demanded. As a corroUary to this we learn
that even the new remedies and methods of treat-
ment advanced will often fail of success unless it
is known exactly at what stage or condition they
were employed and in what manner they acted.

One more general remark may be added and
we will pass to consider some of the more recent
advances indermatologj'. It is this. Not only
' do remedies and measures act differently in
different persons and under diverse conditions,,
and in different stages of a disease, but their ac-
tion may be modified, aided or retarded b}' a num-
ber of influences which are not always thought of,
such as diet, hygiene, and the effect of other
remedies, internal or external. Therefore, in the
use of any newly-recommended measure all other
proper adjuvants are to be employed and all an-
tagonistic elements are to be removed ; and as a
corollary- to this we learn that new remedies are
not always to be judged negatively bj- an appar-
ent failure, nor, on the other hand, can we always
conclude favorably of the effect of anj' special
agent unless all other elements bearing on the
case are also duly considered.

With this much of preface we may consider
some of the therapeutical elements which have in
recent years been introduced into the practice ot
dermatology. Time will not permit of a full con-
sideration of all that might be mentioned with
advantage, much less of the many which have
been brought forward whose claims have not
been fully substantiated. Indeed much even
that might be of interest and value must be left
for my successors in office, who will, no doubt,
consider and present the subjects with abler pens
than mine.

First, among the advances in dermatology-
during recent years to be mentioned should be
the iinr/uDiual therapy of diseases of the skin,
which, when properly employed, aids verj' greatly
in the management of many conditions which had
i heretofore proved very rebellious ; of this there
are several forms. The curette is ver}- servicea-
ble in the treatment of lupus, also in removing
small epitheliomata, warts and excrescences, and
it may sometimes be used with advantage on
chronic patches of eczema, also psoriasis.

The cutaneous punch, as introduced by Keyes'
is also of value in removing small circular por-
tions of skin, the seat of moles and the like, also
powder stains, and likewise in taking .sections of
diseased tissue for microscopic examination.

The cutaneous lance plays an important part
in the treatment of acne, and together with the

> Keyes, Jour. Cutaneous and Ceiuto-Urinarv Diseases. Vol. v,
18S7. p. 98.

1889.]

DISEASES OF THE SKIN.

327

comedo extractor, will accomplish more for some
cases of this disease than weeks or even months
of other treatment can effect without them.

Multiple scarification, performed either with a
scalpel or an especial knife made for the purpose,
with the cutting surface on the end, or with the
many-bladed knife of Squire, serves an excellent
purpose in certain cases of lupus, and will also
yield good results in some nsevi, and in rosacea.
The large veins of acne rosacea, especially on
the nose, ma}^ be removed by slitting them up
carefully and burning the track of the vein with
a point of nitrate of silver. They may also be
successfully obliterated by electrol3'sis.

Electrolysis now plays a considerable part in
dermal therapy, and in some conditions yields
brilliant results. Its use, now so common, in de-
stroying superfluous hairs, need but be mentioned,
as is well known, it offers about the only method of
permanently removing this blemish, which often
proves such a serious annoyance or distress to those
thus afflicted. Theonlj- othermethod known to me
is one which I devised and presented some j'ears
ago, namely, that of boring out each hair follicle
with a three-cornered needle, dipped in carbolic
acid ; when well performed this is fully as suc-
cessful as electrolysis, and is prefered by some
patients who have had both methods used on
them.

Electrolysis is likewi.se of value in destroj'ing
pigmentarj' and hairj' moles, and nsevi of vari-
ous sizes, as also in producing the absorption of
tumors. The galvanic cautery also plays an im-
portant part in the treatment of some affections,
the end, however, being the same as that obtained
by the actual cautery and by Pacquelin ; but with
the galvanic cautery more delicate work can be
done, and Besnier has devised a considerable va-
riety of shapes for the knives, some of them hav-
ing a number of fine points, heated by electricity,
for the treatment of nsevus and other conditions.
The value of the galvanic current, variouslj^ ap-
plied, must also be reckoned among the advances
of recent years. It is most valuable in checking
the pain accompanying and following herpes
zoster, and there is some evidence that it tends to
arrest the progress of the disease ; it is valuable in
relieving the pain in dermatolgia, and to a certain
extent will control pruritis. Galvanization has
also been reported on favorably in connection with
other diseases of the skin, notably eczema, it be-
ing u.sed in the form of general or central gal-
vanization. Faradization has also been recom-
mended in acne rosacea, but is of doubtful value.

Perhaps there are no remedies to which more
attention has been called of late than ichthyol
and resorcin, largely through the instrumentality
of Dr. Unna, of Hamburg, and time sufficient
has now elapsed since their first introduction to
allow of judgment regarding their true merits,
for quite contradictor}* reports have appeared con-

cerning them. They are placed by Unna as re-
ducing agents, drawing oxygen from the tissues,
and altering the corneous layer of the skin.
They are by no means indifferent substances, but
while capable of doing more or less good when
properly used, they are irritating in many condi-
tions, and in my experience, as also that of some
others, the}' have not fulfilled the expectations
excited by Unna's original contributions to the
subject,

Ichthyol should always be used weak at first,
the strength being increased according to the
effect produced ; 2 per cent., either in water or
ointment, is strong enough to begin with, and
rarely will more than 5 per cent, be well borne, at
any rate on American skins. As a lotion, 2 to 3
per cent, in water, it certainlj- often exercises a
remarkable effect on ulcers of the leg, they being
kept wet with it all the time, the dressing being
covered with a thickness of woolen blanket (but
not rubber or oil-silk), to prevent too rapid evap-
oration. It is sometimes well at night to substi-
' tute an ointment, with 2 or 3 per cent of ichthyol
and a little zinc oxide. In certain moist eczemas
about the folds of the body, a light bathing with
a weak, 2 per cent, ichthyol lotion, followed bj- a
calamine and zinc lotion, will give much better
results than the latter alone. In certain cases in
' eczema in infants the effect produced by a
thorough and continuous use of a zinc ointment
j containing 20 grains of ichthyol and 15 or 20 of
salicylic acid, is certainly remarkable, and un-
doubtedly much greater than from either the zinc
ointment alone, or when combined only with the
salicylic acid.

Time does not permit of a fuller consideration
of ichthyol in this place, but enough has been
said to show that it is an agent of some impor-
tance, capable of doing harm when used too
strong, and of moderate value in allaying acute
erj'thematous conditions of the skin.

Resorcin, which has been spoken of much in
connection with ichthyol, is said to have much
the same effect, but its action is more uncertain,
and its use more restricted. It is undoubtedly a
parasiticide, and forms a verj' cleanly and pleas-
ant application in tinea vesicular, used in solu-
tion from 3 to 5, or even 10 per cent, in water
with a little alcohol and glycerine. It is also of
value in tinea circinata and maginatum, and it is
claimed that a strong ointment, from 3 to 10 per
cent., will act most favorabl)' in tinea sycosis.
Resorcin is also serviceable in pityriasis capitis,
used in a 3 to 5 per cent, solution with alcohol
and castor oil. In seborrhoeic eczema it also acts
very well in a strength of 3 per cent., with zinc
ointment. In psoriasis it may be used considera-
bly stronger, even up to 10 to 20 per cent, in
ointments.

Resorcin certainly seems to have considerable ef-
fect upon the sebaceous glands, and is useful in

328

DISEASES OF THE SKIN.

[September 7,

manj' of the forms of acne. Used in an alcoholic
and water}- solution, of from 2 to 5 per cent., it
checks the oih- secretion so common on portions
of the face, and as an addition to lotions contain-
ing sulphur it often aids greatlj^ in the treatment
of acne. It must not be forgotten, however, that
resorcin ma}- prove very irritating if used in too
strong a proportion — 3 to 10 per cent, is quite
sufficient — and also that it often produces a dis-
coloration of the epidermis, which may take some
little time to wear off.

Unna has also, during the few past years, writ-
ten much concerning the uses of various oint-
ments made into the form of plasters, by making
them thicker and more sticky, and then pressing
them upon and into the meshes of muslin ; these
so-called " pilaster -mulle" have been imported
from German}' but little, and are difficult to ob-
tain. They are made to contain zinc, tar, naph-
thol, chrysarobin, ichthyol, salicylic acid, and
other ingredients. These plasters serve a certain
valuable purpose in keeping a fixed dressing in
localities where it would other^'ise be difficult to
retain an application, and also by the maceration
afforded aid in removing disease ; on the other
hand, they often prove too drawing, and unless
the medicament is very bland, much inflamma-
tion may thereby be set up.

In the same line of therapy may be mentioned
the "dermatological plasters," now prepared and
offered by several firms in this countr}-, which at
times serve an excellent purpose ; they are mostly
made up with rubber plaster, and often prove too
heating and drawing, and can hardly be consid-
ered the equivalent either of the ' ' pflaster-mulle ' '
or of proper ointments well spread oh lint and
kept in place by suitable dressings. Among these
new plasters may be found those containing ver}-
many of the more common and newer drugs used
in dermatology. I cannot speak personally re-
garding very many of these, but some of them
prove at times of very great service. Thus, in
thickened patches of eczema, about the hands and
feet especially, the salicylic acid plaster, 10 or 20
per cent., will promote absorption and greatly
reduce the thickening ; those with zinc and tar,
each 10 per cent., are also valuable in eczema,
and those with 10 per cent, of chr}-sarobin act
well in psoriasis ; all are familiar with the value
of plasters containing mercur}- in reducing the
late lesions of syphilis.

Attempts have been made in other directions
as to the means of securing fixed dressings on the
skin, and various preparations have been brought
forward to hold the medicament in solution or
suspension, while it is painted over the affected
surface. The use of collodion, made flexible
with castor oil, has long been known, and this
often serves a most excellent purpose when con-
taining from 3 to 5 per cent, of chrysarobin, or
pyrogallic acid, and as much salicylic acid ; io-

dine may also be successfully applied in this man-
ner. Gutta-percha dissolved in chloroform, the
liquor gutta-perchse of the Pharmacopoeia, or
traumaticine, as it has been called by the trade,
affords another admirable method of affixing me-
dicaments to the skin ; any desired substance,
oxide of zinc, bismuth, tannin, chrysarobin, or
preparations of mercury may be suspended in it,
and made to adhere to the skin thereby.

Another mode of making fixed dressings is that
known as glycerine jelly, made by boiling one
part of gelatin with three or four of glycerine,
and a little water if necessary to make a gelatin-
ous mass. The various ingredients desired are
incorporated with this while hot, by stifring, gen-
erally from 5 to 10 per cent, being added, together
with a little carmine to give a flesh tint if it is to
be used on exposed surfaces. This forms a bland
dressing, and with zinc or bismuth ser\-es well to
protect large surfaces ; it will not adhere when
there is moisture exuding, but on dr}-, scaly ec-
zema, in some cases of liclien planus, and pity-
riasis losea, it forms a serviceable dressing. Car-
bolic acid, camphor, or cocaine may be added to
relieve itching. It is applied by placing the jar
containing the jelly in hot w-ater, when the li-
quefied substance can be freely painted over the
affected surface, forming a smooth protecting coat
as it cools.

Considerable attention has been called to lano-
lin during the past few years, largely, it is feared,
on account of the vigor with which it has been
pushed in a mercantile way. Its merits have
been pretty well tested, and it may be stated that
it has not fulfilled the high expectations which
have been raised concerning it ; it has its value
and its applications, but they are limited, and it
will undoubtedly take its proper place among the
remedies which are of value in the treatment of
diseases of the skin. It does not answer alone
as a basis for ointments, but when combined
with other fatty ingredients, in about 25 per cent.,
it often aids in keeping the skin soft and pliable,
when without it the oily matter would disappear
and leave the surface harsh. It has been advo-
cated largely on account of its supposed power
of inducing absorption of the medicament which
it contained ; if this power existed in this sub-
stance alone, it would not recommend it for uni-
versal use, for in much of dermal therapeutics
the object is not to secure absorption of remedies,
but to act on the outer surface. It would sur-
prise many to see how ver}- little it is used by
those engaged in the practice of dermatology.

Another addition to the class of fatty bases for
ointments which has been brought forward of
late years, is found in the various preparations
made from petrolium, notably, vaseline, cosmo-
line, and albolene. All are familiar with the
wide range of applicability of these substances,,
and the serv-ice which they have rendered is un-

1889.]

DISEASES OF THE SKIN.

329

questionably very great, and they could be illy
spared from the Pharmacopceia. But it is proper
here to raise a word of caution against their too
common use as a basis for ointments, it being
even proposed, I am informed, to make it the of-
ficinal basis of ointments in the coming revision
of the Pharmacopceia. The New York Derma-
tological Society has already taken strong action
in opposition to this suggestion, and every one
who has carefully tested the subject will readily
see that it is far inferior to other substances for
this purpose, certainly in the large proportion of
instances. When it is desired to lubricate the
surface, as in pityriasis, rubra and many drj' and
scaly conditions of the skin, nothing better can
be desired ; and as an excipient, to convey car-
bolic acid, or other anti-pruritic remedies, to the
skin, it answers perfectly. But when it is de-
sired to form a protective covering, which shall
hold a medicament in contact with the skin for
some time, vaseline and cosmoline are found far
too soft, and even albolene does not seem to af-
ford the "bod}'" desired for an efifective ointment,
such, for instance, as is found in good diachylon
ointment made after Hebra's formula.

Here I must speak again for the ointment which
I have often mentioned as preferable, in mj- ex-
perience, to all others, and which I invariably use
in compounding prescriptions, namely : the un-
guentum aquse rosae of the pharmacopoeia. This
is composed of almond oil, spermaceti and white
wax, with considerable water, and is far more
grateful to the skin than lard, and of a consis-
tency which combines best with verj^ many sub-
stances. Brief mention ma}- be made of some
single substances which have come into pretty
general use in dermal therapeutics.

Salicylic acid has been mentioned incidentally
several times. It is a valuable addition to our
armamentarium, but requires some care in its use.
It has a drying effect on the skin, and the addi-
tion of 2 or 3 per cent, of it to various ointments
will often increase their effect greatlj', though
sometimes it proves irritating. Combined with
hair tonics, in a strength of from 3 to 5 per cent.,
it acts excellently in cases where there is an oily
seborrhcea ; dissolved in alcohol and water, 10 to
20 per cent, solution, it is an efficient parasiticide,
and incorporated with oxide of zinc, a drachm
each to an ounce of powdered starch, it is very
efficient in checking excessive perspiration, in the
axilla and elsewhere.

Chr^'sophanic acid, or chrysarobin, as it is now
called, is well known to the profession from the
remarkable power which it has in dispelling the
lesions of psoriasis. When it is desired to remove
the eruption quickly, regardless of all else, no
agent will accomplish this as quickly as this drag,
properly used, but, on the other hand, the disad-
vantages attending its use in the waj' of staining
the skin and clothing, together with the intense

inflammation which it occasionally sets up, has
greatly restricted its use, in private practice at
least; personally I use it but little, and then main-
ly in the form of paint, with collodion or gutta-
percha, as before alluded to.

Pyrogallic acid has to a certain extent takeir
the place of the chrysarobin, but it is less effica-
cious in psoriasis. Its effect in epithelioma, how-
ever, is often quite remarkable, and the powdered
acid sprinkled freely on a small epithelioma will
often quite alter the diseased action, and ensure
healing.

Anthrarobin has also been brought forward as
a substitute for chrysarobin, and appears to have
a marked effect upon psoriasis. Used in a 10 per
cent, ointment it removes the eruption almost as
quickly as chrysarobin, = and without producing
inflammation, or staining as much as the latter.
Alkali baths increase its action.

Naphthol has attained considerable reputation
from its pronounced value in the treatment of sca-
bies, a 10 per cent, ointment sufficing to remove
the disease with little trouble. It is also service-
able in psoriasis, in 15 per cent, ointment, and in
seborrhcea and in some other affections.'

Two or three antipruritic remedies may be men-
tioned before bringing this hasty sketch to a close.
Menthol in from 5 to 15 per cent, solution, with a
little alcohol and gh'cerine and water, often proves
a most serviceable means of allaying itching. Co-
caine, from 5 to 10 per cent, in ointment or solu-
tion, is also a remedy of value in certain cases.
It is also valuable in connection with epilation for
parasitic diseases of hairy parts, used either in so-
lution, or in connection with the ointment applied
it will very greatly diminish or entirely obviate
the pain attending this operation. Campho-phe-
nique, a newly presented remedy, composed of
camphor and carbolic acid, often proves efficient
in pruritus; a drachm to the ounce of vaseline, or
perhaps a little stronger, will often give complete
rest to an intolerable itching.

In this attempt to direct attention to some of
the more recent additions of value to our dermal
therapeutics, I have confined my attention entire-
ly to local treatment, for here it is that the great-
est advances have been made, or rather those which
are most clearly demonstrable. But I cannot close
without again throwing out the suggestion that
this is by no means all of dermatology, and he
will succeed but poorly who relies alone or main-
ly on local measures. While it is of the highest
importance that these be proper and suitable, it is
none the less essential, to real and permanent suc-
cess, that all elements which contribute to the
end, as diet, hygiene, and -internal medication,
should be used intelligently and persistenth'.

Again I feel like apologizing for the plainness

- Bronson. Journal of Cutan. and Genito-Urin. Diseases, No-
vember, 1SS8, p. 409.

? Van Harlingen. Amer, Jour. Med. Sci., October, 1S83, p. 479.

530

THE MEDALS OF BENJAMIN RUSH.

[September 7,

of ray speech, and the urgency with which I press '
this matter ; but my apology is onh' that experi-
ence has so often shown me that failure more com-
monly comes from not perfectly grasping and con-
sidering all the elements bearing upon skin cases,
than from the lack of proper remedies to meet
diseased conditions, that I cannot refrain. The
number of new remedies and measures which have
been proposed and advocated since I first took up
this branch of medicine, twenty years ago, is far
greater than could be imagined by one who had
not specially watched the subject, and even a
brief recital of them might occupj- most of the
time of our Section, and yet ver\- few of them
have stood the test of time and experience, and
still fewer of them have obtained a wide and prac-
tical recognition, and are now emploj^ed.

I would not, of course, discourage attempts to
make therapeutic advances in dermatologj', but I
would only throw out the suggestion of Holy
Writ, both to those proposing and those accept-
ing novelties in this department of medicine,
' ' Prove all things, hold fast that which is good. ' '

ORIGINAL ARTICLES.

THE MEDALS OF BENJAMIN RUSH,
OBSTETRICIAN.

Read at the Fortieth Annual Meeting of the American Medical Asso-
ciation, held at .\eapait, R. I, June, 18S9.

BY HORATIO R. STORER, M.D.,

OF NEWPORT. R. I.

Recently, during researches relative to a paper
upon the medals, jetons and tokens illustrative of
the science of medicine, at present appearing in the
American fcitrnal of Numismatics, I learned of a
gold medal conferred by the Societj^ of Medicine of
Caen, France, upon the late Dr. Jean Charles Fa-
get, of New Orleans, a graduate of the University
of Paris, Chevalier of the Legion of Honor, and
distinguished as an author in various departments
of medicine.' With the impressions of this medal
that have been kindlj- sent me by Dr. Faget's
family, I have received copies of a portion of his
works. Among them is an interesting brochure,
published at Paris by the Baillieres, entitled,
" L'Art d'apaiser les Douleurs de L'Eufante-
ment " (The Means of Assuaging the Agony of
Parturition).

THE CLAIM OF RUSH TO THE TITLE OF
OBSTETRICIAN.

In this memoir. Dr. Faget quotes a striking
statement by the most eminent, perhaps, of Am-
erican physicians. Dr. Benjamin Rush, of Phila-
delphia, for many years professor of the institutes

I The biography of this geutlemati will be found in our Perma-
nent Secretary, William B. Atkinson's work, " The Physicians and
Surgeons of the I'nited States," Philadelphia, 1S7S, p. 44.

and practice of medicine and of clinical practice
in the University- of Pennsylvania. In discussing
the symptoms of labor, and as if directlj^ antici-
pating and answering in advance the objections
that were to be urged half a centur}- later in his
own cit}', by the celebrated Dr. Charles D, Meigs,
Dr. Rush had said: "By some divines these
symptoms, and particularly- pain, have been con-
sidered as a standing and unchangeable punish-
ment of the original disobedience of woman, and,
b}' some phj-sicians, as indispensably necessar}^ to
enable the uterus to relieve itself of its burden.
B3- contemplating the numerous instances in
which it has pleased God to bless the labors and
ingenuity of man, in lessening or destroj-ing the
effects of the curse inflicted upon the earth, and
b}- attending to the histories of the total exemp-
tion from pain in child-bearing that are recorded
of the women in the Brazils, Calabria, and some
parts of Africa, and of the small degrees of it
which are felt by the Turkish women, who re-
duce their sj'stems by frequent purges of sweet
oil during pregnane}-, I was induced to believe
pain does not accompanj- child-bearing by an im-
mutable decree of Heaven." And again: "I
was encouraged (ya. this) by having known deliv-
er}' to take place, in one instance, during a parox-
ysm of epilepsy, and in another during a fit of
drunkenness ; in both of which there was neither
consciousness nor recollection of pain." -

The notable passage referred to above as repro-
duced by Dr. Faget, in his French monograph, is
the following : "I have expressed a hope in an-
other place that a medicine would be discovered
that should suspend sensibility altogether, and
leave irritability, or the power of motion, un-
impaired, and thereby destroy labour pains alto-
gether." '

The "another place" to which Rush here
makes allusion is a letter dated May 12, 1802, to
Dr. Edward Miller, entitled "On the means of
lessening the pains and dangers of child-bearing,
and of preventing its consequent diseases." In
this, when speaking of cases "where the absence
of throes and the slow progress of delivery- indi-
cate a deficiency of muscular irritability in the
fibres of the uterus, ' ' Dr. Rush shows the advan-
tage of opium, and goes on to say, " I think I
have seen the happiest effects from that excellent
medicine in such cases, in destroying useless pains
and shortening the progress of the labor. How
far a medicine (if such can be found) so powerful
as wholly to suspend the sensibilities of the ner\-es.
without impairing their irritability, might succeed
in destroying pain altogether. I know not." '

In this letter, aside from the special point that
I make in the present paper. Dr. Rush demon-
strates, throughout, that he was a skilful obstet-

-■' Medical Inquiries and Observations,"
iSll, iv, pp. 373, 374. 37*-
1 Ibid. . p. 376.
4 Medical Repositor%-, vi, 1803, p. 24.

Third Edition, 1789-

1889.]

THE MEDALS OF BENJAMIN RUSH.

331

rician. In its vety title, he closel}' associates the
pains of labor with its dangers, he announces that
they can both be lessened, he recognizes that they
are the potent cause of subsequent disease, and he
teaches its prevention. Here, as in the passage
quoted by Dr. Paget, Dr. Rush foreshadows the
great discovery which has taken from parturition
its anguish, without interfering with its progres-
sive natural action, and has greatly lessened its
perils to mother and child.

Upon referring to the work of Walter Channing,
of Boston — a native, by the way, of Newport, and
upon this occasion to be spoken of with especial
honor — to whom, as also to Sir James Y. Simpson,
as the first physician to induce artificial anaesthe-
sia in childbirth. Dr. Paget gives due credit, I
find this comment : " It is grateful to recur to
the opinions of our distinguished countryman
(Dr. Rush) on a point which he approached with
sentiments of the profoundest reverence, on ac-
count of the authority on which it is supposed to
rest, whilst he successfully controverted the pop-
ular inference, namely : the penal character, in-
volving a physical necessity' of pain in labor.
He had conceived " a hope. Was it not proph-
ecy ? Had it not so much of truth as a basis,
that the great discovery of our own day seems to be
the revelation of that truth ? His doctrines were
rather inductions, or the generalizations of facts,
than theories." He " expresses ' a hope ' of the
di.scovery of a remedy of (ob.stetric) pain," but
he also states " the reasonableness, the moral evi-
dence, of that hope, .so that it becomes faith."'

It will be noticed that Rush distinctly contem-
plated the removal of sensibility alone, and the
retention of uterine activity. His views therefore
were precisely those of the best authorities of the
present day, regarding the conduct of natural
labor. He was in general sympathy with Syden-
ham, whose works he edited, and for whom he ;
even named his country seat, and it is not unlike- ,
ly that through studying upon this account the
more closely the effects in labor of opium, his
opinion of which I have already quoted — and
that preparation of it which is known as Syden-
ham's to the present day — he came to perceive the
end that was to be searched for in childbirth be-
yond merely soothing its pain, namely : the pres-
ervation unimpaired of uterine contractility and
expulsive power. Dr. Rush, besides, was far in
advance of his time in recognizing the evil effects
of alcohol upon the human system, both in health
and disease. One of the cases which he reports
was of painless labor "during a fit of drunken-
ness." This would have added to his desire to
produce the effect, temporary anodynia, while
avoiding its disreputable and injurious cause.'

That Rush had anticipated by nearly fifty years

5" A Treatise on Etherization in Childbirth." Boston, 1S4S,
p. i;o.

'■" An Inquir>- into the Etfects of .\rdent Spirits npon the Hu-
man Body and Mind," 17S5.

the magnificent idea which was to result in free-
ing woman from the burden of incalculable suffer-
ing that had been borne by her through the ages,
seems to have been recognized by no one besides
Channing, save Paget and one single other.

In 1876 Dr. Gaillard Thomas both noticed and
quoted Rush's aspiration, yet he seems to have
mentioned it as but an incident in the course of his
generous tribute to Simpson, the more striking
from appearing in the very same book wherein
was made the direct implication, of course an ac-
cidental one, that the anaesthetic property of chlo-
roform was an English and not a Scotch discover^'.'
Dr. Thomas, in speaking of the introduction of
anpesthesia into the lying-in chamber as an era in
the historj' of obstetrics, thus declares: "It is
somewhat singular that after the discover}- of an-
aesthesia in this countr)% after the prediction, long
before its discovery, by one of America's greatest
phj'sicians, that ' a medicine would be discovered
that should suspend seusibilitj' altogether, and
leave irritability, or the power of motion, unim-
paired, and thereby destroy labor pains alto-
gether' : after it had been employed here in
hundreds of cases for surgical operations, this
link of the chain should have been forged by a
European. Yet such was the case, and far be it
from any American to begrudge him one atom of
the glory which he deser\-es, or to endeavor to
dim its lustre by ' faint praise.' " '

We do not find Rush's prophecy, where of all
places it would have most naturalh' been looked
for, in the bitter letters of the elder Bigelow, of
Boston, in 1869 and 1870, to Sir James Simpson,
nor in the minute .statement, six years later, by
his son," although both of these gentlemen were
colleagues of Channing in the Medical School of
Harvard University.

Channing seems to have been the first to dis-
cover the great suggestion made b}? Rush. His
reference to it in 1848 was apparently perceived
by none till Thomas in 1876 — thence by none till
Paget in 1880, who again was unaware of the al-
lusion to it that Thomas had made. Prom 1880
till now there exists the same utter silence as
before.

I make this statement with hesitation, for the
fact seems almost incredible. Several friends,
however, have assisted me during the present in-
vestigation. From the Treasurer of the Rush
Monument Association, and e.K-President of our
own, Dr. J. M. Toner, the person of all now liv-
ing probably most familiar with the life of this
.signer of the Declaration of Independence, I have
received for examination manj' biographies of
Rush,'" from his own very extensive collection of

7 *' .\ Century of American Medicine, 1776-1S76," Phila., 1S76,
p. .So.

8 Ibid., p. 262.

9H. J. Bigelow. "A History of the Discovery of Modern .\nres-
thesia." " A Century of .American Medicine," Philadelphia, 1876,
pp. 73-112.

I'!. Sanderson's " Biography of the Signers of the Declaration

332

THE MEDALS OF BENJAMIN RUSH.

[September 7,

medical works now in the Congressional Library,
and he has besides aided me in the search itself.
Dr. Toner writes me as follows: "I have no-
where found allusion to the wonderful hope ex-
pressed by Dr. Rush." Dr. Paul F. Munde, of
New York, who as editor for so manj- 5'ears of
the American Journal of Obstetrics, aside from his
own special researches in this direction, has had
reason to keep informed of all that has been pub-
lished upon midwifer}', reports a similar result.
" I do not recollect," he says, "ever seeing the
name of Dr. Rush in this connection. Certainly,
he had a remarkable gift of prophecj' ! ' ' Dr.
James R. Chadwick, of Boston, the founder of
the great medical librarj' at Boston and a most
faithful obseri'er of all that occurs in obstetrics, j
writes me to the same effect. " The prophecy of!
Dr. Rush was new to me. I have not seen it al- ;
luded to by any writer. It is of very great inter- j
est." And" Dr. Gaillard Thomas, whom alone;
besides Channing and Faget I had found alluding \
to Rush in this connection, informs me that he
recollects no one who has appreciated Rush's
prophecy save Channing.

You and I would, I think, have felt aggrieved
had it been intimated that we were unfamiliar
with the works of Rush and of Channing, and
the chapter by Thomas, but for m}'self I am will-
ing to acknowledge that having eyes I saw not,
neither did I understand. With all m}- interest
in the general subject, the full significance of
Rush's true position toward this question, has
not struck me until now." A student at Harvard
University during the first use of sulphuric ether at
the Massachusetts General Hospital, and though
still an undergraduate a witness of many of the
earlier operations during which ether was there
employed — a friend of Dr. Charles T. Jackson,
whose gold medal from the Swedish Government
commemorates that, however he would have neg-
lected of himself to communicate the discovers- to
the world, the idea of employing sulphuric ether

of Independence — Rush." Philadelphia. 1S23, Vol. iv, pp. 249-2SS.

2. " Report of the Cotnmittee on the Erection of a Mouutuent
to Dr. Benjamin Rush." JorRNAL OF the Amer. Med. Associa-
tion, 18.S5.

3. Dr. Thomas D. Mitchell. " The Character of Rush." Intro-
ductorj' Lecture at Philadelphia College of Medicine, 1S48.

4. Dr. David Hosack. " An Introductory- Discourse, etc., and a
Tribute io the Memory of the late Dr. Benjamin Rush. New York,
1813.

5. Dr. Lettsom. " Recollections of Dr. Rush." London, 1815.

6. C. " A Tribute to the Memory of Dr. Rush." The Port Folio
(Phila.), October. 1813.

7. I)r. David Ramsay. "An Kulogium upon Benjamin Rush.
M.D." Phila.. 1S13.

8. "Benjamin Rush. M.D." National Portrait Gallery of Dis-
tinguished .\mericans, Vol, iii. Phila., 1836. pp. .s2-6i.

Q. "Sketch of the Life and Character of tlie late Benjamin
Rush, M.D., LL.D." Am. Med. and Phil. Register iNcw York),
July. 1813, pp. 1-16.

"10. "Elegiac Poem, on the Death of Dr. Benjamin Rush."
Phila., 1S13.

II. Dr. G. K. Johnson. " Memoir of Dr. Benjamiu Rush." 1S77.

Among other memoirs of Rush, besides the usual Cyclopajdic
ones that i haveconsulted, have been that contained in Tliacher's
Am. Med. Biography (Boston. 1S2SI, and the admirable "Benjamin
Rush and .•\inerican Psychiatry," by Dr. C. K. Mills, of Philadel-
phia {'Medico-Legal Journal, December, 1886).

" I had not recognized Rush's place, or Faget's either, among
obstetricians, when I prepared my paper upon the medals, jetous
and tokens illustrative of obstetrics and gynecology." (New England
IMedical Monthly. November and December, 18S6).'

as an anaesthetic was due to him — a pupil of Chan-
ning, and of Simpson, whose great Montyon gold
medal from the Institute of France was given not
merelj- for his other transcendent merits, but be-
cause b}- annulling the pains of childbirth, he
thereby removed the primal curse, and lessened
in almost equal degree both infantile and fcetal
mortality, and by employing chloroform as the
agent, was better able than with ether to mo-
mentaril}' suspend sensibility, in Rush's language,
without impairing uterine irritabilitj- — and having
mj'self twenty-six years ago, in 1863, contributed
by an essay upon the subject'' that Thomas in the
" Centurj- of American Medicine," already re-
ferred to, was kind enough to call "of consid-
erable value, " " to the work these preeminent
philanthropists had commenced in reference to
the general employment, even in natural labor,
of artificially induced ansesthesia, I have yet
failed, till the present moment, to properlj' recog-
nize Rush in one of the most beneficent of the
many labors in which he was engaged. His work
as a sanitarian had been duly appreciated.'* He
had published papers upon diet,'° climate,'* mili-
tary hj'giene,'" leprosy,'' hydrophobia," and yel-
low fever, =■' and for his great services during the
epidemic of the latter in 1793, he had received
unusual honors ; among them, gold medals from
the King of Prussia in 1S05 and the Queen of
Etruria in 1807, and a diamond ring from the
Czar of Russia in iSii. The chief point upon
which, I predict, his lasting fame will rest was,
however, whollj- unappreciated during his life,
and now, seventj'-five years after his decease, it
seems to have escaped the notice of all his biog-
raphers and to have been but three times alluded
to bj' writers upon midwifery.

Very interesting, moreover, appears the fact, to
which Dr. Faget has also drawn attention, that
Dr. Rush studied at the Universit)- of Edinburgh,

'- " The Employment of Anaesthetics in Obstetric Medicine and
Surgery-." iRead before the Massachusetts Medical Society, June,
1863.^ Boston Med. and Surg. Journal, October, 1S63, p. 249; and re-
published under the title " Kutokia; .\ Word to Physicians and to
Women upon the Employment of .\inesthetics in ch"ildbirth." Bos-
ton. 1863, .Svo. See also, " On Chloroform Inhalation during Labor;
A Reply to Dr. Robert Johns, of Dublin." Boston Med, aild Surff.
Journal. August, 1S63; and " The Practically .-\bsolute Safety of Pro-
foundly Induced .-Vnxsthesia in Childbirth, as compared witli its Em-
ployment for General Surgery." Ediul:urgh Medical Journal, Feb-
ruary, 1S77.

'iLoc. cit., p. 26S.

'♦" The Medals. Jetons and Tokens illustrative of Sanitation "
The Sanitarian, .^pnl, 1S8S, p. 349. etc.

'5 " .\n Inquiry into the Effects of Ardent Spirits," etc.. already
quoted; " Obser\'ations upon the Habitual Use of Tobacco upon
Health. Morals and Property."

'f'Dr. Rush edited Cleghorn on the "Diseases of Minorca." in
1S09: and shortiy after, in 1810, Hillary upon the ".Air and Dis-
eases" of the same island.

T Dr. Rush edited Pringle on " Diseases of the .\rmv," in iSio.
He had lield, under appointment from the Continental Congress,
the high office of Surgeon and Physician-General of the Hospitals
in the Middle Department of the .^rmy.

'-^ ■■ Obser\-alioiis, intended to favor a supposition that the Black
Color of the Negro is derived from Leprosy." Trans, .\m. Phil. So-
ciety, iv. 1792.

'>■! " Reniarks upon the Hydrophobia." .\m. Med. and Phil. Reg-
ister, N. S., July. 1813, p. 16.'

-*' " Facts, intended to prove the Yellow Fever not to be Conta-
gious." 1S03; " An .Vccount of the Bilious Yellow Fever as it ap-
peared in Philadelphia in 1793. 1794. and each successive year till
iSos."

1889.]

THE MEDALS OF BENJAMIN RUSH.

333

and had access to that wealth of mediaeval med-
ical literature in its librar}- in which Simpson so
revelled, and whence he was accustomed during
his researches into obstetric medicine, surgerj' and
sanitation, to adduce so man}- whollj- forgotten
precedents. As a student mj'self of that ancient
school, I can appreciate the influences that formed
Rush's character, as obser\'er, medical philosopher
and practitioner. Born near Philadelphia in 1745,
Dr. Rush took his degree at Edinburgh after two
vears of study there in 1763, and he proved Scotch
in his subsequent methods of thought and of ac- 1
tion. till his death in 1813.

Channing again was a pupil of Rush, to whom
it was always his delight to affectionately refer.
He graduated as a physician at the University of
Pennsylvania in 1809. Through Rush's influence
it was, undoubtedly, that he in turn resorted to
the Universit)' of Edinburgh, and there drank
from the fountain that had inspired his preceptor.
It was not till 18 12 that he received his medical
degree at Harvard. He retained through his life
his affection for the Scotch capital. His relations
with Simpson were intimate, and it was his de-
light that while Simpson was the originator of
actuall)' induced antesthesia in midwifery-, he
himself was the first American to urge its general
use for this end. So far as the realization and
final employment of obstetrical anaesthesia are
concerned, Edinburgh, through Channing its
American, as well as Simpson its direct represen- \
tative, well earned its palm. It is strange that
the first conception of the idea should also have !
been by a foster child of Edinburgh, Dr. Rush. '
Again, Drs. Channing and Charles T. Jackson j
were friends and close neighbors. They had
long before occupied the relations of teacher and
pupil. They lived upon the same street, their I
houses being: but a few feet apart. Thej^ were
terms of acquaintance, with
abstruse research in very un-
The only wonder now is that
the need of suffering woman
which Rush at the verj- commencement of his
medical studies had taught him, for an artificial
solace at the time of her greatest physical trouble,
and the other, having discovered and bearing for
so long in his mind the anaesthetic qualities of
the agent which gave the first step towards
the solution of the problem — that these men
should not have come more closely together, and
the obstetric world's great secret been earlier made
known. Jackson was an accomplished chemist,
and searcher for recondite applications of his sci-
ence to art, and Channing a most remarkable
medical antiquarian. With Channing as his co-
adjutor, Jackson would not probably have been
so grasping for riches and for fame as he proved
when associated with Morton, though this may
have been but the premonition of the mental mal-
ady which, as in the sad case of his competitor,

upon confidential
similar tastes for
usual directions,
the one, knowing

Horace Wells, occasioned his death — while poor
Morton, jealous and all tenacious to the last, died,
though more suddenh- than Jackson, just as con-
sequentially. The fearful quarrel, that involved
in its scandal wellnigh the whole profession of the
time, and indeed almost the good name of science
itself, would perhaps thus have been avoided, and
the birth of the divine idea might not have been,
as it was, attended by the sundering of intimate
personal ties, by deep distress and by wailiug. the
echoes of which have as j-et scarcely ceased.

There is a strong parallel that may be drawn
between the posthumous estimates of the two
illustrious physicians of whom I have chiefly
spoken in the present communication. It was at
the close of the meeting of the American Medical
Association at Washington, in May, 1870, that
the news was received of Simpson's death, tele-
graphed bj' his son to your present reader within
a veri' few moments after the event had occurred,
and there are undoubtedlj- those now here who
recollect with what regret the announcement was
received by the Association, and the solemnity of
the memorial meeting which was held immediate-
ly afterwards by its delegates and the medical
residents of Washington. Whatever the previ-
ous feeling of individual members of the profes-
sion, in favor of ether or of chloroform as an an-
aesthetic, or regarding the respective claims of
Boston and Edinburgh, which had improperly
been made to seem antagonistic, all cavil was si-
lenced at the touch of death. It has been so also
with Dr. Rush. The rivalries of his time, which
were intense, are forgotten. His own city, to
which in his lifetime he was no prophet, points
to him with pride. The great professional centres
of our continent vie with each other in recogniz-
ing him as the most fitting representative of earl}-
American medicine, and the chief ornament of the
far reaching Universit}- whose distinguished pro-
vost is one of the orators at the present meeting
of the Association. Seventy-six years have now
passed since the death of Rush. It is but of late,
as our lamented ex- President Gross said of our
equally great McDowell, that "the chaplet that
should have been worn on his brow has been
placed by a grateful profession upou his tomb." ='
To add a fresh leaf thereto is not my privilege
merely, but a filial duty. It is seldom that a man
can trace back for a hundred years the influences
that have shaped his own life and the little work
he may have attempted to accomplish for medi-
cine. Rush was at Edinburgh in 1768. It was
\ entirelj^ through his advice that thither went his
pupil Channing. It was bj- Channing's influence
that it became my own Mecca in 1854. Sincerely
grateful, therefore, I am to Rush, and delighted
to aid towards the high esteem in which he will
henceforth be held b\- our obstetrical brotherhood.
Should the question ever arise, from the sequences

-' ■' .\ Ceutury." etc., p. 121.

334

THE MEDALS OF BENJAMIN RUSH.

[September 7,

that I have endeavored to trace, whether Simpson,
like Channing, had appreciated Rush's prophecy,
I am sure from what I know of his character, that
such could not have been the case. He ever freely
gave of his knowledge to the world, concealing
nothing, and he was particularly generous in his
treatment of Americans, whether living or dead.
Even after Channing had quoted Rush, the full
meaning of the American prophecy seems to have
escaped Simpson, as it has us all, else he would
have been sure to have used it, sharply, when re-
plying to the senior Bigelow, equall}- unaware of
its existence. The latter of Simpson's answers
to the Boston sage was written, it will be remem-
bered, from his deathbed. It was his farewell to
the profession, of obstetrics and at large — happy,
he said, "if it tend to fix m)- name and memory
in their love and esteem." "' At such a solemn
hour, had he clearly understood what we now
know of Rush, his would have been the hand,
promptest of all, to give justice where it was due.

Just as John Bell, of Edinburgh, in 1794 urged
the performance of ovariotomy, and in 1809 it was
successfully accomplished bj' his pupil, Ephraim
McDowell, of Kentucky, so in 1802 or thereabouts
Dr, Rush, a graduate of Edinburgh, foresaw the
possibility and need of obstetrical anodynia, and
in 1847 his dream, by all forgotten, became reality
at the hands of the Edinburgh professor, Dr. Simp-
son.

Dr. J. R. Chadwick has asked me if Rush could
have been familiar with Joseph Priestley's labor-
atorj' experiments with nitrous o.xide. I have no
doubt that such was the case, aside from the fact
that after 1794 Priestley was a neighbor of his in
Pennsylvania, and most probably also a personal
friend. (It is another curious coincidence that a
near relative of the philosopher. Dr. William O.
Priestly, of London, should have been one of
Simpson's best loved and subsequently most dis-
guished pupils.) It is moreover possible that Rush
had noticed what Davy had just then suggested, in
1800, regarding the use of nitrous oxide as a
purely surgical anaesthetic. However this may
be, the fact remains that Rush had advanced far
beyond the point assumed by Davy. What he
desired and foretold was not the destruction of
sensibility alone, but the retention with this, in
full activity, of a certain usually dormant, but in
obstetrics all-important, .system of nerves. Davy
made no reference to allaying the pains of child-
birth. His whole thought was of surgical anodj'-
nia, the mere quieting of general sensibility. He
evidently never dreamed of obstetrical anodj'uia,
where nervous irritability and uterine contractility
must be retained unimpaired. And so with Bos-
ton. To Boston, indisputably, belongs the honor
of having first demonstrated the general practica-
bility and safety of induced surgical anaesthesia.

■-■ " Modem Histor\'of Aiiicsthesia.'" (Ana'Sthcsifl, Hospitalism,
etc. Edited by Sir W.G. Simpson, Dart.) Kdinburgh, iS7i,p. 41.

against which there did not exist the then seem-
ingly grave theological objections that were so
vehemently urged against its obstetrical employ-
ment, and which made the triumph in this direc-
tion the more difficult, and yet for this verj' reason
the more to be commemorated.

THE RUSH MEDALS.

I have thus brieflj' presented Dr. Rush's claim
to be honored by you, gentlemen, the teachers,
cultivators, and practitioners of midwiferj- in the
United States. Eventually, the memorial deter-
mined upon by this Association, in collecting the
funds for which Medical Director Gihon, U. S. X.,
Dr. Geo. H. Rohe of Baltimore, ex-President To-
ner of Washington, and others of your Commit-
tee, have labored so faithfully, will be erected,
and mankind will be reminded of " the Sydenham
of America."^'' It remains for you to influence
the profession toward the hastening of that time,
marking at last "the Rush renaissance. " "' Mean-
while, that you maj- contemplate the features of
the man himself, and appreciate the better the
parallel that has been drawn between him and the
great light of British medicine, I show you re-
productions, from my own collection, of the two
medals that have been struck in his honor at the
U. S. Mint, of which he was long the Treasurer.
They have been photographed for me from the
originals, greatly enlarged, by my friend, Mr.
Clarence Stanhope, of Newport, and I wish that
copies could be placed in everj' medical, histori-
cal and public library in the countrj'. The fol-
lowing are their descriptions :

I. Obverse. Bust, with queue, to left; a neck cloth un-
der the collar. Beneath shoulder, F(urst). Inscrip-
tion: Benj.\min Rush, M.D., of PHii.ADEi,PHi.A..y

Reverse. A river, flowing from side to side forwards; in
background, the setting sun, with clouds and moun-
tains. Large trees in foreground, to right; to the
left, Sydenham, In front, a block of stone, on
which: Read — Think — Observe. Upon this, an
open book. Beneath, to right: M(,oritz). Fi'RST Fec.
Exergue: A(,nno). MDCCCViii.

Silver (?), bronze, lead. 41 mm. 27.

The legend ttpon the reverse is from the close
of his lecture, "On the Causes which have Re-
tarded the Progress of Medicine. " It is very sim-
ilar to the "Hear. Read. Mark. Learn.'"
upon an old medal of Christ's Hospital School,,
London, which is in my collection, in silver.

I have this medal of Dr. Rush both in bronze
and lead. It is also at the Surgeon-General's
Office at Washington, from the Lee Collection, in
the former of these metals. It is very rare, and
.seems unknown to all numismatic writers. The
die cutter, Fiirst, was at the time an assistant en-
graver at the U. S. Mint.

=iThe above term was first applied to Rush by his frieud and
biographer. Dr. Lettsom. of London. Loc. cit., I,ondon, 1S15, pp.

'•" C. K. Mills. "Benjamin Rush and .\merican P.sychiatry.'*
Medico-I.egal Junrnal, December, 1SS6; Reprint, p. 2.

1889.

MODERN SANITARY CONDITIONS.

335

2. Obverse as in preceding.

Reverse. An altar, upon which rests an open book. In
front, upon an oval panel, a bust of ^?isculapius,
with serpent-encircled staff. In another panel, at
right, an urn. Beneath, to right: M. Furst Fee.
Exergue: A(nno). mdcccvhi.

Bronze, gilt bronze. 41 mm. 27.

Unknown to all writers ttpoii medals. Still
rarer than the preceding. It is in the Lee Col-
lection and my own.

I have endeavored, but thus far in vain, to as-
certain the history of these medals, and have been
aided in my inquiries by Dr. Wm. Pepper, of Phil-
adelphia, through whom I have received letters
from Ho»i. A. Loudon Snowden, long Superin-
tendent of the U. S. Mint, and Mr. R. A. Mc-
Clure, in charge of the Mint Cabinet. Col.
Snowden has written, under date of March 21,
1889 : "The Dr. Rush medal is not in the Mint
Cabinet, and its history is obscure," and again
upon the 27th, " I have taken considerable trou-
ble to seek information from several sources, but
thus far without any particular success." Mr.
McCIure, like Col. Snowden, was aware of the
existence of but the first of the medals described
above, and this he had seen at Mr. Alexander
Biddle's. He reports: " Mr. Biddledid not suc-
ceed in finding any information or clue to the oc-
casion of the striking of the Rush medal. I went
to the Ridgwaj' and Philadelphia Libraries, and
the rooms of the Historical and Philosophical So-
cieties, and looked over the file of two dailj' papers
of 1808, the year in which the medal was struck,
and found nothing." Messrs. Bailey, Banks &
Biddle, prominent medallic artists of Philadel-
phia, have also been unable to furnish nie with
the slightest information. From this will be per-
ceived the extreme rarity of the medals, and the
fact that though both of them were struck at the
Mint, the very existence of one of the two had
passed from the knowledge of the Mint authori-
ties. Of the first of them, there are said to be
known two specimens in silver. It was remarked
several years ago,'° before the revival of an inter-
est in medical numismatics, that these would be
cheap at $20 each. They would probably now
bring very much more than this sum, and it is to
be hoped that they have been secured for perma-
nent preservation by medical institutions, though
as to this I am as yet uncertain.

The portrait bust of Dr. Rush upon the medals
was undoubtedly from sittings for the purpose,
since they were executed five years before his
death. It will therefore be of service, in connec-
tion with the familiar painting by Sully, in giving
his exact features for the monument undertaken
by the Association, when at last its construction
shall be commenced.

In conclusion, a brief quotation from the " Ele-
giac Poem on the Death of Dr. Rush," may not
seem out of place :

=5 American Journal of Numismatics, 1885, p. 70.

"Unchecked by ridicule, unawed by rules,
Fallacious dogmas, and the pride of schools;
With all the ardor of aspiring youth.
From fair experiment, the test of truth.
Deep searching Rush ingenious reasonings drew,
Bold to defend, and potent to subduel
Determined truth by every mean to trj-,
Where others dared not gaze, 'twas his to flv;
He rescued truth from mad opinion's maze.
And caught from Science her inspiring rays;
Beamed o'er the healing art a radiant light.
Like orient phosphor o'er the mists of night." ="

How appropriate beyond the intention of its
writer, who was but lamenting his decease, is the
following, to Rush's supreme anticipation of the
discovery and application of artificially induced
anaesthesia to midwifery !

" Thy light, bright Science, to this sphere confined,
Was far too little for his mightv mind!
Which soared beyond this world, and broke away
From darkened nature to a world of day." ■'

(The above paper was read before the Section of Ob-
stetrics and the Diseases of Women, and by vote of the
Section was referred to the Association itself, with the
recommendation that it be read in general session also,
as containing matter of interest to all practitioners of
medicine. )

MODERN SANITARY CONDITIONS.

RiaJ, by imitation, br/oie the Section of State Medicine at the

Fortieth Annual Meeting of the A tnerican Medical

Association, June, iSSg.

BY GEORGE E. WARING, Jr.,

OF NEWPORT, R. I.

Early in 1855, moved by the most distressing
condition of the sick and wounded in the hospi-
tals of the Crimean army, Lord Panmure com-
missioned Dr. Sutherland, Dr. Gavin and Mr.
Rawlinson to proceed to the Bosphorus and to the
Crimea, and to take instant measures for the im-
provement of the sanitary state of those sadly
crowded buildings.

Mr. Rawlinson, a man of sound sense, great
practical skill, and a genius for direct and positive
action, and then in the prime of life, was quick to
apply to the appalling conditions with which he
was confronted those well-trained abilities which
had already marked him, and which still mark
him, as one of the great lights of Sanitary Engi-
neering.

The order was issued on the rgth of February.
In less than three weeks the work at Scutari was
already progressing and within a month a marked
effect was obvious.

Kinglake says: "Then came on a change
which, if only it had been preceded by mummery
instead of ventilation and drainage and pure
water supply, would have easily passed for a
miracle. Down went the rate of mortality. Hav-
ing already gone down from the terrible February
rate of 42 percent, to 31, it descended in the next
fortnight to 14 ; in the next twenty daj's to 10;

^ Loc. cit., Philadelphia. iFij, p. 15.
-' Ibid., p. 31.

336

MODERN SANITARY CONDITIONS.

[September 7,

in the next to 5 ; in the next to 4 ; and finally, i
in the next twenty days, ending on the 30th of
June, 1855, to scarceh' more than 2." ' 1

This result was achieved by physical changes !
efiected by intelligent engineering.

Dr. Billings, in his work for the Tenth Census
of the United States, estimates the death-rate of
the whole country at about 18 per 1000. It can- j
not be questioned that a proper regulation of the
universal conditions of human life throughout
the whole country would reduce this rate to 1 2
per 1000 ; saving ever\' year, on the basis of the
present population, not fewer than 365,000 lives
which are now sacrificed to neglected filth, with
its attendant contamination of the soil on which
we live, of the air we breathe, of the food we eat,
and of the water we drink.

Disregarding for the moment the enormous loss
of power and loss of heart, and the manifold suf-
fering incident to the sickness these deaths imply,
we are confronted with the stupendous and dis-
graceful fact that in these prosperous and intelli-
gent United States, of which we boast as the
home of the highest modern civilization, one 1
thousand human beings are stricken to death '
ever}' day, cruelly, needlesslj-, wickedly — solel}^
because of the lack of that which it needs only
intelligent direction to secure. We thus wantonly
destroy every three years more lives than were :
sacrificed, directly and indirectlj-, by both North
and South during the War of the Rebellion.
The sum now paid for pensions during three !
years, if intelligentl}- administered, would cover
the improvements required to prevent these i
deaths. 1

The epidemic of yellow fever in 1878 aroused
the active sympathies of the Nation, and even
frightened Congress into an unwonted momentary
activity in behalf of the life and health of the
people. The deaths from that epidemic did not
amount to more than 18,000, The lives wan-
tonly sacrificed to preventable disease amount to
that number everj' eighteen days.

The whole country- now stands aghast at the
fearful sacrifice of life caused by the bursting of
the dam above Johnstown. Estimates of the ac-
tual loss are necessarily vague, but it is entirely
safe to say that thrice each month, thirty-six
times each year, as many persons die lingering
and painful deaths, caused by a universal neglect
on the part of the whole people that is no less
culpable than was the neglect of those charged
with the construction and care of the disastrous
dam.

We stand, one and all, we and our wives and
children, subject to an ever-present and entirely
avoidable danger of a sort that even,- man,
woman and child in everj- enlightened country
has a just right to be protected against.

■The exact figures are 42.7^ 31.5, 14.4, 10.7, 52. 4.3, 2.2. The aver-
age rate in military hospitals in England was 2.9.

Such protection it is quite within the power of
the people themselves to secure, but the people
themselves must .secure it. All that we can do is
to point out the way and to emphasize the neces-
sity. The huge task is one whose doing can be
compassed only by the force of an aroused public
opinion : our task, hardly less huge, it must be to
awaken and vivify that opinion.

What is to be done relates chiefly to the com-
plete removal of the organic wastes of life before
the beginning of putrefaction, and the ultimate
disposal of these wastes, b}- methods now under-
stood, in such a way as to reduce them to their
elements without such contamination* of earth,
water or air as now reacts so fatally on the popu-
lation. The process would be simple. Its seri-
ousness arises only from the wide and universal
dissemination of points needing attention, and
from the enormous aggregate of cases to be treat-
ed. The adequate sanitary improvement would
involve drainage and garbage removal, water
supply, and some improvement of ventilation.
By drainage, we mean, in this connection, the
removal of filth in sufficient currents of water,
and this is bj' far the most important thing to be
done. Accumulations of filth not susceptible of
removal in water must be removed in other ways
or destroyed. While it is obviously necessary to
bring water from a distance for the supply of
those who live in large towns, village communities
maj- safely rel}- on well-water, if only the water
of the ground be protected against contamination,
as it would be by the complete removal and
proper disposal of organic wastes. So also, with
, the prevention of putrefaction in and about habi-
tations, the need for costh' artificial ventilation
will be greatly reduced. The freedom with which
air passes not only through the imperfections of
our buildings, but through the vers- walls of
our houses, is shown to suffice for the favor-
ing of health and longevity, by the great num-
ber of aged and robust persons habitually liv-
! ing in an atmosphere that would .seem intoler-
able to one accustomed to better conditions. It is
j not to be understood that the most complete ven-
tilation is not desirable, only that if all waste
matters be properly removed and disposed of, and
if the water supply be made pure, a reduction of
the death-rate to 1 2 per 1000 might fairly be e.x-
pected, even without such ventilation a.s any sani-
tarian would think desirable.

The foregoing announcement is based on no
untried theor>'. We know liy experience that
under wholesome conditions of life a general
death-rate of 12 to 1000 can be reached in towns,
and that a lower rate is possible in the country-.
We know that where organic refuse, including
that which is voided from our per.sons, is com-
pletely removed without the possibility of fouling
the surface or the interior spaces of the .soil, with-
out the possibility of contaminating our supplies

1889.]

INFLUENCE OF MEDICAL JOURNALS.

337

of water and food, and without the possibility of
sending the gaseous products of its putrefaction
into the*atmosphere that we breathe, the condi-
tions requisite for the maintenance of the zymotic
diseases are substantial!}- annihilated, and a great
cause of malaise, debilitj- and suffering is averted.
If the improvement includes, as it often will in
an incidental way, the correction of hygrometric
conditions tending to the production of malaria,
the relief will be greatly magnified.

It may, therefore, safely be asserted, in the
light of what we know of improvements that
have been effected by simple changes of physical
conditions, that a proper application of the sani-
tary arts of the engineer would of itself suffice to
save to us the thousand daily lives now thrown
away, and to multiply greatly the happiness and
efficiency of myriads whose sickness, though
not mortal, is grievously painful and incapaci-
tating.

It is, of course, not to be understood that even
the zymotic diseases, which are chiefly referred to
in this paper, are to be withdrawn from the do-
main of the physician and entrusted to the unaid-
ed efforts of the engineer. The great advance in
sanitary achiev-ement in the past fifteen years has
taken place not in the field, but in the laboratorj' ;
it is in your profession, not in ours, that the great
wonders have been wrought.

It has long been considered that the rough
measures of the drain builder and the water pur-
veyor were effective in warding off much disease
and death, but the knowledge under which our
results have been achieved has been very largely
of an empirical character. It was onh' when the
biologist entered the arena that real knowledge
of the subject began, and although the biologist
is yet onlj- at the portals of the vast temple of
knowledge to which he has so lately found the
key, he has gone far enough to indicate quite
clearly the reasons for the success of sanitary en-
gineering, and even to justify a conviction that
he has, dimly perhaps, but sureh-, indicated a
new waj' of escape from much of our existing
physical suffering and death.

How many of our diseases are caused by the
invasion of specific organisms we are far from
knowing. We do know that some of them are so
cau.sed, and the study of the life history of patho-
genic microbes has already indicated more than a
possibility, not onl}- that their invasion ma)' be
prevented by suitable measures, but also that after
the invasion of our bodies they may be, by meas-
ures yet to be defined, rendered powerle.ss to per-
form their appointed work of injury or destruction.
It would indeed almost seem that the elixir, not
perhaps of life but of health, will yet be shown
to lie in the death potion of the microscopic in-
vaders of our blood and tissues. Until this is
definitely shown, and probably still more after it
has been shown, your profession and ours must

work hand in hand to stay the tide of destruction
bj- which the communitj- is not onlj- menaced,
but to which it is actually subject, and from which
it is constantly suffering.

You need not now be detained for a discussion
of the processes by which the great end in view
may be accomplished. These are tolerably well
known and are to become better known da}^ bj'
daj'. What is necessary is that you and not onlj^
you, but all of your professional brethren, and
not only they, but all who are subject to their
professional ministration and to their influence
shall be made to know and to feel that this great
calamity is upon us and has been upon us in con-
stantly decreasing degree for all time, and that it
lies within our power to hasten its decrease in the
future until the conditions of life of this whole-
people shall have been made what they might be
and should be.

The whole purpose of this paper is to impress
upon you the commanding need for action — an
action that shall bring modern sanitarj- conditions
into conformitv with modern civilization.

THE INFLUENCE OF MEDICAL JOUR-
NALS ON THE MARCH OF SCIENCE.

I^i'ad before the American Medical Editors' Association at Newport.
BY T. D. CROTHERS. M.D.,

OF HARTFORD, CONN.

In January, 1889, there were published in this
country and Canada, 142 journals which claimed
to represent the science and art of medicine.

The influence these journals have on the march
of medical science opens up a field of unu.sual
intere.st.

The profession are everj- year depending more
and more on medical journals for contemporane-
ous history, criticism, and guidance, and everj'
year these journals are giving more accurate
records of the movements of science, of the rise
and fall of theories, of the evolutions and revo-
lutions that follow along the line of medical
scientific discover},'.

The time has come when accurate conceptions
and misconceptions of truth must seek a hearing
through the press. Books are too slow, pamphlets
are not read, the medical journals nuist present
and defend the facts and theories continously and
persi.stently. Any theory supported in books-
alone has little chance of attracting attention.
No matter how absurd the theory may be, if it
has an organ in the press, it will be heard.
Hence, to-day, in the list of 142 journals we care
trace a history of the empiric stage of science ;
we can see the superstition and credulity and the
quacker}' which gathers about the birth of all
truth : we can see the ph.sychological growth and
conflict of truth and error, and realize that all
these journals of all degrees and kinds are uu-

338

INFLUENCE OF MEDICAL JOURNALS.

[September 7,

consciously writing the history of the world's
progress. We who are journalists, each hope
that our work approximates to that ideal of abso-
lute truth that we are striving after, above the levels
of transient medical journalism, and along the very
front lines of progress. The reality of our pro-
gress is in some degree realized bj' the constant
appearance in the medical press of the latest dis-
coveries and truths of medicine, and we feel that
in some measure the march of science takes its
shape and direction from our efforts. We who
are the actors on this stage cannot fully realize
our individual influence in the play, nor can we
judge from the applause of the audience. We
are too near each other, and our mental vision is
too limited : but we can discern the imperfections
of our work, and prompt each other from the
wings. When some of our enthusiastic brothers
find themselves overwhelmed with confusion by
the discovery- of having advocated some absurd
theorj^ or defended some new remedy which
proves to be inferior to cold water, we can cover
his exit with silence and charity. But when
some of our brothers are attacked with dog-
matism and have delusions that they are the
central orbs of all science, or that other strange
fatal disease, and its opposite, icj- conservatism
and frothy freshness, we put on garments of
mourning long before life is extinct.

Bowing on the stage, or lounging in the wings,
gives us some clear views of human nature and
science. The search for truth and the effort to pre-
sent it, brings out all the stars, the tragedians,
the comedians, the supporters, and the army of
figure heads.

As evolutionarj- optimists, we can catch
glimpses of a progressive movement ever onward,
although in our work this march of science
seems like a confused advance and retrograde
alternately. The incessant revolutions of theories
and practices casts a shadow over our dogmatism
and boasted exact experience, making it clear
that the great drama of which we are actors and
historians is beyond our present comprehension.
The influence of medical journalism on the march

sions covering every line of medical research.
The claim of being practical and addressing
themselves solely to the busy physician is often
contradicted by the work. Such journals like
the single volume text-books fail, because the
subject has outgrown the limits they would place
upon them. A single volume text-book on
practice or surgery can only be an outline view,
more or less imperfect. So a general journal
which attempts to spread the entire field of medi-
cine before its readers, must do so in outline, and
fail in many respects. The journals of to-day
cannot do what was possible a quarter of a century
ago. The heavy quarterlies are fast disappear-
ing, and even the monthly is losing ground.
Our journals must come weekly, and not far
away the medical dailies will appear.

The journals that are taken by the general pro-
fession to-day must come often, and bring theory
and practical experience ; they must in news-
paper parlance "boil down" everj' thing, and
discriminate between the facts and fancies of
authors. The general journal of to-day fails
when its pages are loaded down with minute de-
scriptions of disease and the exact action of
remedies on the organism. It fails when the
editorials are acrimonious and dogmatic. It fails
when it dwindles into a newspaper of personal
items and gossip, and apes the secular papers in
tone and character. It fails when it assumes that
medical science has advanced to the frontiers of
positive truth in an}' direction. When the ideal
general journal comes for the ma.ss of physicians,
it will be a weekly and daily.

It will be strictly impersonal and reflect the
conclusions and results of scientific study up to
the present.

It will avoid the ranks of dogmatism and
credulity, and follow a line of frank conservatism
towards all science. It will aim to find not the
practical alone, but the literal roads for the dis-
cover}- of the probable facts and laws of science.

The ideal journal will arouse and stimulate
further inquirj', and the reader will never be sat-
isfied with the conclusions which it presents.

of science, is also beyond our present compre- The ideal journal will be an outline of what ap-

hension. We -can only draw some outline facts
and apparent conclusions of this influence from
a general study of the journals which claim to
represent the science of medicine to-day. Of the
142 journals which began the year, death has
claimed a certain number, but recruits have
promptly filled their places, and it is safe to say
that there are no vacancies. But the long felt
want is still urged. Journals come, and journals
go, and the procession goes on.

Among the real scientific journals three distinct
classes appear : The general, the special, and the
enryclopadie journals.

The general Journals aim to represent the en-
tire field of medicine, to give papers and discus-

pear to be the best sustained facts concerning the
problems of medicine. Such a journal must have
concentrated power and force of editorial talent,
to write the history of the medical advances
truthfully and clearly to-day. Such work helps
on the march of science and is growing more and
more essential.

The journals devoled to special fields of medicine
occupy a different position.

They give the observations of the picket-
guards of science, the impression of men who
follow up a special line of research. They make
the first sur\'eys of new countries, which of course
are imperfect and lacking in many details.

The probable facts and their conclusions are

1889.]

INFLUENCE OF MEDICAL JOURNALS.

339

only tentative, and are given for the purpose of
exciting inquiry and examination.

The specialists' journals are mapping out the
topography of new countries, and making ob-
servations of its flora and fauna, which must be
• corrected by the armies of the rear, and more
than all other journals do they influence the
growth of science, and are in turn influenced by
it. The multiplication of specialists" journals
comes from the rapid widening of the fields of
medical study ; it shows clearlj' that the day for
the general journal is drawing to a close ; that
like the single volume text-books, the science of
medicine can no more be concentrated in one
journal. In the twenty or more special journals
that occupy the field in this country, this fact is
more and more obvious.

From the smallest and most imperfect begin-
nings they are slowly and surely coming to " the
front," and in the twentieth century the science
of medicine will be studied in these journals.
The specialist journals of to-day, with all their
weakness and narrowness of work, are nearer and
more influential in the real progress of science
They push on the exploration, from the mountain
tops into the valleys, and along the river bottoms
and plains of science. They map out the field
for minute and exhaustive study, and give the
results of individual work as no other journal
can. Such journals cannot exist alone com-
mercial standards of value ; they come in obedi- j
ence to demands of a special audience ; their '
readers are contemporarians, workers along the
.same lines of research. They can only live where
science is most aggressive, most active and most
advanced. The general journal is of the past,
the special journal is of the future. The one is a
survival, the other is an evolution. The great
text-books on the different branches of medicine
are more and more the outgrowth of the work of
special journals, the condensation and elabora-
tion of views that have appeared first in such
journals. On the growth and development of
special journals, many of the great problems of
medical science will depend.

The last class of journals that are prominent
are the cyclopsedial journals. They essay to
give condensed summaries of the progress in all
departments of medicine. Many general journals
combine this feature with their work.

The ideal journal, or book, that will give a
fair view of the medical progress of to-day is 3-et
to come.

The attempts in this field are more promising
than real. The readers of this class of literature
and journals are filled with conflicting emotions
concerning the near approach of a medical
millennium, and the disappearance of the good
old facts of our fathers and the humiliating
thought that all truth comes from over the sea.
No true science in this American A^asarcl/i. The

ideal journal to occupy this field will be a great
power in the evolutionarj- march. The ideal
book giving a correct view of the progress is far
beyond the journal or the special department in
the journals.

These three distinct classes of journals appear
either single or combined in all the medical
papers that claim to represent the science.

Medical journals are slowly emerging from the
stage of childhood, in which the personal views
of its managers are more prominent and emphatic
than facts of science ; a stage in which the in-
tense personality of certain men and colleges, or
teachers, are fixed points about which all other
truth must revolve. Every advance is judged
from this point of view. Such journals resolve
the science and art of medicine into fixed laws,
that never change. They stand out in the great
march as obstructive, like the Bourbon family,
they never learn anything and never forget any-
thing.

The mutual admiration period is anotlier phase
of the childhood of journalism. Journals of this
class are passing away, and are very interesting
psychological studies. The personal news items,
and comments stage is another sign of youth in
journalism. Sneering doubts, and fulsome en-
dorsement of every new view of science are
equally unscientific. We might go on and tabu-
late a long list of signs of youth and feebleness
in the medical press, but a little higher view will
show us that this is part of the natural history of
the sudden birth of a small army of medical
journals, who are each struggling to represent the
whole or some part of this great ever-widening
land of science.

Medical journals, like the science which it
represents, are growths or evolutions from the
lower to the higher, or devolutions from the
lower still • farther back. Medical advance is-
thoroughly revolutionary, and our best facts to-
da}' disappear to-morrow, and give place to newer,
wider views. Our journals ought to be histories
of this restless change. Histories above all
personal interest or motives, except to give the
most probable facts and conclusions, sustained by
all the evidence at our command.

As medical journalists we can never represent
or influence science by allowing personal dogma-
tism or personal gossip criticism to appear in our
work. We can never represent or influence
science by endorsing an assumption that an}^ one
range of facts comprise the whole truth, or that
the last and final truth is bound up in any theory.
We can never represent or influence science by a
partisan support or defence of any minute state-
ment of disease or its exact laws, or the action of
drugs on the system, or theories of physiology
and psychology'. Medical journalism to represent
and influence science must assume the position of
a judge, hear all the evidence, and then present

340

MEDICAL PROGRESS.

[September 7,

to its readers those facts which seem best sup-
ported by research, theorj' and experience. Med-
ical journalism to represent and influence science
must discriminate betu-ecn the probable and the
improbable, between the statements and theories
of men, who trust to fancy or to inductive reason-
ing, must discriminate between facts that are ap-
parent or assumed, and insist that the record of
sciences to-day have some support from the facts
of 3'esterda}'. If this cannot be, the record must
have an assemblage of probable evidence, that
shall give it position and recognition.

Medical jonrnalis)n to represent and infliience
science can never be a newspaper or a transient
journal of the hour. It must rise to the level of
the great laws which govern the evolution and
dissolution of humanity. The individuality of
the discoverer is as nothing compared with his
■discoveries. The truths of science require a
higher standard of representation than the follies
and accidents of life. While the 142 journals in
this country that claim to represent medicine are
in many instances sad reflections of so-called
science, yet the American medical press as a
whole is full of hopeful promise. While the
quarterlies are doomed, and the monthlies are
becoming more and more uncertain, the weeklies
are growing in freshness and vigor. A new era
is dawning for journalism. Both authors and
editors must give the readers the clearest, briefest
facts and evidence to sustain them. The theories
and opinions of the fathers in medicine have of
themselves no longer any weight, unless they
have a direct bearing on the present. Papers
loaded down with authorities are becoming more
and more pedantic and absurd. There are no
absolute facts in medicine, everj-thing is relative,
and good only for the present.

The world is full of working problems, which,
like steps on a ladder, are means for higher and
wider views of truth. In journalism we get the
first surveys, in books, the corrected conclusions,
good onl)' for this day and generation.

Medical journalism reflects more and more
positively the true spirit of the march of science
in this closing century ; not the march of science
in Germany, France or England, but the move-
ment here in our own countr}-, free from, the
blighting conservatism of the past, free from
time-worn theories, and empiric conceptions that
are moss-covered with age and respectability.
Free to question every assumed fact, and demand
the reasons for its existence.

Medical journalism in this countrj' is growing
stronger and more influential everj' year. We
are gaining greater power with every advance,
and realizing more clearly that medical science is
an incessant search for truth, that widens with
every step forward. Both as historians and ex-
plorers we are pressing on into the unknown,
fully a.ssured that greater facts and truths are yet
to come from broad scientific work.

MEDICAL PROGRESS.

The Treatment of Insomnia. — In his con-
cluding remarks in his paper on this subject
(read in the Societj- of Internal Medicine), Ias-'
TROWiTz, of Berlin, considers the following re-
medial applications : Alcolwl may be emploj-ed
in the form of beer, wine, cognac, etc., and it may
be u.sed especially in cases where the other sopor-
ific remedies would occasion considerable weak-
ness of the heart. In patients subject to chronic
insomnia alcohol should only be used in the light
forms of psychical excitement, thus a few glasses
of beer may be given at bedtime. Alcohol should
be avoided in lypemania and h^-pochondria, be-
cause it increases the morning depression common
in these cases.

Opium and morphine. I regard the alkaloids
as the true soporifics, contrary to the general sen-
timent, which regards them as simph' calming
remedies. In spite of the useful action which
antipyrin, phenacetin, etc., exert in pain, we can-
not ignore the claims of morphine, which has also
a tonic action. Thus sportsmen employ it to
stimulate themselves, and inject it into their
horses to increase their resistance to fatigue.
The tonic action of morphine explains its use in
the different states of morbid terror and in the
insomnia of anaemic subjects. It must be cau-
tiously administered in bronchitis, pneumonia and
heart disease. In chronic insomnia it is contra-
indicated, for the morphine habit is much more
difficult to combat than that of chloral, paralde-
hj'de and sulphonal. In certain forms of insom-
nia— in the senile form, in those which depend
upon an intestinal affection, and in chronic lype-
mania, opium acts better than morphine, Nar-
ceine in doses of o.i to 0.15 centigrams is a good
soporific. Codeine in the same doses sometimes
produces convulsions.

Chloral is unquestionabh- the most powerful
soporific, but in large doses it lowers blood pres-
sure considerably and paralyzes the heart. Chlo-
ral is our best remedy in delirium tremens and
epilepsy. According to Liebreich it is contra-
indicated in diseases of the heart and hysteria.
In my opinion it is also contraindicated in cases
where there is considerable adhesion of the lungs,
as well as in those cases where, after a dose of 4
grams, we do not find that excitement which is
manifested in part by contraction of the pupils.
In cases where it is active in small doses chloral
may be employed to as good advantage in chronic
insomnia as in the acute form. It is well to add
a little morphine to the dose, for, by retarding
the elimination of the chloral, it renders the ac-
tion of the latter more permanent.

/'(? ;■«/(/<•// li/fdoes not weaken the heart, but when
employed for a long time it manifests its close re-
lation to alcohol by a chronic intoxication anal-

I889.J

MEDICAL PROGRESS.

341

ogous to the grave forms of delirium tremens.
Because of its disagreeable taste and its elimina-
tion by the lungs paraldehyde is contraindicated
in bronchitis and dyspepsia. It is indicated in
hysteria (because its taste is disagreeable), and
in icterus accompanied with pruritus. It has also
been recommended in cardiac stenosis and reject-
ed in dilatation of the right heart and arterio-scle-
rosis. Paraldehyde acts verj' well in insomnia
from emotional causes and in epileptic excitement,
but its action is less favorable in the four condi-
tions of psychical excitation and morbid fear.

Hydrate of amyl is a good soporific free from
all danger. It sometimes exerts a bad influence
on the stomach, however, and it is then necessar}'
to give it by injection. It has been recommended
in typhoid fever, in heart disease, as a remedy for
cough (when paraldehj-de is contraindicated), and
as a soothing remedj' in cholelithiasis.

Sulphonal enjoys the great advantage of being
tasteless and inodorous, which allows its adminis-
tration without the knowledge of recalcitrant pa-
tients. It exerts no influence upon the heart. In
acute disea.ses its action is not sufficiently rapid
and it has no influence upon pain. It is, how-
ever, an excellent remedy in the insomnia of mo-
tor origin, as, for example, in chorea and all forms
of mania. I administer it often in small sedative
doses during the day and at evening give a large
soporific dose. The prolonged use of sulphonal
produces a peculiar condition of weakness in the
limbs, but unaccompanied by real ataxia. For
this reason it is necessary to discontinue its use
from time to time.

As regards the inconvenience, danger and in-
tensity of their soporific action, the remedies of
■which I have spoken may be classified according
to the following series : As regards their incon-
venience and danger : morphine, chloral, hydrate
of amyl, paraldehyde, sulphonal. As regards
their efficacy ; chloral, sulphonal, h^-drate of
amyl, paraldehyde, morphine.

Thus we see that sulphonal is the least danger-
ous of all, while at the same time it occupies the
second place as regards soporific action. — (iaz.
Med. dc Liige, July 18, 1889.

Abdominal Section for Relief of Intesti-
N.\L Obstruction. — Prof. Ob.\linski, of Kra-
kow, in his review of the history of intestinal
obstruction, shows that, except for incarcerated
hernia, surgical treatment is confined almost en-
tirely to the present century and more particular-
ly to the present decade. He has performed ab-
dominal section in 38 cases of intestinal occlusion
from almost ever)- possible cause; of these 15, or
40 per cent., recovered, and excluding 7 hopeless
cases, the recoveries would reach nearly 50 per
cent. In about 50 per cent, the diagnosis, both
as to location and character of obstruction, was
proven to be accurate. He insists upon a consid-

eration of the following points in the history of
each case: i, duration; 2, rapidity; 3, number
of attacks ; 4, predisposing disease ; 5, direct
cause, traumatic or otherwise ; 6, amount of pain;
7, whether pregnant ; 8, general condition of pa-
tient (whether exhausted or not) ; 9, form of ab-
domen— spherical form in obstruction of coecal,
square form, of lower end of colon ; marked tym-
panitis indicates an acute, a slighter amount a
chronic attack; 10, marked peristaltic action in-
dicates a mechanical, absence of this a functional
obstruction; 11, palpation, recognition of painful
spot ; 12, vomiting and absence of flatus indicate
obstruction but do not locate it; 13, decrease in
urine maj' indicate peritonitis ; 14, manual exam-
ination of rectum is sometimes useful. With all
of these aids a certain diagnosis is possible only
in one-third of all cases. In the other two-thirds
he advises an early exploratory, median incision.
If the intestines are much distended they are
taken out of the cavitj', and in extreme cases a
transverse incision is made into the gut, the con-
tents carefully evacuated, the opening closed and
the intestine replaced. Whenever possible the
obstruction is removed ; if not, an artificial anus
is made above obstruction. — Archiv fi'ir Klinische
Chirurgie, Vol. 38, Heft. 2,

A Case of Intestinal Obstruction and
Gangrene. — Dr. W. A. Briggs, of Sacramento,
reports a case of intestinal obstruction and gan-
grene. The patient applied for treatment on June
13, 1889, complaining of vomiting and paroxys-
mal pain. There was no abdominal distension
and no tenderness on pressure. On the next day
there was stercoraceous vomiting and abdominal
pain. The patient had had a similar attack three
weeks previously. On the 15th there was less
pain, but a tumor had appeared in the right iliac
region, accompanied bj' abdominal distension. On
the same day a laparotomy was made. On open-
ing the peritoneum turbid serum welled up and a
gangrenous odor was manifested. The peritoneum
was inflamed throughout. An elastic tumor of the
size of an orange occupied what seemed to be the
site of the caecum ; this was formed by a segment
of small intestine constricted by adherent bands.
A gangrenous segment of the intestine 8 inches
in length was found and resected, when it was
discovered that there was a second gangrenous
tract 6 inches long, separated from the first gan-
grenous portion by 3 inches of healthy tissue.
These two portions were accordingly included in
the resection. The bowel was united by a double
row of catgut sutures — continuous as regarded
the mucous membrane, interrupted as regarded
the peritoneum. The mesentery was brought to-
gether with interrupted sutures. Patient died in
collapse two and one-half hours after the opera-
tion. The operator directs attention to the fol-
lowing points: I. The ease with which death

342

MEDICAL PROGRESS.

[September 7,

might have been averted bj' timely operation. 2.
The slight constitutional disturbance prior to ac-
tual gangrene. Three daj'S after complete ob-
struction and two daj's after the supervention of
stercoraceous vomiting, the patient traveled thir-
ty-five miles, and the day after walked two miles.
3. Were the peritoneal bands causing the con-
striction of so recent origin as the attack three
weeks prior to the final one? — Occidental Medical
Times.

Physiological Action of S.\ccharin. —
Petschek and Zerner have conducted a series
of experiments with saccharin with the object of
studying its action upon the organism and its
therapeutical effects. Their first investigations
concerned its effects upon pytaline pepsin and the
ferment of the pancreas. Saccharin in concen-
trated solution impedes the action of pytaline
upon starch because of its acid reaction. If the
the solution of saccharin be neutralized or if its
soda salt be employed the conversion of starch
into dextrine and glucose takes place as usual.
The action of pepsin is not changed hy saccharin,
it is merelj' retarded when in place of using a
combination of soda and saccharin the latter is
employed alone. Saccharin in powder dissolves
slowly and does not allow the pepsin to exert its
digestive action until solution takes place. Ex-
periments upon the living subject show that
saccharin in doses of from 0.05 to 0.30 grm. exerts
no influence upon digestion. In doses of from
0.50 to I grm. it retards digestion when taken
pure ; its soda salt, which is more soluble, ma}'
be taken even in doses of 5 grm. without dis-
turbing digestion. The action of saccharin on
pepsin is nil when its soda salt is used, while sac-
charin in substance exerts an unfavorable action,
because of its acid reaction. Petschek and Zer-
ner reach the conclusion that saccharin should
not be employed except when combined with
soda. As a substitute for sugar saccharin may
be taken for a long time without impairing the
appetite or the patient's well-being. Saccharin
is eliminated by the urine, but not by the saliva.

From a therapeutic standpoint Petschek and
Zerner have employed saccharin in 50 cases, in
doses of from o.i to 10 grm. Its antipyretic ac-
tion is almost nil, as estimated by the action of
the pulse, respiration and transpiration. They
have never observed the supervention of albu-
minuria after the administration of saccharin
even in invalids predisposed to nephritis. The
antizymotic action of saccharin is especially man-
ifested in cases of abnormal intestinal fermenta-
tion. No .specific action of the remedy has ever
been noted in any disease. In cystitis saccharin
exerts no influence. In two ca.ses of otitis media
purulcnta which resisted the action of boric acid
the otorrhcea was cured in a few days. The most
decided successes have been witnessed in dys-

pepsia and gastric disorders produced by abnormal
fermentation. In doses of from 0.3 to i grm.
every two hours, combined with irrigation of the
stomach, saccharin soon ameliorates all symp-
toms of fermentation, which however reappear as
soon as its administration is suspended. In dia-
betes the employment of saccharin, together with
a suitable regimen, is soon followed by a rapid
diminution of the quantitj- of sugar in the urine.
—Gas. MM. de Liege, July 18, i88q.

Diabetes Mellitus after Extirp.^tiox of
THE Pancre.\s. — ^J. v. Merino and O. Minkow-
sky have made, in the laboratory of the medical
clinic in Strassburg, a number of experiments the
results of which are given by them as follows :
Diabetes mellitus occurs in dogs after extirpation
of the pancreas. It begins some time after oper-
ation and continues for weeks, without interrup-
tion, until death. Besides sugar in the urine,
there was polyuria, intense thirst, excessive ap-
petite, acute emaciation and debilitj" despite
abundant nourishment.

A dog, whose pancreas had been removed, and
which had eaten nothing for 48 hours, passed
urine containing from 5 to 6 per cent, of sugar.
Another dog 8 kilogr. in weight, which was given
nothing but meat, passed almost one liter of urine
containing from 5 to 6 per cent, of sugar, everj"-
daj-. After adding grape-sugar to the food the
proportion increased temporarilj' to 13 per cent.,
by far the larger portion of the sugar added to the
food being excreted unchanged. It maj- also be
mentioned that the urine of the animals operated
upon contained noticeable quantities of aceton.

The proportion of sugar in the blood is largely
increased; in one case it amounted to 0.30 per
cent., in another 0.46 per cent. Glycogen disap-
pears from the organs ; it could be found neither
in the liver nor in the muscles of a dog that had
been diabetically affected for four weeks and was
killed while digesting meat.

The solar ganglion was not injured in the op-
eration, the diabetes being a direct result of the
extirpation of the pancreas. Transfusion of blood
from a diabetic dog into the veins of a healthy
animal did not cause sugar-excretion in the lat-
ter. Finally, in animals without pancreas the
resorption of fat is greatly impeded, the utiliza-
tion of the albumen also seeming to be verj- im-
perfect.— Centralblatt Jitr Klinisehe Mediein, No.
23, 1889.

Enuresis. — Dr. RiCH.\Rns recommends a com-
bination of bromide of potassium and tincture of
belladonna in nocturnal incontinence. He reports
two immediate cures in boys of 12 years where
the affection had lasted from infancy. Ten grains
of the bromide and fifteen or 20 minims of the
tincture were given at night. — British Medical
Journal, June 22, 1889.

1889.]

EDITORIAL.

343

Journal of the American Medical Association

PUBLISHED WEEKLY.

SuBSCRtPTioN Price. Including Postage.

Per anitcm. in Advance $5.00

Single Copies 10 cents.

Subscription may be^n at any time. The safest mode of remit-
tftnce is b\' bank check or postal money order, drawn to the order
of The Journal. When neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
letters.
Address

Journal of the American Medical Association,

No. 6S Wabash Ave.,

Chicago, Illinois.
All members of the Association should send their Annual Dues
to the Treasurer, Richard J. Dunglison, M.D.. Lock Box 1274, Phila
delphia. Pa.

London Office, 57 and 59 Ludgate Hill.
SATURDAY, SEPTEMBER 7, 1889.

THE TREATMENT OF LOCOMOTOR ATAXIA BY
SUSPENSION

Seven years have passed since Motchoutkowsk}-,
of Odessa, after using Saver's apparatus for the
application of a plaster jacket to an ataxic pa-
tient suffering from Pott's disease, observed an
improvement in the symptoms of his patient.
Although he published, in the following year,
the results of this treatment in sixteen cases of
tabes, claiming favorable results in all but two,
it was not until Charcot, in January' of the pres-
ent year, lent the weight of his authority to the
method, that it attracted any general attention.
Since then, observations have multiplied, and it
may be considered the fashionable treatment.
Although the status of any therapeutic measure
in a disease of so protracted and irregular course
can only be determined after much more pro-
longed observation than has been had in most of
the cases thus far treated, the reported results
have been, temporarily at least, so generally fav-
orable, and the difficulty and risk of the treat-
ment, under proper precautions, are so slight,
that it would seem worthj^ of a general trial.

The only extensive statistics thus far published
are those of Charcot, who had, in March, 1889,
treated 114 cases of tabes by this method. Of
these, sixty-four did not remain long enough
under treatment to determine its effects. Of the
remaining fifty, thirty-eight were decidedlj- bene-
fited, seven unimproved, and in five cases, the
effects were injurious.

In favorable cases, nearly all the troublesome
symptoms of the disea.se are said to disappear,

wholly or in part. Coordination, sensibilitj' and
sexual power improve ; control over the bladder
is regained ; lightning pains cease. The patellar
reaction does not seem to have been recovered in
the reported cases, and the degree of improve-
ment varies greatly. It is not usualh' noticeable
until the eighth or tenth suspension, and maj- be
delayed as late as the twentieth. The perma-
nence of the improvement must, for the pres-
ent, be considered uncertain, although one of
Motchoutkowsky's patients is said to be able to
take long walks five years after the cessation of
treatment.

The rationale of the treatment is not very evi-
dent. Experiments have shown that in the
cadaver, at least, the vertebral canal is sufficiently
elongated to exert slight traction upon the spinal
cord bj' the nerve-roots, but why this should be
beneficial is not clear. Althaus suggests that it
may be due to the breaking up of adhesions in
the meninges and neuroglia. For the present,
the method must be considered empirical rather
than scientific.

In view of the fact that two persons who have
attempted to conduct the treatment on their own
persons have died from asphyxia, and that death
has occurred, apparenth' as the result of sus-
pension in two other cases where it was practiced
without medical supervision, it would seem ad-
visable that when undertaken it should be con-
ducted bj- the physician, and begun with caution.
Pulmonarj\ cardiac and vascular disease, great
debility and anaemia are held to be contra-indi-
cations.

It is probably not well to be too sanguine in
our hopes from this or any other treatment. The
operation of nerve-stretching for the same affec-
tion is not quite forgotten, although it seems to
have pa.ssed into "innocuous desuetude" and
the inflation treatment of phthisis .seems to have
pretty thoroughly collapsed. If even temporary
comfort can be given to any large proportion of
the sufferers from this disease, it will be a great
boon to both physician and patient, and, so far,
mitigate what has been one of the opprobria of
medicine.

Medical Periodicals. — It has been ascer-
tained that the principal medical periodicals of
the world number 266 ; 1 74 are published in the
United States and 92 in all other countries.

344

A FORLORN HOPE.

[September 7,

A NEW DISCOVERY.

The successful disposition of sewage is the ques-
tion of all-absorbing interest in nearly every large
city in the world. Nowhere, perhaps, has there
been a greater need, nor has the subject received
elsewhere more able and critical study than in the
city of London. Up to the date of the last month
the royal commission on metropolitan sewage dis-
charge have been unable to report any feasible
plan for the purification of sewage by precipitation.

A Mr. Wollheim, of London, now claims to
have discovered a method by which this result
may be successfully accomplished. He utilizes
certain organic bases belonging to the group of
ammonia compounds in combination with lime.
As the result of chemical reactions, a gaseous re-
agent is evolved to which he gives the name of
" amminol." It is a powerful disinfectant and, as
stated in the London Times, when introduced into
sewage rapidly extirpates all microorganisms ca-
pable of causing putrefaction or disease. When
thoroughlj' intermixed with sewage the eflfect is
almost instantaneous, the putrid odor of the sew-
age being at once replaced by that of the reagent.
In thirty minutes the liquid portion of the sewage
can be discharged deodorized and sterilized with
perfect safety.

According to reports made by Dr. Klein,
F.R.S., the disinfection as well as the deodorizing
is complete. He states that a sample of sewage
examined by him contained 2,400,000 organisms
in a cubic centimetre, 'and that the affluent after
treatment was absolutely free from all or any or-
ganisms. Dr. Klein suggests that the effects of
the treatment on specific microorganisms such as
bacillus anthracis, the cholera comma bacillus,
the typhoid bacillus, the pneumonia bacillus,
should be ascertained. We shall watch with
special interest for the verification of Dr. Klein's
experiments. If this new discovery can be util-
ized successfully it may prove to be one of the
most important achievements of the present age.
And if its germicidal power can be utilized in the
destruction of the microbes producing specific dis-
eases its value may be beyond anj- possible esti-
mate. Its claim to our confidence will be absolute
when this is fullv verified.

A FORLORN HOPE.
His experimental work in previous years had

been such as to gain for the name of Brown-S^-
QUARD a prominent and permanent place in med-
ical literature. In view of the reputation which
he had thus worthily achieved, it is not singular
that any views put forth by him should command
immediate and critical attention. Again, he could
hardly have struck a more responsive chord than
when he gave assurance that the secret of peren-
nial youth was at his command. If at last the
dream of the poet and theme of the muse were to
be realized, when age would be able at pleasure
to take on its youth, what name or what claim
could in a day command more world-wide atten-
tion. This alone is sufficient to account for the
immediate and universal discussion of this ques-
tion by pen and bj' press, by saints and by sinners
alike.

But the possibility of immediate rejuvenation
is so utterly at variance with all known laws,
either biological or physiological, that we can
only regard such a promulgation as the senseless
vagary of one, enfeebled by age, and beyond ques-
tion in present and pressing need of such rejuve-
nation. His utterances have seemed to us too
absurd to warrant serious consideration in the
columns of The Jourxal. For this reason
we must decline to publish a score or more of
letters, many of them witty and some of them
wise, all bearing upon this same subject. We
can by no means indulge this forlorn hope of life
renewal.

In this connection we desire heartily to com-
mend the forceful and timely utterances of the
Medical Record in its issue of August 24 and the
experimental study of the subject, as conducted
by Prof. Loomis, and published in the same
number of the Record, could hardlj- have been
committed to better hands. But we confess to
no little surprise that with such results as are
there detailed Prof Loomis should have reached
such conclusions.

For the time, no doubt, the subject will com-
mand very general attention, and be seized up-
on by some as a stepping-stone to personal noto-
riety, and as a means of cheap advertising. For
a time the victims of injudicious and unwarrant-
ed experimentation will suffer the penalties which
are sure to follow, but later this theory also will
be numbered with the delusions of the past, and
the name of Brown-Sequard will hardly receive
additional honor bv reason of such connection.

1889.]

EDITORIAL NOTES.

345

BRAIN SURGERY.
Dr. Edmond Souchon, of New Orleans, has de-
monstrated by experiments on dogs a useful and,
as it seems, a safe method of exploration of the
brain for the purpose of locating pus cavities. To
obviate the necessit}- of removing a large button of
bone, as is usually done, by means of the ordina'r}-
trephine, he emploj^s a watchmaker's drill, which
makes an opening just large enough to admit a
needle with a calibre about twice the size of an
ordinary hypodermic S3-ringe. This method per-
mits one to make several tentative punctures with
the infliction of comparativel}- little injurj'. In
his experiments he made use of dogs, in which
he found that four such operations of trephining
and puncture, in a single animal, were unattended
by noticeable efiects. After the results of the
first operations were obliterated the animals were
kept at rest for two weeks, when the same opera-
tions were repeated, with similar results — no re-
mote effects whatever bein? witnessed.

EDITORIAL NOTES.
HOME.

The American Association for the Ad-
vancement OF Science is now in session at
Toronto.

The American Academy of Medicine will
hold its annual meeting at Chicago on the 17th
and iSth inst.

The N.\tional Association of Dental Fac-
ulties at their recent meeting at Saratoga adopted
the three-term course in all Colleges of the Asso-
ciation. This rule will go into effect after the
session of 1S91-2, and the terms not less than five
months each.

Money for the Johns Hopkins University.
— The will of John \V. McCoy, recently admitted
to probate, makes the Johns Hopkins University
the residuary legatee and bequeaths to that insti-
tution $100,000. Mr. McCoy also leaves it his
magnificent librar>% and gives to the Peabodj' In-
stitute his collection of paintings. The rest of
the estate, about $150,000, is divided up among
literarj' friends,

A Correction. — We notice that a number of
our contemporaries are publishing a statement to
the effect that typhoid fever is epidemic in Chica-

go. It is simply a misapprehension of facts. The
only fever that Chicago is troubled with just now

is the World's Fair Fever ! It seems to have
spread already beyond the limits of ordinar}' sani-
tarj' control, and evidently Congressional legisla-
tion will alone be equal to the emergency. We
hardly look for its subsidence before the close
of 1892.

Surgeon Harvey E. Brown, U. S. A., died
August 20, at Jackson Barracks, near New Or-
leans. He was a son of Gen. Har\^ej- Brown, of
the regular army, and born in New York. He
graduated from the University medical department
in 185S. He was surgeon of volunteers from 1861
to 1863, and then became Assistant Surgeon,
U. S. A.; became full Surgeon and Major in 1S81.
He was the author of a valuable compilation and
historical sketch of the Medical Department of
the Array from 1775 to 1873. He was identified
with nearly ever}- epidemic in the Gulf District
for twenty-five years. His final disease was lin-
gering and painful, due to consumption.

Dr. Holmes at Four Score Years. — A
despatch to the daily press says that Boston's
tj'pical son, Oliver Wendell Homes, celebrated
his Soth birthday on the 2gth ult., and despite its
informal character the anniversary was a most
charming one. He spent the days at his summer
home at Beverly Farms. This is a quiet place,
liberally embowed in vines and flowers, and most
suited to such a festival. The flowers outside the
house were nearl}^ equaled by those within, the
gifts of friends, which had been sent in the earlj'
morning. From nine o'clock throughout the
da)' until night fall there was a continuous suc-
cession of v'isitors, mainl}- from the neighboring
north shore estates. The doctor, seated in his
comfortable library, with his attractions and allur-
ing furnishings, received all his friends with a
bright and pleasant smile and hearty cordialitj'.
His surroundings added much to the charm of
the occasion, the room being a genuine- old-
fashioned study of the kind our grandfathers
loved, with a tall, quaint firescreen and open fire-
place with its blazing logs resting on the ancient
firedogs, whose polished brass standards reflected
the careful housewife. The floor was covered
with neat canton matting and a mammoth rug
spread out before the fire. In one corner was a
simple rolltop desk and in another a book-case

346 EDITORIAL NOTES. [September 7,

with the doctor's favorite authors convenient for ' Papers of interest have been promised by promi-
ready access. The chief charm of the entire in- nent men.

terior was its thorough homelikeness. This organization will be independent of all

One of the many pleasant features of the day other societies. It will be an association of indi-
was the coming of the children. In the fore- vidual members of the Profession of Medicine,
noon the boys and girls of Beverly Farms school and will be managed in the interest of medical
to the number of twenty-six called in a body, progress. The session will continue two days,
and were given a most cordial reception, the ! Those desiring to read papers or exhibit specj-
doctor entering heartily into the feelings of his mens should notify the Secretary at an early date,
little friends, giving each a warm shake of the A circular will be issued in due time announc-
hand and his friendly smile. To each he pre- ing the titles and authors of papers,
sented a prettv bonbonniere filled with sweets, tied

with a bright bit of ribbon, and bearing on its ^he Ontario Medical Library Associa-
cover a miniature vignette of the poet, with his ^ion, at Toronto, is in its second year. It is
name beneath. The children of the neighbor- energetic and ambitious. The cataloguing will
hood came in the afternoon, and the lovelv, , ^^ ^^^^^ °" *^^^ P^^"^ °^ '^^ ^"'^^^ catalogue of
shaded roads and bypaths were filled with white | tbe Surgeon-General's Office at Washington. The
clad little maidens going and coming. Besides trustees have established a bureau of nurses, and
flowers there were many other pretty souvenirs of during the current year they expect to publish
the anniversary.. Among them was a handsome ' ^ complete physician's register for the city of
cup, presented by lady friends of the doctor. It , Toronto,
bore the following motto : j Death from Nicotine.— A case of excessive

' ' ' ' August, XXIx', MDCCCLXXXIX. • ^igar smoking, followed by death, is given by Dr.

'• 'Tis the heart's current lends the cup its glow, • B. W. Richardson in Asdepiadior May. A man,.

^^^''flow."''" ^°""''''" '''^'"" ^''' '^'''""^' "^^^ '■ aged 35 years, of slight build, much worried by

— Olivey Wendell Holmes. ■ the cares of business, indulged in smoking almost

The pledge of friendship. • continuously for twenty-four hours, and taking

The cup is of silver, lined with gold. During nothing but a little brandy and water. Within a
the day letters of congratulation were received period of twelve hours he smoked fourteen large
from J. G. Whittier, George William Curtis, I strong cigars and forty cigarettes. He became
Charles Eliot Norton, and a large number of ' prostrated, excited and tremulous, with loss of
others muscular power in lower extremities. At this

point, the author was called in. Supporting

A New Tri-State Medical Association.— treatment was ordered, but without avail ; the
The following call has been issued by Frank j^^g ^f muscular power increased and extended
Trester Smith, M.D., Chattanooga, Teun., Secre- ^o the upper part of body. Unconsciousness and
tary of Committee : "The members of the med- convulsive svmptoms set in and increased until
ical profession in Alabama, Georgia and Tennes- ^^^ evening, when death took place by asphyxia,
see are requested to meet in Chattanooga on the through accumulation of fluid in the bronchial
third Tuesday in October, for the purpose of passages. The author traces these conditions to
forming a Tri-State Medical Association. All ujcotine poisoning. He concludes by stating that
will be admitted to the meeting of the Associa- ; jf j^^ ^j^g to deal with another case of this nature,
tion.-but the membership will be restricted to j^^ ^^,jii try the eflfects of transfusion,
graduates of regular medical colleges in good
standing." Dr. D. Tilden Brown. — TheA'crr York World

This call is signed by committees from Jack- of August 25, contains an interview with Dr. D.
son County, Ala., Medical Society ; Chattanooga, Tilden Brown, formerly at the head of the Bloom-
Tenn., Medical Society; Cleveland, Tenn., Med- ingdale Asylum, New York, who has been report-
ical Society; Cartersville, Ga., Medical Society; ed to have died in Europe. Dr. Brown is now
Dalton, Ga., Medical Society. It is hoped that farming and practicing in a limited field, a few
there will be a general turnout of the profession. \ miles distant from Chicago. There are a host of

1889.] EDITORIAL NOTES. 347

former friends of Dr. Brown who will rejoice that | foreign.

lie is alive and well, and that they need no longer Pasteur is now a baron and Edison a count.

speak of him as " the late Dr. Brown." ^ _ . .

The Emperor of Austri.\ is establishing

The W.\ter Supply of Phil.\delphia.— The sterilizing apparatus on a large scale for the gra-

Philadelphia Inquirer \s responsible for the follow- tuitous preparation of milk for the chidren of°the

ing : It states that it has caused a new investi- poor.

gation to be made concerning the alleged contam

ination of the Schuylkill River, which is one of
the sources of the water supply of that q\\.\\ I
makes the statement that the river is ' ' little bet

., r .. . 1 r ^T, . •. T* Ametican says : The Hotel Bemina, at Samaden,

the sources of the water supplv of that citv. It , - . , - '

_„,.„ .u„ „.„. . .u„. .u/j :. ,>,:..•' u_. tas for some time been lighted with electricity.

Cooking by Electricity.— The Sdeyitific

merican says : The Hotel Bemina, at Samaden,

5 for some time been lighted with electricity,

power being supplied by a waterfall. As during

ter than an open sewer," since almost the whole , , , . . ,

,- , f »!, 1 ■ ^ vu p • ^ the day the power is not required for lighting,

distance from the coal mines to the Fairmount . . , ^ . ^ & »■

„, ^ , ^ c A \. A ^ ■ c ^^'^ IS therefore running to waste, the proprietor

W aterworks may be found abundant agencies for ^ , , , , , . , . , f r

„ ^. • ,.1, A A A ■ ■ f ..u °f t"^ 'I'^^^l ^^s hit upon the idea of utilizing

pollution, in the unguarded admission of the , , , . , . *

J . c \, A A A ^\. A c-^ ^^^ current for cooking when it is not required

drainage from hundreds and thousands of houses, . ,. , . , . ^

r A c ^ ■ 'Tu ;• • 1 fo'' lighting, and an expenmental cooking appar

farms and factories. The Inquirer makes an es- r , , «, . & fi' »

atus has been constructed. This contains Ger-
man silver resistance coils, which are brought to a
red heat by the current, and it has been found

timate that there is a population of not less than
250,000 persons, whose drainage more or less con-
tributes to the fouling of the stream which gives ... - „ ,
J . ,. ^ . .„. r 1 A«, ^ possible to perform all the ordinarv cooking oper-
drinking-water to a million of people. The onset . . ^ , . , .' ° ^

i- ^ , ■ , f 1, u r M .1 1- ations in a range fitted with a series of such coils,

of typhoid fever has been fulh- a month earlier

than in most former years ; there having been al- In Gre.a.t Brit.ain Dr. E. McDowell Coso-rove

ready reported more than 400 cases. has been appointed physician to Mercer's Hospi-

Rush Monument Committee.— We have" re- : ^^^' Dublin. There are upwards of 140 writers
ceived the following communication to which we on the editorial staff of the 5;7V/5//.I/..<//ra/y<;,.r«a/.
invite the special attention of our readers: At The Pnnce of Wales is still suffering from a goutj-
the meeting of the Rush Monument Committee, a^e^t'on of the leg. The citizens of Perth are
held at Newport, R. I., on the 26th of June, last, , agitated over a possible contamination of their
Dr. D. C. Patterson, of Washington, D. C, was ^'^}-^^ ^^PP^>'- Scarlet fever is prevalent in Bir-
elected Treasurer, \nce Dr. J. M. Toner, on nomi- ™i°gliam.

nation of the latter, who asked to be relieved of Diet in C.\ses of Foreign Body in the
this portion of his duties as member of the Com- Alimentary Canal. — At a recent meeting of the
mittee. \ Societe Vaudoise de Medecine, Dr. Rous, of

Notice is also given that the limitation of con- Lausanne, communicated the case of a woman
tributions having been removed sums of anj' who, ha\-ing undergone Schoenborn's plastic op-
amount will be received, and it is earnestly ' eration on the soft palate (destroyed by syphilis),
hoped that the enthusiastic and unanimous ap- swallowed a cur\-ed needle fixed in the retro-
proval of the projected monument at the New- pharj-ngeal flap. She was treated by feeding
port meeting of the Association will find expres- with potatoes alone, in large quantities, with the
sion in prompt and liberal remittances, which result that the foreign body was discharged with
should be addressed to Dr. D. C. P.atterson, , faeces on the third day, without having caused
Treasurer, 919 I St., N. W., Washington, D. C. any unpleasant symptoms from the first to last. —
Albert L. Gihon, M.D., Chairman. \ British Medical Journal.

•George H. Rohe, M.D., Secretary. n^^.r..-^^^^.. xr^^ ^ .^ -n. ^ ^

' Compulsory Notification. — Dr. A. C.

Mississippi Valley Medical Association. I Munro, in the London lancet, presents data show-

— Our reader will bear in mind that the annual | ing that in the little town of Jarrow, England,

meeting of this Association will be held at ' the system of compulsors- notification has been

Evansville, Ind., on the loth, nth, and 12th the means of saving, during the last ten years,

inst., and rates have been placed at a fare and a 1 an average of eighty lives and i.ooo cases of

third on all the roads centering at that point. I sickness per annum.

348

TOPICS OF THE WEEK.

[September 7,

TOPICS OF THE WEEK.

THE ANNUAL MEETING OF THE BRITISH MEDICAL ASSO-
CIATION. ENDORSEMENT OF THE BRITISH MEDICAL

JOURNAL.

The recent meeting of our associated C07tJ'rtres across
the Atlantic was a success, both in attendance and in the
character of the work presented. The eminent gentle-
men who were selected to prepare the addresses fulfilled
their tasks admirably. We regret that our space does
not permit us to publish these addresses in full, but we
hope to be able from time to time to make such selec-
tions from them as will be of interest to our readers.

The financial statement of the Treasurer of the Associ-
ation showed an increase in receipts of £i, 105 over 18S7,
and an increased expenditure of ^1,169. In view of the
balance in hand for the year, amounting to /'4.000. it was
decided to send The Journal to the Colonies and India
postage free.

Dr. Bridgwater, the President of the Council, in mov-
ing that the Report of the Council be adopted, eulogized
the Editor aud the General Manager for the able manner
in which they had conducted The Journal, and replied to
the critics in such a manner that the report was unani-
mously adopted.

Dr. Bridgwater also laid before the meeting a letter
from Sir Joseph Lister on the conduct of The Journal,
tocether with his reply thereto, and the resolution passed
by the Council, as follows:

To the Council of the British Medical Association.

London, ArcrsT i, i88g.
Gentlemen:— Many members of the .Association have been much
disappointed to find that the hopes which they had been led to en-
tertain of an improvement in the conduct of T/ie/oiirnal have not
been fulfilled. So strong is this feeling that a large number of men
. in influential positions in the profession, warmly attached to the
Association, but jealous of its honor and despairing of seeing the
improvement they desire, have expressed their determination to re-
sign their membership.

But before carr>-ing into eflect a resolution so serious, it has been
thought right to approach you, as the governing body, with the re-
quest that you will give this matter your earnest consideration, aud
take such steps as shall make The Journal in all respects worthy of
the Association which it represents. We have the honor to be, gen-
tlemen, your obedient ser\-ants,

(Signed) Joseph Lister, Chairman,

W, H. Allchin, "I
\V. A. Meredith, -Secretaries.
John Willi.\ms, J

Reply of President of Council.

Dear Sir:— I beg to acknowledge the receipt of your letter dated
August I. I will lay it before the Council when they meet in Leeds
next week. I must be permitted, meanwhile, to assure you that
vou may safely leave the honor of the Association where it has been
safely preserved for so many years. Yours faithfully,

(Signed) T. Bridgwater.

Resolved, " That the Council do not admit that the signatories of
this letter arc better judges than themselves, or more solicito\is
than they art for the honor of the .Association and of the profes-
sion, but if there are any points which the signatories desire to
particularize, in which they consider that rA(r_/i>«»ri(i/ admits of or
calls for improvement, they will, as they ever have been, on receiv-
ing them through the Representatives of their Branches in the
Council, be ready to give such suggestions their careful considera-
tion."

Mr. Lawson Tail llien moved the following resolution,
which was carried with only one dissentient:

Resolved, That this meeting desires to express its satisfaction
with the result of the present representative system of goverument
of the British Medical Association, and their approval of the steps
taken by the Council for the management of The Journal.

THE MENT.AL HYGIENE OF PHYSICI.ANS.

In a presidential address delivered at the Medical
Alumni .\ssociation of the University of Michigan, June
26, 1S89, Dr. E. P. Hurd considered at length the subject
of "The Mental Hygiene of Physicians." The address
is able and eminently practical. W the expense of other
matter we give space for its conclusions :

" If physicians would retain good mental health and
intellectual vigor sufficient for the discharge of their
varied duties in the best possible manner the}- should
avoid :

"First. Overwork and the train of physical and men-
tal S3*mptoms which accompany it. To this end they
should systematize their work, aud as far as possible
perform every duty at its proper hour. Office hours
should be kept scrupulously ; hours for meals, for sleep
and for recreation should be as scrupulouly obser\-ed. If
a call comes which destroys the rest for a single night
the lost sleep should be made up as full}' as the circum-
stances of the case will permit. Much of a physician's
time is frittered away by duties aud occupations which
are foreign to his true work. Guard your time sedulously
from ueedless interruptions. Work done amid con-
stant interruptions is always performed at an increased
exp'enditure of ner\'ous energy'. The miud works best in
accustomed grooves. When your attention is claimed
by half a dozen different topics in as many moments the
transition from one to another is always accompanied by
a mental wrench which is dentrimental to good work.
Every physician should secure an annual vacation and
relinquish toil altogether even if it is only for a single
da}-.

" I am aware that plan we never so wisely overwork is
sometimes inevitable, and an injurious strain upon the
physical and mental forces is frequently unavoidable.
The physician becomes sleepless, loses appetite, fails in
strength, and shows other signs of exhaustion. Shall he
at such a time spur on his jaded energies by stimulants
or relieve his disagreeable sensations by narcotics ? It
were suicidal for him to do so. .\ stimulant or a narcotic
may temporarily whip up the exhausted energies, but at
the expense of more serious disaster later. The real
remedies are rest aud nutrition. Physicians should live
well and avoid exhaustion by making a special study of
foods and their effects upon themselves when suffering
from exhaustion. .\ cup of cocoa, a glass of milk, a cup
of bouillon, or coffee, will do as much as a stimulant,
and more, because food is thus supplied in addition. The
vexed question of tobacco has a bearing upon this point.
If the narcotic it contains is promptly eliminated by the
system and the indulgence leaves no unpleasant ta.ste in
the mouth, an occasional cigar or semi-occasional pipe
mav prove of benefit. For the sake of example let me
suggest that smoking be done surreptitiously in the pri-
vacy of home or the .sanctity of the inner office, far from
the gaze of the curious, because in my judgment it can-
not be denied that nonmedical men who do not smoke

1889.]

TOPICS OF THE WEEK.

349

from such pure motives, but mereh" because they enjoy

smoking and without any ulterior considerations of
health are generally injuriously affected by the indul-
gence.

"Second. The social side of the physician's life should
be cultivated. He should attend social gatherings, balls,
picnics, lodges, churches, everything which will bring
him into contact with his fellow men in a non-profes-
sional way. I know by experience how difficult it is for
a physician to meet his fellows non-protessionally. The
hypochondriacal patient ^vho desires an opportunity to
talk over his symptoms gratuitously with a physician,
the busybody who is so much gratified to have an oppor-
tunity to discuss the ailments of some one else and wring
a prognosis, favorable or otherwise, from the family
physician, the professional philanthropic who is sure to
ask you what to do for half a dozen of his poor depen-
dents— these and a hundred others conspire to rob the
physician of any change of occupation even when he
goes among his fellow men for social purposes. Do not
hesitate to shake off these men. They are sponges not
worthy of consideration and should not receive any.
Dismiss them, in the same category with the man who
stops you in the street to inquire what is good for rheu-
matism or what he shall do for a cold. Many physicians
finding their best efforts to meet the world socially, fail-
ures, by reason of unforeseen interruptions and untimely
calls fall into the habit of accepting social deprivation as
an inevitable lot. Do not yield thus, but make a diligent
effort to break through the growing habit of indifference.
Meet your friends and neighbors socially as often as you
can.

" Third. Avoid the danger of looking wholly at the
material side of vital phenomena. Human life is not
solely the result of organization and cannot be e.xplained
satisfactorih- from a consideration of its constitutional
atoms. Vital growth, vital-action, the beginning of life,
the onset of death, all imply something that is beyond
mere material organization. From the standpoint of
many physicians, as far as material organization is con-
cerned there is little or no appreciable distinction between
a Washington or a Lincoln or a Benedict Arnold. There
were, however, hidden spiritual forces in the material
organization of the former which rendered them a bless-
ing to the world, and in the other a lack of it which has
made the name odious. There is something in each man
above, beyond, and higher than his physical organization.
If vitality were but the result of organization medicine
ought to be an e.xact science. No one knows better than
we do how unlike the chemical crucible or the retort the
body of man is, and how uncertain its reactions are.
Life is God-given — a spark from Deity. Such views en-
able our profession and give us new zeal in the discharge
of duty.

"Fourth. The life of the true physician is a practical
religion. It is full of self-sacrifice and zeal for the wel-
fare of others. It is a perpetual sacrifice of inclination
to duty. The welfare of the patient is the first consider-
ation, the comfort of the physician the last. Little needs
to be added to the ethical side of the true physician's
character. There should be added to this, however, a

belief in an over-ruling Providence personally interested
in the affairs of men. This trust and confidence in the
arrangement and disposition of human affairs by an all-
wise Creator should be cultivated by every physician.
Nothing is better calculated than such a belief to remove
the unfortunate habit of worrying over the untoward re-
sults of disease. Death should not be looked upon as
necessarily due to your neglect to do this or j-our failure
to do that. ' Having done all ' in his power to staj- dis-
ease the physician should ' stand fast ' in his own recti-
tude He knows he has done the best he can under the
circumstances — possibly not the best that could have
been done absolutelj', but the best he could do with the
knowledge he had when he proffered his advice, or gave
the medicine, or treated the patient. Nothing helps so
much in bearing such cares or responsibilities as a genu-
ine trust in a Higher Power and an Over-ruling Provi-
dence.

"Fifth. Allied to this, and growing out of it, is the ne-
cessity of cultivating a cheerful, hopeful spirit for the
physicians own good. The absolute necessity of
such cheerfulness and hopefulness on the part of
even,' physician in the sick-room is obvious. If
'Christian Science,' so-called, has met with any success,
it is because of its constant inculcation of hopefulness
upon the invalid. ' You are not sick.' 'You are well.'
' You only have a mistaken idea of sickness,' etc. Such
are its formulae, which often are unmeaning enough, and
yet which appeal powerfully to a most potent agency in
the treatment of disease. I did not, however, design to
speak of this aspect of the matter as much as of the duty
of cheerfulness for the physician's own good and for the
preservation of his own mental health.

"Sixth. Occupation, professional and otherwise. Every
physician should have some subject for special study —
Some hobby if you chose to call it so — all absorbing in
its character, into which he can retire and forget for the
time lieing the cares and annoyances of his daily life. This
should be some branch of medical studj' in which he is
an original investigator or a special student. I recognize
the fact that we do not all possess the required talent to
make deductions from observations carefully collated
and recorded, but all have the ability to do the latter and
to gather and arrange scientific or medical facts for
master minds to interpret. The effect of such individual
investigation upon the physician who makes them will
be inestimable. When thus engaged he has a kingdom
of his own into which he can enter without fear of in-
trusion— a city of refuge from the w'orld without. The
influence of such special investigations upon the pro-
fession at large in promoting knowledge and unifying
effort would be incalculable. There are numerous
branches of medical knowledge where careful, painstak-
ing, personal observations such as any practitioner can
make no matter where he maj' practice, are required to
give better indications for treatment. I refer to cer-
tain anomalous forms of fever which are nowhere ade-
quately described in any text-books ; the action of reme-
dies, new or old, upon different organs of the body ; the
relations of certain eruptive fevers and the laws of their
development ; the causation of pneumonias by atmos-

350

SOCIETY PROCEEDINGS.

[September 7,

pheric conditions ; the phenomena of hypnotism, and
the like. These are but samples of subjects concerning
which every thoughtful physician can furnish original
and valuable contributions to our stock of knowledge,
provided he has formed the habit of observing accurately
and recording carefully what he has seen. Beyond
this, even,^ physician should have a pursuit or study,
wholly outside of medicine, to ser\-e as a diversion and
means of recreation. In choosing such pursuit, it
should not be forgotten that the medical is one of the
learned professions. Hence, the pursuit should be
allied to medicine and calculated to increase one's zest
for medical study or to throw side lights upon it. Bot-
any, comparative anatomy, microscopy, photography,
etching, drawing or sketching, meteorology, hygiene,
natural history, modern languages, these are a few of the
studies which many physicians are constantly pursuing.
I have read with great interest, but recently, of the vigor
and enthusiasm with which the lamented Douglass
Houghton, tie second professor appointed to a chair in
this University — the first professor being the late Asa
Gray, of Harvard — prosecuted the study of chemistry,
botany, and geology, while pursuing the active practice
of medicine in the city of Detroit. Such studies keep
the mind active, and furnish diversion and needed recre-
ation. They help to get our minds out of routine pur-
suits, and enlarge our ideas, and broaden our mental
horizon. The intense man who is constantly applying
himself to a single pursuit is much more likely to lose
his mental health, than one whose energies have been
diverted into several channels.

"Seventh. Avoid professional jealousies and heart-
burnings. They come too often from the feeling that
pecuniary returns are the proof of professional success,
and from unworthy and ignoble views of the profession
itself Medicine should not be pursued as a trade — a sim-
ple means of livelihood, a stepping-stone to wealth, but
as a learned profession, a true vocation, requiring the
largest mental acumen, the keenest insight, the most
rapid generalization, often from insufficient data, and the
broadest mental grasp of any profession. The mission
of the physician is Mot to make money, but to relieve
suffering, to help Nature in her eftbrts after health, and
to lav the foundation for the future Science of Medicine,
which is surely coming. Every physician should com-
fort himself, amid doubts and discouragements, bj' the
ancient motto, ' It belongs to all to deserve success, not
to attain it.' .\11 can deserve the character of a good
physician, even if the emoluments of the profession are
not theirs, and pecuniary success is uncertain. Profes-
sional jealousies and sharp competitions are unworthy
the man who possesses this high ideal of his calling.
The soured, disappointed, cynical, embittered physician
has mistaken his calling.

" Finally: If we would retain good mental health, we
must not lose faith in the future of our noble profession.
The great advance in every department of medical science
during the past twenty years, leads us to anticipate most
encouraging developments in the near future. We are on
the threslioUl of a new era. Nature is yielding her secrets
to patient inquiry. Mystery is becoming certain knowl-

edge and assured truth. The future of medicine is in-
spiring. The thought of it richly solaces us for temporary-
disappointments and seeming failures. Let us be content
to be humble laborers in the erection of the great edifice
of scientific truth and accurate knowledge, which is rising
before us." — Physician and Surgeon, July, 18S9.

G.\STRIC ULCER.
Dr. Longfellow, of Cincinnati, gives in the Lancet-
Clinic a fornmla which he has used in gastric ulcer with
very satisfactory results :

B

Liq. potass, arsenit 3J

Tinct. opii deod o'js?

Sig.-
milk.

Acid hydrocyanic, dil.
.\qujE destil. q. s. ad.

•3iv

•One teaspoonful every three hours, after taking

Minute doses of cocaine have at times been indicated,
and combined with the above, with the result of decided
relief of pain. All starch aud sugar foods are to be
withheld.

Dr. Stepp, of Nuremberg, according to the Lancet, has
employed chloroform internally with good effect. He
prescribes it in the proportion of " 15 grains in a 5-ounce
bismuth mixture." He regards it as beneficial bj- reason
of its disinfecting, astringent and stimulating proper-
ties.

SOCIETY PROCEEDINGS.

Medical Society of the District of Columbia.

Stated Meeting, February 20, i88g.

Charles E. H.\gner, M.D., President,
IN THE Ch.\ir.

Dr. D. S. L,.\mb presented

TWO SPECIMENS OF CHRONIC OSTEITIS.

In one case the right tibia is much enlarged
by sclerosis, with a central abscess cavit\- : me-
dullary- cavity almost entirely obliterated. Abun-
dant exostoses. From a colored man, aged 60,
who died of chronic diarrhcea. The post-mortem
examination showed some fatty degeneration of
mitral valve and some atheroma of aorta ; heart
weighed 13 ozs. Liver congested. Spleen atro-
phied. Colon deeply ulcerated throughout. A
few small cy.sts of kidneys. Prostate enlarged.
No history of injurj-.

The second specimen showed sclerotic thicken-
ing of lower part of femur, with large exostoses
(osteophytes). I'pper part of corresponding
tibia porous. Some ulceration and exostoses in
knee-joint ; and patella firmly anchylosed to
front of femur. From colored man, aged 70,
who had inflammation of knee-joint when 15
years old. When 62 years old abscesses formed

1889.]

SOCIETY PROCEEDINGS.

351

around the joint and were opened. He had also
chronic ulcers of tibia.

Dr. C. \V. Rich.\rdson read a paper on

AN INTERESTING TOXIC MANIFESTATION
OF COCAINE.

The interesting case of cocaine toxaemia which
I am about to narrate is for the purpose of calling
the attention of many to a hitherto unheard of
toxic manifestation of cocaine, and impress upon
those who are already acquainted with this pecu-
liar effect the possible danger which may arise
from the incautious and somewhat careless man-
ner with which this drug is frequently adminis-
tered. Many of you are no doubt aware that
cocaine is capable of unduly exciting the sexual
passions ; but few, probably, are aware of its
capability, like ether, of exciting undoubted ob-
jective erotic manifestations.

During the month of October,' 1888, it was my
intention to operate upon a certain woman, in
order to remove from the left nasal cavity a car-
tilaginous spur projectingfrom the septum, which
was pressing upon the inferior turbinated body,
giving rise to certain nervous phenomena and
complete obstruction of that nasal cavity. The
object of the operation was to restore the calibre
of the pa.ssage and to prove the dependence of
the nervous symptoms upon the existing deform-
ity. She was a well-developed, well-nourished
woman of 25 ; married ; had had one child ;
large physique ; handsome, modest and reserved.
After explaining to her the nature of the opera-
tion and possible relief to be obtained she readily
assented to its performance. On the day ap-
pointed she reported, being accompanied by a
lady friend. Before operating my patient told
me that she expected to be sick on the morrow,
but did not wish to have the operation delayed
unless necessarj'. In order to make the operation
as painless as po.ssible, experience having demon-
.strated the fact that cocaine applied locally has
ver}' little effect in rendering operations upon the
septum painle-ss, I concluded to administer hypo-
dermically directly into the tissue to be removed
a few minims of a 10 per cent, solution. Five
minims of 10 per cent, is equivalent to one grain
of the drug. After using the injection, for a
moment, I gave no further heed to my patient,
as I little anticipated the rather unpleasant results
that followed my injection. My attention was
suddenly attracted, and to my surprise, and the
consternation of her companion, the patient be-
gan to manifest the most remarkable and decided
evidence of erotic excitement. It is entirely un-
necessary for me to give a resume of her actions,
facial and verbal expressions — her objective
demonstrations were unmistakable. It required
some time to bring her to even a moderate degree
of quietness. As quickly as possible I removed
her, with the a.ssistance of her friend, from the

chair on which she was sitting to a sofa. While
reclining she made incoherent remarks ; called fre-
quently for her husband ; and kept her head in
almost constant motion. Afterwards she walked
the floor, wrung her hands and gave other evi-
dences of great excitement. She states that she
had no unpleasant sensations in connection with
the circulatory or respiratory system : no faintness,
heaviness ; or wakefulness. She retired on going
home, and when I saw her, at eight in the even-
ing, she was in a normal condition. A few days
afterwards I attempted again the removal of the
spur, being on this occasion assisted by Dr. H.
B. Deale. In this attempt I used ray cocaine, not
only in a local manner, but sparingly. Even on
this occasion she manifested unmistakable, but
decidedly mild evidence of an erotic excitement,
not sufBcient however to cause any interference
with the operation, which was completed, and
attended with a most happy result. The case
which I have just narrated aroused several inter-
esting and pregnant thoughts with regard to the
danger which may possibly arise from the admin-
istration of this agent.

1. The danger of forming the cocaine habit.

2. The danger arising from the uncertain
action of this drug. Cocaine, like chloral, at
times, acts out of all proportion to the amount
used.

3. As cocaine is comparatively a new drug
there exists the danger of causing new, unex-
pected and unpleasant symptoms.

The first two of my observations are so well
recognized that it is hardly necessary to give
them more than a passing notice. All who have
used cocaine to any extent can recall cases in
which they regret having used the agent, and
have also demonstrated that small doses have
produced toxic sj'mptoras out of all proportion to
the amount of drug administered. We certainly
should be more cautious in administering the
agent, and always impress upon patients the
danger attending its too frequent use. One-half
grain usually produces its full physiological
action ; one grain may be considered a maximum
dose. There exists a strong tendency among
most men after they have used a certain agent for
a long time without producing any serious or un-
usual effect to become careless and reckless in its
application. The above fact remains true whether
we know little or much about its physiological
action and toxicologj-. I had until last summer,
although thoroughly conversant with the then
knowledge of the drug, doubted very much some
of the asserted facts in connection with its toxi-
cology simply because I had used the drug freely
and frequently without any unpleasant effects.
My first alarming case occurred in a female mem-
ber of my own family, who was remarkably sus-
ceptible to the action of the drug.

The case we have just narrated presents to us

352

SOCIETY PROCEEDINGS.

[September 7,

another interesting phase in the physiological
action of the drug, /. e., the excitation of the
sexual desires. I am not a pioneer in this field
of investigation, as equally interesting cases have
been reported hy Sandre, of A'ienna, Cunning-
ham, of England, and others. While both of
the above-mentioned investigators called atten-
tion to these interesting symptoms, thej- did not
take into consideration the possible medico-legal
aspect. By medico-legal aspect I mean the possi-
ble danger that might result to a physician's repu-
tation in case of the excitation of erotic symp-
toms in a female patient should they be alone.
The question now arises as to the danger being a
probable one. Is the danger as great as in its
congener ether ? Is there any danger of this
character in the use of ether ?

The last question I shall answer first. Ether,
as we all know, in certain rare cases produces
erotic sj^mptoms of a most decided character, and
many cases are recorded where there are evidences
of the occurrence of complete venereal orgasm.
Du Bois states that a woman under his observa-
tion requested, while being etherized, an atten-
dant to kiss her, and after returning to con-
sciousness stated that she had dreamt of having
cohabitated with her husband. I refer to the cele-
brated case of Com. vs. Beach' to illustrate the
danger to reputation and liberty that has been
caused by the occurrence of this symptom in the
patient. This danger is so well recognized in the
use of ether that no one would think of adminis-
tering this anaesthetic to a female patient without
the presence of witnesses.

Is the danger from this aspect as great
as in the use of ether ? We would at once
answer this question in the negative. There ex-
ists a vast difference in the action of the two
agents. In the one consciousness is destroyed,
while in the other it is retained. The erotic
.symptoms produced in etherization occur during
the stage of excitement, before there is a com-
plete loss of consciousness, but there is a sufficient
obtunding of the sensibilities as to cause the pa-
tient not to connect the relationship between
cause and eff"ect. In the eroticism produced by
cocaine the patient is conscious — conscious of
her surroundings and all that is occuring, although
she may not be able to repress the feeling arising
within her. In one case, supposing no attendant
present, the patient remembers the dream, the
sensations, and has no means of convincing her-
self that the physician has not taken advantage
of her unconscious condition. In the other the
patient, while experiencing the same sensations,
is positively aware that nothing of that character
occurred.

Is the danger a probable one? If all women
were honest and non-hysterical we would . cer-
tainly answer this question in the negative, but

■ Med. Jurisprudence and Toxicologj', Reese, p. 559.

as such is not the case it is a danger to be thought
of, though of an minimal nature. It is only
necessary' to suppose the occurrence of such
sj-mptoms in a hysterical woman, who, on her
return home becomes mentally unstrung — remem-
bering onh' her sensations — it would be almost
impossible to convince her that liberties had not
been taken ; or the occurrence of the same symp-
toms in a designing woman, there is danger
enough.

Dr. J. Ford Thompson thought he had been
ver}' fortunate, as he had been giving cocaine to
men, women and children since its introduction
and had never seen any such result as that re-
ported by Dr. Richarson. He used it almost
everj^ day on different parts of the anatomy, but
had not seen such an effect. He would be more
careful in future, especially when administering
it to females. He had, however, seen unpleasant
effects in other ways. He thought a loper cent,
solution was too strong for hypodermatic use : 4
per cent, is better, and 2 per cent, hypodermicalh"
will generally suffice. He thought that it might
be used more frequentlj' in the extraction of teeth.
The reason for its failure in dentistrj-, he thought,
was because the gum around the tooth to be ex-
tracted is generalh- painted instead of injecting
the solution into the gum.

He had frequently seen irritation and inflam-
mation produced about the incisions in opera-
tions. The worst effect he had ever seen was in
a case of circumcision, in which he injected into
the prepuce a few minims of a 4 per cent, solu-
tion of the muriate of cocaine. The man fainted
and vomited. After the operation he went home,
and when Dr. T. saw him the following morning
there was an extensive inflammation about the
penis and .scrotum, which he thought was erj-sip-
elatous. On the third day there was gangrene
on the under side of the penis and scrotum. It
was wor.se than any case of phlegmonous erA"sipe-
las he had seen, and in spite of the extensive
sloughing it got well without contraction. It
might be claimed that this case was due to septic
instruments, but as he alwaj-s attends to the
cleansing of his instruments he was sure that
thej' were aseptic. At that time he was accus-
tomed to carry a solution of cocaine in little vials,
which he now thought had undergone decompo-
sition. Since then he had carried the tablets of
cocaine and a vial of distilled water, and mixes
the solution at the time of operation — and never
uses what is left. He also takes the precaution
of heating the needles of his syringe to a white
heat before using them. He might be accused
of being too careful, but since he has adopted
this method he had not had an accident : there
had been no failure to produce immediate effect :
there had been no inflammation ; and union of
the wound had not been interfered with.

Dr. Bermann was accustomed to use cocaine

1889.]

SOCIETY PROCEEDINGS.

353

every day and was glad to hear the report of Dr. j
R.'s case, as he had never seen any such excite-
ment produced by the drug. This case might be
classed with those idiosyncrasies in which the
patient is particularly susceptible to the action of
the drug. We see such unusual toxic effects from
atropin and other drugs. The near approach of
the menses maj- have had some effect in this case.
He thought a 10 percent, solution was too strong
for hypodermic use in such a case. If it had
been applied localh^ it would have answered the
purpose. He had used a 20 per cent, solution in
post-nasal surfaces without bad effects. He ob-
tained good effects from a 5 per cent, solution if
he waited a little while, or it might be necessary
to repeat it. One lady to whom he had applied
a 5 per cent, solution on cotton complained of
nausea. A man objected to its use because it
made him feel unpleasant a whole day, but ex-
perienced no erotic excitement. The gangrene j
in Dr. Thompson's case may not have been caused
by germs, but by the contraction of the blood-
vessels, which alwaj's follows the use of cocaine.
He had had no experience with the hj-podermic
use of the drug, as he had always obtained the
desired effect from its local application. He had
painted the mucous membrane of the naso-
pharynx with a 5 percent, solution and anaesthet-
ized the part.

Dr. Mtirray was glad to hear Dr. Richardson's I
paper. It suggested the possibility of overdosing
with cocaine, a possibilitj' forcibly emphasized bj' 1
, the literature of the subject. Within a little
more than two years after the introduction of
cocaine as an anaesthetic Dr. Jilattison, of Brook-
lyn, had collected and published the records of
six fatal cases, and ninety in which poisoning to
a greater or less extent had occurred. Cocaine
seemed to be elective in its action, influencing 1
different centers in individual cases. Dr. Schadle,
of St. Paul, Minn., has reported two cases in 1
which the sexual organs were affected ; in one ;
the patient's powers were stimulated and in the
other impotence was induced. Mr. Mayo Robin- '
son, of England, reports a case in which aphasia,
lasting four hours, followed the application of
cocaine for the removal of nasal polypus. The
fatal case reported by Dr. Simms, of Philadelphia,
showed the respirator}- center to be mo.st affected.
He thought cocaine dangerous and agreed with Dr. ;
Thomp.son that strong solutions should be avoid- ;
ed. He used cocaine as little as possible, had j
substituted electricit}-, using constant current, in
cases in which he desired to relieve obstruction
due to engorgement of the erectile tissue of tur-
binated bodies. It acted as quickly and nearly
as efficiently as cocaine, and was valuable in such
cases for its tonic action. Cocaine frequently
applied he believed harmful to mucous mem-
brane.

Dr, Thompson would call attention to the use

of cocaine in tracheotomy. He had used it for
this operation in two adults during the past two
weeks. He introduced the solution hypodermat-
ically along the line of the incision and there
was no pain during the entire operation. This
use will be still more important in children.
During anaesthesia from ether and chloroform
there is spasm of the glottis and the surgeon is
compelled to hurry with the operation ; but with
the use of cocaine he can take "his time. In
neither of the two cases referred to was their
haemorrhage. Painting with cocaine is of little
use in surgerj'. He had tried it in dilating the
female urethra, but there was intense suffering.
It may obtund the sensibility in mucous mem-
branes but it is not alwaj-s satisfactory in this use.

Dr. Rich.\rd.son, in closing, said he did not
consider 10 minims of a 10 per cent, solution too
large a dose when we take into consideration
that we were dealing with a patient in a normal
condition. He had frequentlj- operated upon the
septum and always failed to produce complete
anaesthesia bj' local application of the drug. He
doubted the possibility of a 4, or even a 10 per
cent, solution causing sufficient lowering of sensi-
bilitj^ of this part to render operations painless ;
at least, such had not been his experience. It
was only last Monday that he operated upon a
young man of considerable courage, for a de-
flected septum. In order to render the operation
painless he first painted the septum with a 5 per
cent, solution of cocaine, and after a few moments
tested it with a probe and found the mucous
membrane quite sensitive. At the request of the
patient, in whom he had used a 10 per cent, so-
lution twice before, without unpleasant effect, he
resorted to a solution of similar strength. Within
a minute after painting the septum he noticed his
patient become markedly pale, his hands were
cold, pulse weak and rapid, and he complained of
sickness and faintness — in other words, toxic
effects. The patient was quickly restored.
Even after the production of toxic symptoms the
operation was excessively painful. This case
also demonstrates the uncertainty of the action of
the agent. We all know that the naso-pharynx
is not as sensitive as other portions of the upper
air-passages. Twice during the past month he
had removed adenoid growths from this region —
an operation occupying nearh- half an hour —
without the use of an anaesthetic. One of these
was a boy of 15, the other a A-oung lady of 22
years. Both suffered some pain, but, neverthe-
less, were capable of jesting during the op-
erations.

Dr. I. Hermann read a paper on

THE POSSIBILITY OF LATENT SYPHILIS CAUSING
INFECTION.

About sixteen months ago Mr. N. N. brought
his wife to me for treatment for some throat trou-

354

SOCIETY PROCEEDINGS.

[September 7,

ble, which had been existing for some time. One
look at the lad3''s throat was suiBcient to show
me quite extensive ravages of sj-philis. I at
once took her husband into an adjoining room
and put the question to him whether there was
an}- possibility of her having been infected b}'
him. This was denied. Under the circumstances,
remembering that tuberculous lesions of these
parts, in rare cases, can resemble very much those
of her's, asked him whether anj- member of her
family had died of consumption. This was con-
firmed by him very decidedlj% so that I resolved,
no special hurrj- being necessarj', to leave the
diagnosis for the present in suspense, until I had
made a thorough examination of her chest and
examined the sputum for bacilli. I gave her a
disinfecting spray for the throat and nose, touched
the ulcerations with lapis in substance, and wait-
ed for the developments which the microscope
would afford us. Next daj' the sputum was
brought, examined, and found to be free from
bacilli. When they came again, which was after
about three days, I took the gentleman aside and
told him I had no doubt the disease was syphilis,
and must be treated at once as such. He begged
me to do exactly what I thought was proper, and
I prescribed a 33 per cent, solution of iod. potass.,
of which 25 drops were to be taken three times a
day, between meals, besides advising that the dis-
infecting sprajf should be continued and that she
should come to see me everj' other day. I will
here describe the nature of her lesions. Both
tonsils were covered with ulcerations, another
was on the pharyngeal wall, the arcus palate
uvula was on the left parth- destroyed, which the
husband ascribed to the use of nitric acid, with
which he had tried to cauterize it before coming
to me. Rhinoscopic inspection showed extensive
ulcerations in the post-nasal cavitj-, and the lar-
yngoscope revealed a tumefaction over the right
er>-themoid cartilage, somewhat resembling a
syphilacci. I found it necessar\% in view of these
lesions, to make a thorough general examination,
which, however, furnished only negative results.
There is no need of going into further details of
the case, as I do not think that you will doubt
the existence of syphilis. How the infection took
place was a very interesting point to me, and I
inquired of the husband, whom I had asked to
call and see me alone, whether he had any lesion
of doubtful character on his person. I was not
satisfied with a negative answer, and asked per-
mission to examine him. This was granted, and
a thorough examination revealed nothing but a
few infiltrated glands in the groin. The lady
improved so rapidly that after a fortnight, apart
from the destroyed portion of the soft palate,
there could not be found a trace of anything re-
sembling syphilitic lesions, and to this day, six-
teen months since I first saw her, she has been
not only absolutely free from all symptoms of

syphilis, but her general health has improved to
such an extent that I failed to recognize her when
I saw her a few months ago on the street, she
having grown quite stout.

Some months after the lady had been discharged
by me, at least for the present, as cured, her hus-
band came to consult me in regard to his health.
He complained about some sj-mptoms of catarrh,
but especially about a feeling of lassitude and
general debility, which seemed to make all work,
both phj-sical and mental, a great effort to him.
He imagined also that he had some kidney trou-
ble. I told him that his case interested me very
much, but that before I could do anything for
him he would have to answer me some questions.
These questions I put and his answers are con-
tained in the following history : Is 45 years old;
father died when 70 years of age of morbus Addi-
soni. Mother living, nearly 80 years old. No
brothers or sisters. About 18 j^ears ago he was
treated for syphilis — according to his description
an Hunterian chancre, sine exanthemata — with
biniodide of mercury, for some time. The chan-
cre disappeared very quickly and no sequelae, that
he is aware of followed. I will here state that
after I had told him raj- views of the case he was
perfecth' willing to give me all information in his
power, and was ven.^ candid in his answers. He
was married in the summer of 1872, believing
himself perfecth' well and being assured to that
effect by his phj-sician. There are no children
to the marriage, and only one miscarriage oc-
curred after two months. None later, and his
wife did not complain of sore throat until eight
years afterwards. At no time had he any sore
throat or ulcerations in his mouth or throat, nor
anj'where else, as a repeated thorough inspection
demonstrated also to me. At least I could not
find any cicatrices which are so characteristic of
syphilitic lesions. Of course my diagnosis in his
case was latent syphilis, and as he was very much
run down I put him for the beginning on syr.
ferri iod., 10 gtts. three times daily. Under
this medication he improved rapidly, gaining 20
pounds in about six weeks, and said he felt much
better than he had for years. Of course I in-
formed him that his case would require prolonged
super\'ision and treatment, and last fall I sub-
mitted him to mercurial treatment with hypoder-
mics of bichloride, as he was complaining of do-
lores ostocopi, followed afterward 63' kal. iod. for
si.x weeks. He has been getting on ver>- well
under this treatment, but has had now and then
infiltration of submaxillary lymphatic glands,
also of the prteauricular glands. Repeated in-
spection of larynx and pharynx at that time gave
always negative results, and the infiltration of the
glands disappeared very soon under application
of tine. iod. and kal. iod. given internally. He
feels perfectly well and strong now, and makes
the impression of being in perfect health. Whether

1889.]

DOMESTIC CORRESPONDENCE.

355

lie will remain so is a question that only time can
answer, and I am still keeping him under super-
vision.

The natural conclusions which this case seems
to allow us to form as decidedlj' as can be done
under the circumstances, seems to me, that an in-
fection of syphilis can take place through an in-
dividual afflicted with latent syphilis, probably
through seminal fluid or other secretions.

The President : Did she cohabit with any
other than her husband ?

Dr. Bermann could not answer this question
definitely. The only interesting point in the pa-
per is whether a woman could be infected b}' her
husband eight years after marriage and eleven
years after he had been treated for the primary
lesion of syphilis, without any manifestations of
syphilis during this period ?

Dr. Thompson thought that if the woman
caught the disease from her husband it must
have been when she became pregnant. The se-
men is not directly contagious ; the child gets it
from the semen and the woman from the foetus.
The physiological fluid itself is not infectious.

Dr. Smith : Will a hypodermatic injection of
the seminal fluid of a man suffering from syphilis
produce the disease in an uninfected individual ?

Dr. Thompson thought not, but had never
seen it tried. He did not think that the syphil-
itic bacillus was in either at this late date. He
would also question the benefit of mercury at this
time of the disease. If it were .syphilis it was
the tertiary form. Neumann divides his cases
into three classes : in one he does not give any
mercury ; in the second he gives mild doses ; and
in the third he gives heroic doses. In the ter-
tiary form of the disease hypodermatic injections
of mercury would not be of much benefit. The
children of parents with tertiary syphilis are not
sj'philitic, but have scrofula or struma. He did
not believe in the presence of syphilitic bacilli in '
the tertiary form of the disease. There is no virus
in the suppurative and later stages, and the fluids
of the body are not inoculable.

Dr. Busey: According to Dr. Bermann's state-
ment the man has had syphilis for eleven years ;
three years after the primary' chancre he had mar-
ried, his wife became pregnant and aborted at
the second month on account of .syphilitic infec-
tion, and eight years afterwards syphilis became
manifest. Is it possible for a man to have latent
syphilis for eleven 3'ears before the development
of secondary or tertiary manifestations? and a
woman to become infected by her foetus and not
exhibit symptoms of the disease for eight years ?
From the history he would suppose that the wo-
man contracted syphilis long after that miscar-
riage, j

Dr. Bermann: The man had been treated for'
syphilis two years before his marriage ; his wife [
miscarried at the second month of her married

life ; and eight }-ears after she had syphilitic le-
sions of the soft palate. She did not contract the
disease from anj^body else ; then the latent symp-
toms in the man produced the secondarj' symp-
toms in the wife.

Dr. Busey : There were two remarkable coin-
cidences which he was not quite willing to ac-
cept. It would seem that the only way for the
woman to have become infected was through the
pregnancy, and if that was so there would have
been earlier manifestations of syphilis. He
thought she contracted the disease subsequent!}-.
He doubted the duration of latent infection. He
did not believe either the history of the man or
of the woman. It must be demonstrated that a
man could have a Hunterian chancre and then
infect his wife eleven j'ears after, before he could
accept it.

Dr. Berm.\nn : If the woman had had syphi-
lis during this term of years more of the soft pal-
ate would have been destroyed. He was confi-
dent that she contracted it just before seeking
his advice. Here we have a syphilitic husband
constanth- cohabiting with his wife, then whj'
could not the latent disease take on fresh action
and thereby cause infection in the wife?
{To be concluded.)

DOMESTIC CORRESPONDENCE.

LETTER FROM XEW YORK.

(from odr own correspondent.)

Dr. Janeway 071 the Diagnosis and Treatment of
Basedou's Disease — Dr. J. Lewis Smith 07i Idio-
pathic Contractions, or Tetany ijt Infancy and carlv
Childhood.

The last meeting of the New York County
Medical Association for the present season was an
unusually attractive one; valuable papers by Pro-
fessors E. G. Janeway and J. Lewis Smith consti-
tuting the main features of scientific interest. Dr.
Janeway 's was on "The Diagnosis and Treatment
of Basedow's Disease," and in it he said his object
was not to include the whole range of this affec-
tion, but rather to present some points derived
from his personal observations in a considerable
number of cases which might be of practical ser-
vice. When well developed and presenting all
the marked features characteristic of it, exoph-
thalmic goitre could be at once recognized by any
tyro; but the case was very different in the incipi-
ence' of the disease, or when some of the charac-
teristics were obscure. Thus, at the beginning
the general state of the patient's health was not
infrequently more apt to strike thephysician than
the distinctive features of Basedow's disease, and
sometimes perhaps lead him to give a wrong name
to the malady.

356

DOMESTIC CORRESPONDENCE.

[September 7,

Of ttie three terms most commonly used to con- j
ceal the absence of definite knowledge regarding
the disease present in more or less obscure cases :
neurasthenia, malaria and lithaemia, the two for-
mer are occasionally applied to this disease. As
regards the neurasthenia, the presence of ner^'ous
debility gave some ground for its use, while in
other cases the patient not only grew weaker, but
had a sense of heat, or even elevation of temper-
ature ; thus making the diagnosis of malaria
plausible. The adoption of either of the.se terms,
however, was of bad import for the patient ; for
the treatment appropriate to these conditions
would not be successful in Basedow's disease. Dr.
Janeway said he had known even a supposition of
phthisis to exist, on account of the emaciation,
loss of strength, and sense of warmth present, |
sometimes in connection with a cough due to an ;
intercurrent cold or to congestion dependent upon
enfeeblement of the heart. In such cases the goi-
tre present might press on the larynx and trachea,
causing congestion of these parts ; while the en-
larged heart was liable to cause some congestion
of the lungs, and of itself produce some dulness.
Moreover, from these causes a modification of the
respiration occurred, and patients with advanced
Basedow's disease had been thought to die of pul-
monary tuberculosis when none was found at the
post-mortem examination.

Each of the three factors of the disease, exoph-
thalmus, goitre and palpitation, he went on to
say, may be used as a designation of a disease,
without having regard to the nature of the pro-
cess. It is not uncommon for the exophthalmus
to be overlooked by the patient and his friends,
owing to its gradual super\'ention, Graefe's di-
agnostic rule, that the upper lid does not follow
the eyeball, as in the normal state, in looking
downwards, is not a certain criterion, for we may
not find it in all cases where slight exophthalmus
exists. Moreover, he had seen it present in one
eye, and absent in the other. An experienced
physician can often detect the exophthalmus where
its presence has been hitherto unsuspected ; and
an excellent test is to ask old acquaintances who
have not seen the patient for some time their con-
clusion in the matter. It is to be remembered, of
course, however, that everj- case of exophthalmus
is not dependent upon Basedow's disease.

The enlargement of the thyroid gland may de-
ceive by its presence or mislead by its apparent
absence. In the milder ca.ses the slight growth
or vascular engorgement of the thyroid (the pa-
tient in the meanwhile having grown thinner),
may keep the neck of only normal fulness. At-
tention, however, to the condition of the circula-
tion in the neck will serve to prevent misconcep-
tion. Even when-the thyroid is but little eylarged,
the peculiar va.scular turge.scence, arterial thrill,
and arterial and venous murmurs can be made
out. When the thyroid is enlarged the thrill is

particularly noticeable in the superior thyroid ar-
teries ; while when this is not the case, he has
felt it rather in the carotids themselves. Base-
dow's disease has sometimes been mistaken for
aneurism, on account of the enlargement, thrill
and accompanying murmur ; and this is particu-
larh' apt to be the case when the enlargement is
predominantly on one side. An occasional case
will present the difficulty of deciding whether the
disease present is an illustration of parenchyma-
tous goitre accompanied by palpitation or is reallj^
Basedow's disease.

The condition of the heart, Dr. Janeway said^
may be misleading in several ways :

First. Basedow's disease maj- complicate or-
ganic heart disease of preexistent date.

Second. At times it becomes difficult to deter-
mine whether a murmur of mitral insufficiency is
due to an old lesion or is dependent upon muscu-
lar incompetence or relative insufficiency of the
mitral valve. He has known hearts considerably
enlarged as far as the left ventricle was concerned,
and having well marked systolic murmurs audible
posteriori}-, yield under treatment to such a degree
that the murmur disappeared and the heart re-
turned to a nearly normal size. This constitutes
one of the greatest liabilities in the way of diag-
nostic error in cases possessed of moderate goitre
and exophthalmus, as the tendency is to consider
the case one of incurable cardiac disease. In cer-
tain cases, to which he thinks sufficient attention
has not been paid, the patient will suddenly fall
or have his legs give way under him ; but almost
immediately will be able to resume the standing
position or walk. The question of cerebral or
spinal disease may be raised in connection with
these ; but the rapidity of the occurrence and of
its disappearance disprove such a supposition.
The cases in which he has met with it have been
weakened by diarrhcea or vomiting, or as a result
of the malnutrition accompanying the disease,
and, under excitement or physical exertion, have
had an extremely rapid heart action.

Third. As previously mentioned, the conges-
tion of the lungs from the weakened heart may
raise the question of phthisis.

Fourth. Cases are met with of palpitation
without exophthalmus or goitre, but having, as
far as the heart and the general condition are
concerned, phenomena identical with those oc-
curring in exophthalmic goitre. Such cases he
has been accustomed to consider as allied to Base-
dow's disease.

As to the condition of the heart in this disease,
his experience is that cases occur without any
very marked enlargement, while others are met
with in which, with an antecedent history- of free-
dom from cardiac disea.se, hypertrophy with dila-
tation is produced by the Basedow's disease. Ir-
ritable vomiting is at times a distressing acconi-
, paniment of the disease, and may cause death.

1889.]

DOMESTIC CORRESPONDENCE.

357

The treatment, Dr. Janeway said, must have
relation to the condition of the circulation, to the
accompanj'ing anaemia, and to any coexisting ir-
regularity in the functions of the body, especially
menstrual disorder. It must not be forgotten,
however, that menstrual irregularity may be a
result as well as a cause of the trouble. One of
the most prominent features in the treatment con-
sists in finding an agent which will quiet the ra-
piditj' of the heart's action, and his experience
had led him to give up the use of digitalis for this
purpose. Formerly he emploj-ed tincture of aco-
nite to a considerable extent, and he has seen
good results from it in cases where, but for the
name of the disease, he would not have ventured
to use it. As a rule, the best results have been
from the continued use of small doses.

Of late, however, he has emploj-ed the tincture
of strophanthus in doses of 5 minims three times
a day, gradually increased if necessary, Of eight
cases in which it was used, three have been lost
sight of, while in two a cure has occurred ; the
only other remedy employed being iron. In one
other, complicated with mitral insufficiency and
considerable dilated hypertrophy of the left ven-
tricle, there has been a cessation of the palpita-
tion and a considerable improvement in the heart's
condition. In the seventh case recovery occurred,
but galvanism was also used. The eighth patient
had such irritable vomiting that it was impossible
to give the remed3^ or even to administer much
food, by the mouth, and she succumbed to the
exhaustion of the disease and vomiting in a
neighboring city, after she had passed from his
immediate observation. On the whole, the re-
sults from strophanthus have been such as to
convince him of its real utility in this disease.
He has found it to succeed sometimes in cases
where digitalis had failed, and he prefers it to
aconite as less dangerous, particularh- in cases
where the heart is somewhat enfeebled. He tried
spartein iu two cases, but iu neither of them did
it prove of much service.

It is worthy of note that electricit}', which has j
been highly lauded b}- some authorities, in this
disease, has been of little value in his hands ; and
the same result was given by Dr. Alfred 1,. Car-
roll and others in the discussion of the paper. It
was formerly Dr. Janeway's custom in all cases to
advi.se galvanism, in conjunction with iron and
some cardiac remedy ; but he stated that he has
not had a single case of cure where galvahism
alone was used. The recent good results obtained
by him from strophanthus and iron seem to ren-
der it probable that the benefit formerly noted
when galvanism was resorted to was in reality
due to the remedies used in conjunction with it.
Personally, he has not used atropia, though he
has seen cases in which it has been used, but
without favorable result.

Rest, both physical and mental, is a necessary

adjuvant in the treatment, as well as the avoid-
ance of worr}- and emotional excitement. He
thought it reasonable to suppose that the condi-
tion of the circulation in this disease tends ta
produce the restlessness, often associated with in-
somnia, met with in some cases ; and in a certain
proportion of these it will yield to the ordinary
treatment of the disease. Sometimes additional
remedies are required, and in one case he has used
sulfonal with good results. Formerly choice had
to be made of the bromides, morphia (or, prefer-
abl}', codeia), and chloral, or the use of the bath
or wet pack. Iron is not invariablj- necessary,
but is usually indicated by the coexisting anaemia.
Attention should be paid to the condition of the
nutrition, as evidenced bj' the appetite and gen-
eral feeling and by the weight of the body ; and
whenever this is at fault appropriate measures
adopted for its improvement. In conclusion he
said that confidence on the part of the physician
that he can produce an amelioration in his condi-
tion is of decided benefit to the patient. More-
over, it has seemed to him that hospital and dis-
pensary' patients are less amenable to treatment
than those in the better walks of life ; for where
fright or worrj' is a prominent factor in the pro-
duction of the disease, as is often the case, it cer-
tainly does not add to the efficiency of the treat-
ment to have the patient surrounded by the sick
and dying.

An interesting discussion of the paper was par-
ticipated in by Drs. Carroll, Hepburn, MacGregor,
Oberndorfer and J. Lewis Smith, and by the Pres-
ident, Dr. C. S. Wood; and in closing it Dr.
Janeway said that certain points had been brought
up by some of the speakers which he had not
touched upon in the paper. Thus, he had not
referred to the pathology, for the reason that this
was so extremely obscure. In some of the cases
in which autopsies were made the cervical sj-mpa-
thetic had been found entirely normal, and this
would certainl}' disprove the hypothesis that the
lesion of Basedow's disease is located in this por-
tion of the ner\'ous system. More recent investi-
gations would seem to show that the trouble
originated, either directly or indirectly, in the
medulla oblongata. As to the starting-point of
the disease from a clinical point of view, it would
not do to always attribute this to such a cause as
fright or emotional excitement. In one of the
cases mentioned in the paper, where the patient
was a lawyer of distinction, there was no fright,
no special anxiety, and no mental strain from
overwork. In this instance a complete recovery
followed the use of strophanthus and iron. It
was a well established fact, however, that a good
many of the cases do originate from fright, worry
or emotional excitement ; and hence the disease
was more common in women than in men, though
he had met with a considerable number of cases in
males.

358

DOMESTIC CORRESPONDENCE.

[September 7,

He thought it advisable to avoid, if possible,
the use of such agents as opium, as sooner or
later the nutrition would become affected by the
drug ; and it was of the highest importance that
the nutrition should be maintained as perfectly as
possible. He had met with cases in which stro-
phanthus and other appropriate remedies produced
no effect as long as the nutrition was impaired ;
but when this had become improved the distinc-
tive features of the disease began to subside under
their use. In neuralgias also, and all chronic
nervous diseases, he disliked to u.se opium for the
same reason. There were, however, certain cases
of Basedow's disease attended with rapidity of the
heart's action in which nothing acted so efficiently
in controlling this symptom as opium ; and the
same was true in some cases of aneurism in the
region of the neck.

Dr. J. Lewis Smith's paper was devoted to the
subject of "Idiopathic Contractions, or Tetany,
in Infancy and Early Childhood." Having given
a resume of the literature of the disease from the
time it was first taken up by the French writers
in 1 83 1, he stated that the term tetany is applied
to an affection which is characterized by tonic
contraction of muscles, commonly those of the
extremities, but sometimes also those of the face
or trunk, produced by causes external to the ner-
vous system, and usually of temporary duration.
In tonic muscular contractions arising from dis-
ease of the brain, spinal cord, or their meninges,
or of the nerves supplying the affected members,
the contractions are not the malady itself, as in
the case of tetany, but are merely symptoms of a
disease located elsewhere.

Tetany may occur at any age, but is most fre-
quent in infancy, in early childhood, and in early
adult life. As a rule, there appears to be no he-
reditary predisposition to the disease, but the oc-
casional occurrence of multiple cases of the dis-
ease in families would seem to show that there
may perhaps sometimes be an inherited neuro-
pathic tendency. Nearly all writers assign the
most important place in the causation to diseases
of the digestive apparatus. Thus, Trousseau
states that in the cases coming under his observa-
tion diarrhoea was commonly present (many cases
met with in 1854 following cholera) ; but in one
instance the cause seemed to be obstinate consti-
pation. Dr, Smith then related in detail a case
of his own, occurring in an infant, in which con-
stipation was the only assignable cause ; after
which he went on to say that Erb states that all
forms of intestinal disease may cause tetany, but
that it especially occurs after protracted and ex-
hausting diarrhoea. Gowers also regards diarrhoea
as the chief cause. There is no recorded instance
in which lumbrici or ascarides caused the contrac-
tions; but Gowers alludes to three cases caused by
tapeworms. Remarkable as it may seem, denti-
tion per se is but seldom a cause of tetany ; but in

a case which Dr. Smith related, which he saw in
consultation with Dr. Janeway, teething was re-
garded, after repeated and thorough examina-
tions, as the chief cause of the trouble. The
child was 20 months old, and the gums were
found swollen and congested over the crowns of
five advancing teeth, which appeared to be in
nearly the same stage of development, and were
evidently soon to protrude. The contractions
continued for three weeks, by which time all, or
nearly all, the imprisoned teeth had escaped : and
after this there was never any return of the tetany.
Speaking further of the etiology, he said that te-
tany is more liable to occur in those whose .systems
are enervated by preexisting disease than in those
who are robust. Billroth and Barthez, Erb, Gow-
ers and others mention a number of febrile affec-
tions as a sequel of which it is liable to occur,
and Gowers also states that in young children at-
tacked by it indications of rachitis are rareh- ab-
sent. Another recognized cause of tetany is expo-
sure to cold, and hence it has been regarded by
some as in reality a rheumatic affection. In in-
fancy and early childhood, however, other causes
are apparently much more common than taking
cold.

Dr. Smith then gave the following clinical pic-
ture of the disease : Ordinarily tetan}^ occurs
without any marked premonitory symptoms, but
in some instances it is preceded by pain in the
head or spine, vomiting without any previous in-
digestion or gastric disturbance, and a general
feeling of indisposition. Usually, in those old
enough to express their sensations, it begins with
tingling, burning, or other unusual sensor}^ man-
ifestations. The tonic contractions occur sudden-
ly, and sometimes simultaneously in the upper
and lower extremities. Rarely the contractions
occur in the muscles of the upper extremities
alone, or in the muscles of the trunk. At first a
feeling of stiffness is experienced, and this is fol-
lowed by the tonic contraction, with the fixation
of the affected part in a state of persistent flexure
or extension. As regards the upper extremities,
the contraction of the thenar and hypothenar mus-
cles usually causes hollowness of the palms of the
hands; the first phalanges of the fingers are flexed,
the second and third phalanges extended, and the
thumb adducted and flexed, Usuallj' the hand is
slightly flexed, as is also the forearm. The mus-
cles which move the arm commonly escape, but
exceptionally there is adduction of the arm on
the shoulder. The hand may be extended, instead
of flexed, and all the points of the fingers extend-
ed; or they maj' all be flexed, and the first closed.

The thighs may be adducted or flexed, the foot
extended, forming a talipes equinus, and the toes
flexed. In cases of ordinary severity the con-
tractions are limited to the muscles of the ex-
tremities, and are more marked and persistent in
those which move the hands, feet, fingers and

1889.]

DOMESTIC CORRESPONDENCE.

359

toes than in other muscles ; but in the severer
cases the muscles of the trunk and head partici-
pate. Contraction of the abdominal muscles
produces rigidity of the abdominal walls. Spasm
of certain of the thoracic muscles occasionally
occurs, causing dyspnoea, and even lividity ; and
in some of these cases of embarrassed respiration
the diaphragm is probably involved. Opisthoto-
nos, retention of urine, anteflexion of the neck
from contraction of the sterno-mastoids, fixation
of the jaws from spasm of the masseter, retrac-
tion of the angles of the mouth, stiffness of the
tongue, and indistinct articulation, are occasional
symptoms in severe cases.

The contractions render the affected muscles
hard and unyielding, and the child cries from
pain when attempts are made to straighten the
limb. If the spasm be slight, some voluntary
movement of the affected muscles is possible,
though it is restrained and difficult ; but in severe \
cases voluntary motion is impossible. Unless the
attack is very mild, pain in the contracted muscles
such as even.'one experiences when a spasm occurs
in the calf of the leg. It may occur in paroxj'sms,
with distinct intermissions, or without interrup-
tion ; and it may vary at different times, probablj' ,
from some variation in the degree of spasm. |
Certain subjective symptoms, such as numbness
and tingling, which sometimes occur in tetany,
may continue during the intermissions. After
some hours or days the rigidly contracted muscles
relax and the disease disappears, except, perhaps,
that a degree of stiffness remains. But the respite
is usuallj- of short duration. The spasms recur,
and several successive recurrences and intermis-
sions take place, running over weeks and months,
before the disease is permanently cured. During \
the intervals in the contractions the affected nerves
and muscles are in ordinary cases unduly excita-
ble ; so that sudden pressure or percussion causes
some contraction. It was Trousseau who first
noted that, a s a rule, compression of the artery
and nerve supplying the contracted muscles causes
or increases the contraction. Dr. Smith said it
was an interesting fact that in cases which he has
observed the spasms did not cease in sleep,
though perhaps the contraction of the muscles
was not as great as when the patient was awake.

Gowers, Erb and others have noticed that the
electrical excitability of the nerve which supplies
the contracted muscles is increased ; but occasion-
ally in long-continued cases the muscles undergo
a certain amount of atrophy, which is attended
by diminished electrical irritability. When the
contractions are strong oedema sometimes occurs,
especially upon the dorsal surfaces of the hands,
and Henoch attributes this to compression and
consequent passive congestion of the veins. In
some cases perspiration is sometimes noted, and
an erj'thematous redness may appear over the
affected muscles. Occasionally in acute attacks

the temperature is moderately increased, but or-
dinarily it is normal.

The patholog}- of tetany. Dr. Smith said, was
still involved in great obscurit}-, though it was
supposed that the motor cells of the spinal cord
and the axis cylinders are in some way affected.
As to its diagnosis, the bilateral and s}^mmetrical
nature of the affection was a point of great im-
portance, and the fact that certain groups of
muscles on the two sides were affected enabled us
to distinguish it from the muscular contractions
due to central lesions of the ner\-ous sj-stem.
Moreover, the spasms in tetany, as had been seen,
were as a rule attended with intermissions, and
the ner\-es over the affected area were increased in
sensitiveness, while spasms could be produced by
compressing the latter ; thus forming a further
contrast to the symptoms present in muscular
contractions produced by di.sease located in the
nervous centers or in the ner\'e supplying the
affected muscles. With regard to prognosis, he
said that tetany, whether intermittent, remittent,
or occurring with little daily variation, sometimes
soon ceases, and does not return ; while in other
instances it does not cease altogether for months,
although van,-ing in severit}- at different times.

In speaking of the treatment Dr. Smith said
that the cause or causes of the attack, so far as
ascertained, should obviously receive prompt at-
tention. The bromide of potassium is a most
useful remedy, and it should be given in decided
doses ; 4 grs. every three hours being required for
a child of from 1 8 months to 2 years of age. Chlo-
ral, Indian hemp, and chloroform b)^ inhalation,
are also of service in allaying the spasms. Chlo-
roform is said at first to increase the spasms, but
they cease when the patient is fullj^ under its in-
fluence ; though liable to return when the inhala-
tion is discontinued. Hauber states that two cases
which were not relieved by other treatment were
soon cured by active massage practiced when the
patients were under chloroform narcosis. Stimu-
lating liniments containing chloroform, applied
over the affected muscles, have also been found of
benefit in some instances. In his remarks on the
electrical treatment of tetany Gowers states that
faradism is contraindicated, but that good results
have sometimes been obtained from the voltaic
current. When rachitis is present, cod-liver oil,
lime, and syrup of the iodide of iron are ration-
ally indicated ; and since so manj- cases originate
from gastro-intestinal disorders, it is important
that the diet should always be bland, easily di-
gested and nutritious. p. b. p.

English authorities have concluded that dy-
namic cooling, if not the .sole cause of rain, is at
all events, the only cause of any importance, all
other causes being either inoperative or relatively
insignificant.

360

MISCELLANY.

[September 7, 1889.

BOOK REVIEWS.

Transactions of the Southern Surgical
AND Gynecological Association. Vol. I,
Session of 1888. Caldwell Printing Co., Bir-
mingham, Ala.

This is a well appearing volume containing
some thirty papers. Asepsis in surgical proced-
ures is emphasized by several essays, entitled,
"Antiseptic Surgery in Countrj* Practice," by
J. M. Taylor, M.D. ; " Practical Aseptic Surgerj',"
by J. W. Long, M.D.; and "Aphorisms in Anti-
septic Surger}- and Gj'necology," by F. T. Meri-
wether, M.D.

We notice that S. M. Hogan, M.D., in "Treat-
ment of Strictures of the Urethra by Electroh'sis, ' '
according to the method of Dr. Robert Newman,
of New York, meets with gratifying success,
further that j. D. S. Davis, M.D.', has treated
enlarged prostate by electrolysis, following also
the teachings of Newman, whose electrode he
uses. This is introduced, after first being lubri-
cated with glycerine, never with oils, into the
prostatic urethra. It is then made the cathode
or negative pole for a current of from 5 to 19
milliamperes. This current may be continued
from ten to fifteen minutes. The anode should be
applied to the back or hips. It should be under-
stood that while physically there may be no dif-
ference between a current of 55 milliamperes con-
tinued for five minutes and a current of 5 milli-
amperes for fiftj--five minutes, there is in fact a
great physiological and therapeutic difference.
In the former a chemical galvano- cauterization
would result, while in the latter a galvano-chemi-
cal absorption, which the author defines as a
chemical decomposition, which borrows its imme-
diate effects from the separated non-nitrogenous
bodies, there generating warmth, relaxation, soft-
ening and absorption of tissue. This is the char-
acter of current to be used in enlarged prostate.
The other electrolytic action, known as chemical
galvano-cauterization arises from the decomposi-
tion of salts which set free acids at the positive
and bases at the negative pole, and said acids or
bases attacking the tissues in their vicinity, giving
rise to a caustic action chemical in its nature.
The author quotes Apostoli, who expresses it
very clearl3- in the following words : ' ' The effect
of electroly.sis is, therefore, entirely analytical,
and prepares for the subsequent caustic action,
which is rather synthetical. ' '

Bracken, Ind.; Dr. R. W. Ramsey, St. Thomas, Pa.; Dr.
A. Blair Frazee, Eldbridge, N. Y.; Dr. H. R. Storer,
Newport, R. I.; Dr. C. L. Ford, Wequetonsing, Mich.;
Dr. W.S.Hall, Haverford College P.O., Pa.; Frank
Kiernan & Co., New York ; Dr. David S. Booth, Sparta,
111., Dr. J. F. Kennedy-, Des Moiues, la.; Lea Bros. &Co.,
Philadelphia ; Cincinnati Sanitarium, Cincinnati, O.; N.
S. Niles, Boston ; Geo. H. Hirsh, .\nn .Arbor, Mich.; Dr.
G. W. Lowrv, Hastings, Mich.; Dr. N. Senn, Milwaukee,
Wis.; J. H. 'Bates, New York; Dr Clayton Parkhill,
Denver, Col.; Dr. W. E. Casselberry, Chicago; Dr. Jos.
A. White, Richmond, Va. ; Dr. Geo. Brown, Barre, Mass.;
Dr. Laura Hulme, Worcester, Mass.; Dr. J. B. Vail, Lima,
O.; Ward Bros., Jacksonville, 111.; Dr W. S. Swan, Har-
risburg. 111.; Dr. F. Tester Smith, Chattanooga, Tenn.;
George Kiel. Philadelphia ; Dr. Amos Sawver, Hillsboro,
III. ; Dr. G. W. McCasky, Ft. Wayne, Ind. ; Dr George
O. Mead, Newmarket, Eng. ; Dr. Claude M. Ferro, Tracv,
Minn.; Dr R. J. Dunglison, Philadelphia; Dr. D. B.
Wise, Mt. Eaton, O.; Dr. Walter Channing, Brookline,
Mass.; Dr. J. M. Farrington, Binghamton, N. Y. ; P.
Blakiston & Co.. Philadelphia; Dr H. G. Chritzmau,
Welsh Run, Pa.; Dr. E. A. Cobleigh, Chattanooga, Tenn.;
Dr O. E. Abel, Winchester, Ind. -^ Dr. A. B. Judsou, New
York; Dr. Jno. G. .Ames, Marblehead. Mass.; B. Glick,
Kansas Citv, Mo.; Dr. J. M. Toner, Washington ; W. H.
Schieffelin'& Co., New York; Drs. Allen & Ray, Philips-
burg, Mont.; Dr. D. N. Skinner, .Vuburn, Me.; Dr. T. .A.
Renefeck, Newport, R. I.; The Racine Malleable &
Wrought Iron Co., Racine, Wis.; W. W. Rokker, Spring-
field, ill.; Dr. R. S. Sutton, .Allegheny, Pa.; Dr G. F.
Cook, Oxford, O.; Dr. Daniel G. Lass, Rodney, la.

Official List of Changes in the Stations and Duties of
Officers Serving in the Medical Department. U. S.
Army, from August 2/, iSSg, to August jo, iSSg.

Bv direction of the acting Secretary of War, Major Wil-
liam S. Tremaine, Surgeon, now on sick leave of ab-
sence at Buffalo, N. Y., will report in person to the
commanding General Dept. of the Missouri for assign-
ment to temporarv dutv at the post of Ft. Leavenworth,
Kan. Par 4. S. O. 19S, A. G. O., August 27, 1SS9.

Major Benjamin F. Pope, Surgeon U. S. .A.rmy, is grant-
ed leave of absence for one month, with permission to
apply through Division Hdqrs. for an extension of two
months. Par. 7, S. O. 54, Dept. of Texas, August 17,
1S89.

PROMOTIONS.

Capt. Washington Matthews, .Asst. Surgeon, to be Sur-
geon with rank of Major, July 10, 1889, vice Town,
promoted.

Asst. Surgeon Charles B. Ewing, July 5, 1S89; Asst. Sur-
geon Walter D. McCaw, August 20, 1SS9 — to be .Asst.
Surgeons with rank of Captain, after five years' ser-
vice, in accordance with act of June 2j, 1874.

MISCELLANY.

LETTERS RECEIVED.

Dr. A. M. Hayden, Evansville, Ind.; Dr. Chas. W. Fry,

Official List of Changes of Stations and Duties of Medi-
cal Officers of the U. S. Marine-Hospital Service,
for the T-.iv Weeks Ending August 24, /SSg.

P. A. Surgeon J. H. White, granted leave of absence for
thirtv days, on account of wound. .August 16, 1SS9.

SurgeonAV. H. Long, to proceed to Gallipolis, Ohio, as
inspector. .August 7, 1SS9.

Asst. Surgeon .a'. W. Condict, detached from revenue
bark " Chase " and ordered to Louisville, Ky., for tem-
porarv dutv. -August 19, 18S9.

.Asst. Surgeon J. F. Groenevelt, ordered to South Atlan-
tic Quarantine Station for temporarv duty. August
8, 1S89.

,^4

THE

J ournal of the American Medical Association

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.
PUBLISHED WEEKLY.

Vol. XIII.

CHICAGO, SKPTEMBER 14, 1889.

No. II.

ORIGINAL ARTICLES.

THE MASSACHUSETTS LUNACY LAW.

Read in the Sectto'i of Medical Jurisprudence, at the Fortieth An-
nual Meeting of the American Medical Association,
June l8Sg.

BY T. W. FISHER, M.D.,

OF BOSTON, MASS.

The question of a revision of the lunacy laws
of Massachusetts has excited much interest the
past year, and maj- soon become the subject of
legislative inquiry-. Dr. Stephen Smith, ex-Lu-
nacj- Commissioner of Xew York, has published
a " Report on the Commitment and Detention of
the Insane," which recommends uniform legisla-
tion on these subjects.

Patients are now admitted at the Boston Lu-
natic Hospital in six different waj-s. The major-
ity of them are regularly committed by the Judge
of Probate on the certificate of two physicians.
There is little to criticise in the law by which this
is done, except the provision which forbids phy-
sicians connected with asylums from certifying.
This is a reflection on their honesty not warranted
by anj^ experience in this countrj-. The large
number of private Asylums in England, kept by
medical men for profit, rendered desirable a law
that no physician should certif}- a patient into
his own asj'lum. This law was transplanted to
this country — where private asylums are rare — and
changed so as to forbid any phj^sician connected
in anj' way as officer, or trustee, or commissioner,
or member of a board of lunacy even, with any
hospital for the insane, public or private, from
certifying a private patient into any hospital for
the insane. This is not only a gratuitous insult
to the specialty, but a hardship to the friends of
the insane. Superintendents of hospitals — espe-
cially in countrv^ districts — are the only physi-
cians whose knowledge of insanity is of much
value. Such an one's advice is naturally sought
by the relative of the patient in obscure cases, and
it is something of a shock to be told, after receiv-
ing his valuable opinion and advice, that his cer-
tificate is of no value. His opinion in court may
settle questions of damages of large amount, or
determine the disposition of large fortunes by
will ; the life or death of an insane criminal may

depend on his judgment ; but having advised so
simple a thing as hospital treatment for some pri-
vate patient, two strange physicians must be
called in, at added cost, to reexamine the person,
before he can be sent to a hospital for treatment.
Fortunately, the provision of law, that the judge
may see the insane patient, is not mandatorj-. If
it was, it would be impossible, or at least harm-
ful, to many patients to carry it into effect in Suf-
folk county. Here 500 or 600 patients are com-
mitted annuall}- bj- one judge, and he is necessa-
rily obliged to give some formal reason for not
seeing the patient. This provision is merely su-
perfluous, as a judge could insist on seeing a pa-
tient without it.

The second form of admission is upon emer-
gency papers. This method, though of general
application, is in use only in Suffolk county, and
at this hospital, no emergency cases being reported
bj- the State hospitals. The emergency law was
passed to allow excited and dangerous patients
to be speedily admitted to hospitals for temporary
detention, and to prevent the necessity of insane
persons arrested by the police of Boston, on Sun-
days, holidays, and after business hours, when no
judge can be found, being sent to the station-
houses or city prison. This was an excellent
object, and the law is absolutelj- necessar}^ for
the safety' of the public and the good of the in-
sane. Instead, however, of being simple and
eas)^ of application, more papers are required,
more time is necessary-, and the method is more
complicated than that for a regular commitment.
In an emergencj-, having an excited lunatic to
dispose of, few phj-sicians remember the law, or
know where to look for it, and either make
out faulty certificates, which cannot be received,
or send the patient with his friends or by the po-
lice to the hospital without any papers. In a
regular commitment, which many physicians
have learned to understand, the two physicians
sign the same certificate : while the emergency
law requires them to sign separate ones, and also
to add to the usual form the statement that the
patient is sent as an emergency case, /. c, that
he is so insane that he cannot wait for the regu-
lar commitment process. We ver>' seldom receive
correct emergency certificates, except from the
examining physicians to the Board of Directors.

362

THE MASSACHUSETTS LUNACY LAW.

[September 14,

This necessitates, when such a case arrives, the
rejection of the faulty papers, and sending out
into the city for two other physicians living near-
est the hospital, who are strangers to the patient
but able to certif}' properly. This puts the rela-
tives to the expense of four physicians instead of
two, and causes the prolonged detention of an ex-
cited patient in an out reception-room Human-
itj- requires that these cases should be received,
but we cannot admit them to the wards without '
the proper certificates. Another absurdity of this ;
law is the requiring of a bond of $100.00 to be
given by somebody representing the patient, to
remove him within five days unless regularly
committed. No superintendent would dare to
keep the patient beyond the legal limit; as he
would expose himself at once to a suit for illegal
detention and heavy damages. In the great ma-
jorit}- of cases, however, the bond is a mere form
which might be dispensed with. It is either
signed by some poor and irresponsible friend of
the patient, or by some policeman, or. more often
still, by one of the certifying physicians. An-
other absurd provision is that requiring that the
mayor or one of the selectmen should sign the
application. In Boston, where most of these
cases occur, the law is evaded in the following
manner (if it were literalh- enforced ver}- few
emergencj' cases would be received. It would be
as easy to find the judge as to find the maj-or or
his representative) : The Maj-or of Boston dele
gates his authoritj- both under the emergency law
and the law for regular commitment, to the Board
of Directors for Public Institutions. In the lat-
ter case the clerk of the Board signs for the Maj-or
an acknowledgement that he has been notified
and puts it on file. In the former case he signs
in advance blank applications for the admission
of emergency cases, and gives them in charge to
the Superintendent of this hospital and the ex-
amining ph}'sicians of the Board. Suppose the
police or the relatives of an excited lunatic had
to find this oflBcial at short notice, by night, or
on a holiday, or on Sunday, as usually occurs,
how often would the delay prove dangerous?
These deviations from a strict interpretation of
the laws relating to the commitment of the in-
sane are at present humane and necessarj-, and I
fully approve them. I think, however, that the
red tape and complicated requirements of the
emergency law stand in the way of its general
usefulness, especially in the small cities and
towns. Before the physicians of a country vil-
lage could have found and read the law and made
proper certificates, and invented a form of bond,
and found a selectman who knew how to make
an application, the lunatic might have murdered
his family or burned the town. Practically, the
law is not used in the countrj- or outside of Bos-
ton. The violent lunatic is seized by the local I
police or town constable, handcuffed, and put |

into the lock-up to await the slow action of the
regular process of commitment before a judge of
probate in some distant town, perhaps. The
whole procedure in emergency cases should be
simplified so as to consist merely in the sworn
certificate of two physicians as to the dangerous
condition of the lunatic.

The admission of voluntary patients is the third
method to be considered. A recent law allows
the Superintendent to receive as a "boarder" any
person who makes written application to that
eflFect ' ' whose mental condition is not such as to
render it legal to grant a certificate of insanity."
This law, strictly construed, would prevent the
admission of any insane person, or dipsomaniac,
as a voluntary' patient. This would only leave a
certain class of nervous patients, who were ap-
prehensive of becoming insane, and were desirous
of early treatment as a means of prevention, to
be admitted under this law. Applications of this
kind are very rare at the public hospitals. The
McLean Asylum, at Somerville, has almost a
monopoly of this class of patients, and I am afraid
many of the cases admitted there and elsewhere
do not come within the terms of the law. A few
inebriates have been admitted to the Boston Lu-
natic Hospital as voluntary patients, by order of
the Board and otherwise, and some of .them have
remained a long time under treatment, and have
apparently recovered.

Some patients, no doubt, are made willing to
come voluntarily by the threat of commitment
held over them by their relatives, and the knowl-
edge that they can go on three days' notice by
another written application for discharge. It is
certain that some insane persons are admitted as
voluntary patients : also, that many become in-
sane and are committed before the three days'
grace are over. It seems a breach of confidence
on the part of the superintendent to have a vol-
untary patient committed, and yet it often be-
comes necessary. The opinion of Dr. Cowles, ot
the McLean Asylum, would be of especial value
with reference to this law. It seems to me, how-
ever, that I should change it, so as to allow any
person — sane or insane, or a dipsomaniac — ad-
mission on his voluntary application ; but with
the definite understanding that he was liable to
be committed if his case proved serious or in-
tractable. The term ' " boarder' ' is somewhat ob-
scure. Does it mean a private patient, or simply
an inmate, without regard to the payment of
board ? If the latter, may not a desire to be com-
fortably cared for at public expense induce some
to apply ? The law depends largely on the dis-
cretion of the superintendent for its successful
application.

The fourth form of admission is under the Ha-
bitual Drunkard law.'

' Since this paper was read a law has been passed providing a
special hospital for inebriates.

1889.]

THE MASSACHUSETTS LUNACY LAW.

363

This law, as it stands, is defective, and liable
to abuse in several ways. In the first place, ine-
briates should be committed to some special in-
stitution, and not to lunatic hospitals. They not
only take up the room needed by the insane, but,
after the first few days, they are practically sane,
and find themselves surrounded bj' the depressing
influences of an insane hospital, and subjected to
restraints and regulations primarily adapted to
the insane. To be sure they are better ofi" than
when at large, exposed to temptations to drink,
and much may be done for them in the way of
kind treatment and moral management. But
they are out of place, and the}- often feel it, and
show it ; while many are considerate and give
little trouble, sometimes the}' interfere sadly with
the discipline and interrupt the harmony of an
asylum ward. They may refuse to associate with
the insane or claim privileges which cannot be
granted their insane neighbors and which, if
granted them, cause more or less jealous}"- and
hard feeling.

la the second place, they should be committed
for a definite time, either for one, two or three
years. This is necessar}-, because a long course
of hygienic treatment is required to restore the
enfeebled brain to its normal state of health and
vigor, and to allow the weakened will to regain
ascendancy over the appetite for stimulants. The
inebriate's whole constitution needs reconstruct-
ing, and this process must not be interrupted by
occasional drinking. It is better, also, for the
inebriate to know definitely what he is to look
forward to, so as to ensure contentment and re-
pose of mind as far as possible. The patient
should expend his energies in healthful employ-
ment, and in the attempt at recovery, and not in
efforts for his own release. The present law sub-
jects the superintendent to constant importuni-
ties for discharge on the part of the inebriate and
his friends. Plausible reasons are advanced, in-
genious schemes are made use of and all sorts of
influence brought to bear for a patient's discharge,
when one would have supposed that removal from
home for a year would have been a great relief
to the inebriate's family and friends.

I have endeavored to conform to the rule here
that no habitual drunkard shall be discharged
under a year's detention, as that was the shortest
period of commitment ever proposed in the dis-
cussions in Legislature and Parliament. I
failed in applying this rule in almost the first case
committed. After a two months' residence, this
person was allowed to go home on trial, at the
personal request of the judge who committed
him, to avoid a long and unprofitable rehearing
of the whole case on its merits. Fortunately, this
patient has so far justified the confidence reposed
in him, and has been discharged.

In the third place, the law should allow com-
pulsorj' labor to be performed by inebriates, with-

I in certain limits, and at the discretion of the su-
; perintendent, partly to reimburse the Common-
I wealth for their support, but more especially as a
hygienic measure. Idleness in the wards of a
lunatic hospital is as far as possible from the best
treatment of inebriety. Varied employment, in
the open air when possible, for a few hours daily,
with similar periods for recreation out of doors, is
the essential feature of such treatment. The ma-
jority of insane persons are unable to work, while
most inebriates are. It would be wrong to com-
pel an insane person to work, while inebriates
might be induced to work, by promise of reward,
deprivation of privileges, and other forms of
moral suasion. The opportunities for work in
most hospitals are already too limited, and lack
in variety, while in an inebriate asylum there
would be no. objection to the use of tools of any
kind.

The law is also liable to abuse in several ways.
In the first place, physicians are not unlikely' to
apply the law to some inebriates who are not of
unsound mind. The use of both terms, "dipso-
maniac" and "habitual drunkard," tends to cre-
ate confusion and ambiguity in certifying. Dip-
somania, either inherited or acquired, would be a
proper cause of commitment. Persons affected
with an inherited tendency to that form of impul-
sive insanity, characterized by an insane desire
to drink, are dipsomaniacs by inheritance. These
cases are rare ; they have a defective or degener-
ated cerebral organization which leads them to
impulsive acts through a weakness of the will,
and excessive energy of the animal instincts. In
another more numerous class the brain has been
•so damaged by inebriety or other causes, such as
ill health, blows on the head, sun-stroke, etc., as
to prevent all possibility of self-control in relation
to drink. These are cases of acquired dipsoma-
nia. Persons of sound mind who drink habitu-
ally from choice are not proper subjects for com-
mitment. They are vicious drunkards, and should
be punished rather than treated. These are nice
distinctions it is true ; but they are real ones, and
it is therefore important that physicians should
look carefully for the element of unsoundness of
mind in the cases they are called on to examine.

There is also some danger that judges may not
sufiiciently regard the clause which requires that
satisfactory evidence shall be furnished that the
inebriate is not a person of bad repute or of bad
character apart from his habits of inebriety. Such
evidence is not likely to be presented unless de-
manded and the facts carefully elicited from re-
luctant witnesses. It would, indeed, be unfor-
tunate if our insane hospitals should be used as
convenient retreats for vicious and disreputable
drunkards to recuperate in.

For many years there have been attempts on
the part of superintendents of insane hospitals to
secure the passage of a law allowing the commit-

364

THE MASSACHUSETTS LUNACY LAW.

[September 14,

ment of dipsomaniacs to some special institution
for their custody and treatment. In England
this movement resulted, after manj- 3'ears of dis-
cussion in Parliament, in the passage of an Ha-
bitual Drunkard's Bill, wherebj^ such persons
may voluntarily seclude themselves in special in-
stitutions for definite periods. The writer has
often advocated before legi-slative committees and
the Board of Health, Lunacy and Charity, and
in a paper on "Insane Drunkards" read before
the Massachusetts Medical Society in 1879, le-
galizing the commitment of inebriates to special
institutions for long periods of from one to three
years. He also demonstrated, in defending an
action for damages for improper certification of
an inebriate, at considerable trouble and expense,
that, in the opinion of the Supreme Court of
Massachusetts, there is such a disease as dipso-
mania, and that, in the absence of special insti-
tutions, such cases might be committed to hos-
pitals for the insane. Soon after this decision, if
not in consequence of it, renewed efforts were
made by the Board of Health, Lunacy and Char-
ity to secure the passage of a law on this subject,
and in 1885 the following law, not wholl}' in ac-
cord with their recommendation, was passed :

A71 Ad Concerning Hospital Treatment for Cer-
tain Persons Subject to Dipsomania or Habitual
Drunkenness.

Be it enacted, etc., as follows :

Section i. Whoever is given to or subject to dipso-
mania, or habitual drunkenness, whether in public or in
private, may be committed to one of the State lunatic
hospitals ; provided, however, that no such person shall
be so committed until satisfactory- evidence is furnished
to the judge before whom the proceedings for commit-
ment are had that such person is not of bad repute or of
bad character, apart from his habits of inebriety.

Sect. 2. The provisions of chapter eighty-seven of the
Public Statute, and of acts amendatory to such chapter,
relative to the commitment of an insane person to a lu-
natic hospital, shall be applicable to, and shall govern
the commitment of, any person under this act except
that in all proceedings relative to the commitment of anv
such person it shall be specifically alleged that he is sub-
ject to dipsomania, instead of alleging that he is insane.

Sect. 3. All the laws relative to persons committed to
lunatic hospitals on the ground of insanity shall apply
to persons committed thereto under the provisions of this
act ; provided, that no person so committed shall be dis-
charged therefrom unless it appears probable that he
will not continue to be subject to dipsomania or habitual
drunkenness, or that his confinement therein is not longer
necessary for the safely of the public or for his own wel-
fare.

Sect. 4. This act shall take effect upon its passage.

Approved f line iS, /SS).

It will be seen this act does not include this
hospital in its provisions ; but it has been con-
stnied as applying to it by the committing mag-
istrate. The provision allowing commitment to
lunatic hospitals may have been a compromise on
the part of the legislature to avoid the expen.se
of establishing a special institution for inebriates.
It certainly was not what superintendents had

asked for, but what they had alwaj's earnestly
protested against. They had hoped for a law to-
relieve them of such inebriates as did from time
to time get committed to their hospitals on the
claim that they were insane ; and a law was passed
legalizing the commitment to insane hospitals of
habitual drunkards without any inquirj- as to-
their sanity. This law was passed in the face ot
the fact that all the hospitals were full to over-
flowing with cases of ordinarj' insanity, so that
hundreds were compelled to sleep in the attics
and on corridor floors. Under this pressure one
superintendent expressed himself as having de-
generated into a big policeman, spending his
time in tr\-ing to keep order and maintain disci-
pline in a crowd of lunatics and inebriates, in-
stead of devoting his time to his proper work of
treating insanity.

The fifth method is by transfer from State hos-
pitals for the insane. This has never been made
use of in the history of the hospital until the
past year. In fact, it was by Chapter 3 1 9 of the
Acts of 1886 that it was first authorized. This
provides that the order of commitment of an in-
sane person, whose friends are unable to support
him, holds good until his recover^', and he may
be transferred, bj' the vState or city authorities, to-
anj- "hospital, asylum, private dwelling, or other
place," at their discretion, provided he has had a
trial of hospital treatment, and has been insane
twelve months. After this initiation, he may be
subject for a lifetime, if he does not recover, to-
the control of the State, civic, or town authorities.
He may be transferred from one as\ium to an-
other, regardless of the convenience or contiguity
of his friends and relations. Boston patients, for
instance may be, and are, .sent to Northampton.
He maj' be boarded out in some remote village,
possibly to be overworked, underfed, and seldom'
visited bj- friends or inspectors. Ignorant and
economical selectmen may without medical advice
seclude him in some remote poor-house, or they
ma}' board him or farm him out on some distant
farm. This control only ends with the life of the
patient, and he tnay be still held by his first com-
mitment paper years after the physicians who ex-
amined him and the judge who comtnited him
are dead and forgotten. This is called "adminis-
trative commitment." If exercised by medical
men, experienced in dealing with the insane, and
humane men, remembering that the love of home
and friends is not always extinguished in the in-
sane at the end of twelve months, and that many
recoveries occur after one j-ear, and even after
five years of insanity, it may not work much
harm to the insane. If the selection of the
boarded-out insane is ver>- carefully made, and
their inspection verj' thoroughly conducted by
competent physicians, having e.xperience in the
treatment of insanity, not much harm may be
done, and .some money may be saved to the State.

1889.]

CHRONIC SCIATICA.

365

I think, however, the law is rather in the interests
of economy and administrative convenience than
for the best good of the insane. An insane
person's family and friends are the natural in-
spectors and supervisors of his treatment and con-
dition. I see no reason why, because an insane
person is poor and may never fully recover, he
should be moved all over the State, like a pawn
on a chessboard, because this or that hospital is
too full, or because he can be boarded out at $2 a
week, while it costs $4 at the State hospitals.
Since writing the above I have read Dr. Park's
last report, from which I extract the following :
"Some forty chronic and incurable cases were
transferred to the Tewksbury Almshouse and the
Westboro' Hospital, and their places supplied by
an equal number of similar cases from Danvers.
Apart from the temporary pleasure of the day's
outing, including the ride on the cars, which was
afforded them by this trip, no improvement in
their mental condition can be expected as a re-
sult of their change of residence."

The sixth method of admission is by the return
of excited patients from the Retreat at Dorchester.
We have received ten patients in this way —
under a general order of the Board to take all pa-
tients sent to us by the superintendent of that in-
stitution. Nine of them were originally sent
there under a similar order. The other case was
that of a man who has lived in four different hos-
pitals in the last two j'ears on one commitment.
I do not know whether the patients sent from
this hospital to the Retreat were sent under the
law of 1886 or not ; if so, the original papers did
not accompany them. There is a law which is
open to criticism, but we have been exempted
from its operation. It directs that all those in-
sane committed from Suffolk Count}' unable to
pay board shall be sent in turn, and in equal
numbers to each of the State hospitals and this
hospital. At first commitments were made for six
weeks to each of the above hospitals, including
the Homoeopathic Hospital, without regard to
the question whether patients desired homoeo-
pathic treatment or not. This hospital was early
exempted from the operation of this law by the
Board of Lunacy and Charity' as a single week's
commitments would have overwhelmed us on the
female side. For several months all patients
have been sent to Westboro' . According to the
terms of the law, and in practice, only homceo-
pathists and paying patients are allowed to select
their own hospital.

A New Swiss Pharmacopceia. — A new Swiss
Pharmacopoeia is shortly to be published. A
request has been sent, lay the collaborators, to
Swiss medical societies and practitioners,, request-
ing suggestions as to the introduction of new
remedies and the retention of old ones.

THE PATHOLOGY AND TREATMENT OF
CHRONIC SCIATICA.

Read before the Section of Surgery and Anatomy, at the Fortieth
Annual Meeting of the American Medical Association, at New-
port, June, 1SS9.

BY J. G. CARPENTER, M.D.,

OF STANFORD, KY.

Pathology. — Chronic sciatica may be the result
of the acute form, or may be chronic from the
beginning and run a tedious, painful and pro-
tracted course — at times almost abating, to be
again renewed with increased paroxysms of pain.
It has been truly said of sciatica that "it is an
unwelcome guest who returns when least ex-
pected." The points of greatest sensitiveness
are the buttock, sacro-sciatic notch, post tro-
chanteric line, head of fibula, outside of leg,
maleolus, sole, outside and two-thirds of the
dorsum of the foot.

There are two factors in the pathology of
chronic sciatica, viz : one a neuralgia or neurosis,
the other a neuritis or perineuritis, inflammation
of the sheath, and surroundings of the nerve
trunk. The disease may be located in the peri-
pheral or central portion of the nerve. Chronic
sciatica may be the manifestations of a neurosis —
functional derangement of a nerve centre found
in neuropathic constitutions. There may be
anaemia or hypersemia of the nerve and sheath,
or nerve centres, pressure of tumors, or a reflex
irritation of the nerves from genito-urinary or
rectal diseases as a urethal stricture, displaced
uterus, or ovary, fissure, haemorrhoids, pressure
of the nerve by a contracting cicatrix, deposit of
callus on the ner\'e or some of its branches, the
rheumatic or gouty diathesis, spinal concussion,
syphilis, malaria, pregnancy, over-lactation, al-
coholism, venereal excesses, lead and mercurial
poisoning, excessive fatigue, diseases of the verte-
bra, or pelvic bones, a damp or cold climate.

In the consideration of chronic sciatica, this
question presents itself, viz : Is the pathological
condition a neuralgia or a neuritis ? In neuralgia
of the sciatic nerve on ante- and post-mortem in-
spection, there have been no pathological lesions
found in the nerve or its coverings ; if the above
causes were the only factors concerned in the
pathology of chronic sciatica a removal of them
a priori would cure the disease, but such is not
the case ; for though the cause may be removed
the disease may still exist in all its obstinacy,
and another factor must be considered, viz : a
neuritis, or a peri-neuritis which makes chronic
sciatica so rebellious to treatment. In chronic
sciatic neuritis the pathological state is rather in
the sheath of the nerve than in changes of the
nerve fibres ; the nerve fibres may undergo some
pathological change in this condition, but what is
at present known is, that the neurillema or con-
nective tissue sheath of the nerve, including its.
minute prolongations between and around separ

366

CHRONIC SCIATICA.

[September 14,

ate bundles of nen-e fibrils, becomes much more
liypersemic than natural, and that on microscopic
examination there is to be found in addition to
the increased vascularity, a multiplication of new
tissue elements and the presence of migrator}-
leucocytes. These changes may cause considera-
ble swelling of the nerve sheath and of its pro-
longations, and thus may produce irritation, or
more or less compression of the nerve tubules,
according to the amount of new tissue elements
which accumulate in, or are produced within the
sheath. In neuritis the ner\-e often appears to
the eye normal, and the characteristic changes
are only revealed by the microscope.

The microscopic changes in neuritis may ex-
tend to all the constituents of the ner\'e and pre- j
sent the ordinary- picture of acute inflammation,
hyperaemia, exudation, accumulation of white
corpuscles in .the tissue, and even the formation
of pus. The nerve fibres, exhibiting in various
degrees, the destruction of the white substance of!
Schwann and the axis cylinder, or, as in chronic {
neuritis, the alterations ma\- consist in the more ,
gradual proliferation of the peri- and endoneurium,
which contracting renders the nerve dense and
hard, and destroys the nerve fibres by compres- ;
sion. When the perineurium has been the
principal seat of the inflammation in chronic
neuritis, the trunk of the ner\-e becomes hard
and thickened, from proliferation of the connec-
tive tissue. Sclerosis of the ner\-e.

In chronic neuritis as in the acute, the peri-
neurium may be exclusivelj- aS'ected, the fibres
remaining normal (Crushman and Eisinlohr).
The nerve fibres themselves may be the primary
and almost exclusive seat of neuritis, exhibiting
more or less complete destruction of all their
constituent parts, excepting the sheath of
Schwann without hyperaemia, with little or no
alteration of the interestitial tissues. Sometimes
the fibres are aifected at inter\-als, the degenera-
tion occupying a segment between two of Ran-
vier's nodes, leaving the fibres above and below
normal. (Neurite segmentaire periaxle). Gam-
bault. " All of these lesions of the nerve fibres
may be recovered from by a process of regenera-
tion, the fibres showing a remarkable tendency to
recover their normal structure and function. The
nerv^e does not always present the appearance of
a continuous inflammation, but the evidence of
neuritis may be seen at points along its course
which are separated by sound tis.sue. These
points of predilection are usually exposed posi-
tions of the ner\-e or near joints."

" In chronic neuritis, the morbid anatomj- con-
sists of an increased vascularitj' of the affected
ner\'e, sometimes of a varicose state of the blood-
vessels, of a thickening and induration of the
neurilemma in consequence of coagulate exuda-
tions. In variable degrees the nerve assumes some-
what of a slate color, loses its characteristic

opacit}', and when examined under the micro-
scope the ner^-e fibres are found to have fallen to
a greater or less extent into a state of disintegra-
tion. The inflammation may attack the sheath
of the ner\-e chieflj-, and contract adhesions to
neighboring tissues, the ner\'e itself remaining
movable, although compressed. In other cases
the nerve as well as the sheath is the seat of in-
flammation. In the growth of new connective
tissue the proper nerve elements are compressed,
and consequently atrophj- and disappear, nothing
remaining but a fibrous cord. On microscopic
examination there is but little hj'perasmia ; the
interstices are crowded with leucocytes and
granular cells, but the most important change is
the overgrowth of interstitial connective tissue,
and the consequent fatty and atrophied degenera-
tion of the nerve fibres with their axis cylinder ;
with injur}- to the ner\-e, occur secondary- trophic
changes. ' '

Secondarj' trophic changes in chronic neuritis :
The trophic changes dependent on chronic neu-
ritis are frequently verj- prominent and important.
Most commonly there is paresis, which may
deepen into parah'sis with atrophy of the mus-
cles and degenerative reaction. The skin some-
times becomes rough and scaly, sometimes
atrophied, smooth and shining fglossj- skin).
OJdema of the subcutaneous cellular tissue is
often seen. The hair of the affected part shows
sometimes increased growth, sometimes it falls
off. The nails ma}' become thickened, rigid,
and distorted. Deformity of joints with enlarge-
ment of the ends of the bones is not infrequently
met with as the result of chronic neuritis. In
short, we may meet with all of those trophic
changes which have been described as arising
! from neural irritation, and which occurs in
chronic neuritis as the result of compression of
nerve fibres by the contraction of the proliferative
I connective tissue in the nerve trunk."

The diagnosis of chronic sciatic neuritis from
chronic sciatic neuralgia cannot always be made,
but the following conditions may be obsen-ed,
viz. : That the neuralgia is generally dependent
' on some constitutional dyscrasia reflex irritation,
; compression of ner\'e by a contracting scar, a
I morbid growth, or a callus, and by removing the
cause or disease on which the sciatica is depend-
ent, the latter is ameliorated or cured ; ante-
mortem inspection of the nerve on exposure, may
give no evidence of disease, and be considered
neuralgic, though in obstinate ca.ses it may be
presumed there was a neuritis, or a perineuritis,
or at least a hyperaemia of the uer\-e for the start-
ing point. Heat, redness, swelling and pain are
not absolute in neuritis as in other inflammatory
affections.

There may be relative constancy of pain with
the secondary trophic changes, spasm, atrophy,
and paresis of the muscles, with atrophy and

1889.]

CHRONIC SCIATICA.

367

coldness of the limb supplied b}' the nerve and
conditions of causalgia, hyperaesthesia, paraes-
thesia, or anaesthesia with tenderness of the ner^'e
along its tract together with the long standing of
the disease ; and in addition there may be or-
ganic nutritive changes affecting the skin, hair,
nails, or the bones which would be diagnostic of
neuritis or perineuritis.

The sciatic nen-e being a mixed nerve, both
sensory and motor. There will be two sets of
symptoms in chronic sciatica. The sensory symp-
toms usually precede the motor, and are much
more prominent for manj' weeks, months or years.
The motor may be absent altogether. From the
sensory there will be more or less continuous pain.
At times paroxysmal, perceived at different points
along the nerve trunk extending into its peri-
pheral branches, and sensations of heat, cold,
numbness and tingling sensations, hyperassthesia,
causalgia, or anaesthesia in the trunk or peripheral
branches of the ner\-e. From the motor fibres
there may be twitching and impaired functions
of the muscles, amounting in many cases to
spasms, or the motor fibres may be so involved as
to cause paresis and atrophy of the muscles with
impaired circulation, and nutrition with atrophy
and coldness of the limb. Fortunately, for the
victim of chronic sciatica many of the morbid
states of both the motor and sensory fibres are
absent. In most cases only a few having all the
conditions enumerated.

Sciatica may extend centrally and involve the
spinal cord. It is often quite painful or impossible
for the patient to assume the sitting posture, owing
to the extreme tenderness of the nerve trunk near
the tuber ischii. Again it is impossible for the
patient to lie in bed on the side of the affected
ner\re, or even on the back, owing to the great
tenderness at the posterior inferior spine, of the
ilium and fold of the buttock, unless the pressure
of the bed is removed from the tender points b}'
soft pads, or pillows placed under the knees and
back, or the latter, and outside of the thigh.

There is an attitude and gait peculiar to the
chronic sciatic patients, accurately described bj'
M. Charcot in The Journai, of the American
Medical Association, vol. xii, Feb. 16, 1889,
No. 7. and he is the only writer, or authority-
known to the writer, who has given this descrip-
tion. In both of my patients who were ner\^e
stretched the gait was quite characteristic. The
first patient had chronic sciatica of the right
sciatic ner\-e. The trunk was inclined to the
left, the vertebral column described a curve with
its convexit}- to the right, the left hand descended
much lower than the right, the right lower ex-
tremity was semi-flexed, the buttock of this side
presented a flattened appearance, the gluteal fold
being elevated ; finally the heel of the right foot
did not touch the floor (Charcot attitude). The
limb was atrophied and cold, one inch and one

half smaller from hip to foot than the left, and
patient was unable to sit on the right buttock.
The condition of the nerve on exposure before
stretching was this : The neurilemma was found
to be thickened, congested, and numerous reticu-
lations of small blood-vessels ramified in the
sheath ; the latter, had lost its opacity, and was
of a pinkish 3'ellow color, had manj' nodular
deposits, and had many adhesions to the adjacent
tissues, showing plainly that the case was one of
chronic sciatic perineuritis. Attitude of second
case, left sciatic nerve affected, the trunk was in-
clined to the right, the vertebral column described
a curve with the convexity to the left, when the
pain was great or recurred in paroxysms, the left
lower extremit}' partly flexed, except when walk-
ing on the street the buttock of this side pre-
sented a flattening, the gluteal fold being ele-
vated, the heel of left foot did not touch the
ground, or floor, without pain in the thigh. In
the recumbent posture the left limb was flexed,
pads or pillows had to be placed under the knee
and back to remove pressure from the tender
points, otherwise the patient could not lie on the
back or left side ; the limb was one and one-half
inches smaller from hip to foot than the right
one, and cold and atrophied, and patient was un-
able to sit on the left thigh and buttock. The
pathological state of the ner\'e found on cutting
down upon it and exposing it, were some fibro-
cystic tumors and nodular deposits on the nerve
(perineuritis nodosa chronica), and bands of
lymph and adhesions. Between the sheath and
adjacent tissue the neurilemma had lost its normal
appearance and showed signs of fatty degenera-
tion, and was traversed by many small blood-
vessels. This was also a case of chronic peri-
neuritis. Both of these patients had the hyperaes-
thesia of the skin in which touching, or brushing
the affected parts causes a peculiar, disagreeable,
nervous thrill, from which the patient shrinks,,
but which, however, is not a pain

The treatment of chronic sciatica may be med-
ical, mechanical, electric and surgical. It is pre-
sumed that tonics, restoratives, alteratives, and
all other constitutional measures have been given
a thorough and faithful trial, and that the condi-
tion, or disease on which the chronic sciatica was
dependent has been removed or cured, and that
such local measures as the employment of mor-
phine, chloroform, sulphuric ether, osmic acid,
atropin, cocaine, ice- water, antipyrin, and
spraying locally with sulphuric ether, chloride of
methyl, or rubbing the nerve tract with menthol
or aconitia ointment, or ice, the free use of blis-
ters, the hot or cold douche, massage, electricity,
and actual cautery have been used, weighed in
the balance, and found wanting, before the num-
erous surgical procedures are resorted to.

The local application of the actual cautery
over the bed of the nerve, at three to five points,.

368

CHRONIC SCIATICA.

[September 14,

at inten'als of two to six inches, frequently
ameliorates the condition of the patient, or cures
the disease. The cauterj- iron, the paquelin cau-
terj', or a glass rod heated to a white heat, over a
spirit lamp, and applied in quick succession at
points two to six inches apart, is preferred by the
author. The latter does not blister, nor cause a
running sore, but makes a dry bum of the integu-
ment, and is equally as effective as the other
cauteries. Sulphuric ether or chloroform, at first
seem to have a counter-irritant, than an anodyne
effect when inserted into the bed of the nerve,
and should be used in drops ten to thirty daily,
or two or three times a week. The local use of
morphine, atropin and cocaine, is much en-
hanced by combining one or more of these agents
with one or the other of the drugs.

Graham speaks ver^' highly of massage in the
treatment of chronic sciatica, and gives a number
of cases of several years duration — one case ex-
tending over nine years. Not only is it highly
essential to the neuralgia or perineuritis, but it
arrests and prevents secondan,- trophic changes ;
it increases the circulation, nutrition, and growth
of the limb, and is anodyne besides.

Before cutting down and laying bare the ners-e
trunk to stretch, or even to perform Nussbaum's
bloodless nerve stretching for the relief of pain,
or anj- other purpose whatsoever, massage should
be thoroughly tried, as the action of this method
is somewhat similar to that of the other, releas-
ing the nerve from neighboring tissues that com-
press it, and producing changes in its structure
and circulation, and lessening its irritability,
perhaps, bj^ over-stretching. Massage and mild
stretching might succeed when more violent
stretching would fall. Langenbeck makes use of
massage in the vicinity of the wound, after the
violent stretching by surgical operations. In
both of the writer's cases which were nerve
stretched, massage had been given a faithful trial,
and all other milder procedures, before resorting
to nerve stretching. In the early and late stage
of neuritis, massage is indicated ; in the early
it would act as a proph\-lactic, relieving conges-
tion bj' causing a free circulation in the surround-
ing tissues, and by pushing the blood out of the
distended ve.ssels. In the late, by causing ab-
sorption of inflammatory products, the repeated
mechanical effect of manipulation and percussion
upon old neuralgia benumbs and lessens the
sensibility of the nerval filaments, and gradually
decreases it, hence its use in chronic sciatica ;
not only may pain be relieved, but states of
hypernesthesia, paresthesia, causalgia and anaes-
thesia are relieved by massage, in addition to
massage inunctions of va.seline, or olive oil are
indicated in the secondan,- trophic changes . of
chronic sciatica. Massage should be used by
gentle stroking, firm pressure, and slow, deep
kneading. Acupuncture in chronic .sciatica is a

valuable remedy, as well as in lumbago and other
neuralgias, and rheumatic afi'ections. Patient is
laid upon the face, the tender points are found,
and one or more needles inserted from half to one
and a half inches, and allowed to remain from a
half to two hours. The number of needles used
is from one to six. In sciatica the needle should
actually penetrate the ner\^e. This is known by
the patient complaining of a sudden, sharp,
shooting pain down the back of the thigh : this
action may be due to the escape of ner\'e fluid,
also to its counter-irritant effect. Cocaine may
be used hypodermaticallj^ in connection with
acupuncture.

Electricity . — The galvanic current has the pre-
cedence over the faradic, in relieving neuralgia,
and also in chronic sciatic neuritis. It causes
better nutritive and functional changes in the
ner\'es and nerve centres, and causes restoration
from many morbid conditions of the senson.-
fibres. The faradic is, perhaps, better indicated
in the secondary- trophic changes of chronic
sciatica neuritis, affecting the motor fibres.
Electricity has an anodyne effect and relieves the
accompanying neurasthenia. It makes little differ-
ence whether the anode or cathode is used in the
neighborhood of the nerve. The direction of the
current is of no material importance.

Treatment. — In addition to acupuncture, the
following surgical measures maj- be resorted to
when other means have failed. Brown-Sequard
has recommended exposure of the nerve and
washing it in ether to effect the same end as
ner\'e stretching. Nussbaum recommends blood-
less nerve stretching in sciatica, which consists in
having the patient etherized, whereupon the
thigh is forcibly flexed on the pelvis, and then
the leg extended on the thigh, and the foot on
the leg — dorsal flexion — and held for a short time
in this position. A considerable degree of stretch-
ing of the sciatic nerve is possible— in this way,
a number of cures have been made — though less
dangerous than stretching the exposed nerve, it
is no trivial operation. The effects of ner\-e
elongation are these, viz: Central elongation
affects sensation, and peripheral mobility, direct
and reflex excitability of the nerves disappear
under the influence of strong traction, and is in-
creased under limited traction. Sensibility is in-
crea.sed at first, and disappears more or less com-
pletely and more or less permanently according
to the force employed and duration of the time of
traction. Sensory fibres lose their excitability
before the motor fibres. ( Baum and Nussbaum).
Mobility is less influenced than sensibility, and is
reestablished by slight elongation.

Modus operandi 0/ elongation. — This is con-
sidered by some neurologists to act by diminish-
ing the conductibility of the nerve, others by
freeing it from adhesions, of pathological sources
I of compression. As regards function, nerve

1889.]

CHRONIC SCIATICA.

369

stretching has but little influence on mobilit}',
and when well performed is never followed by
persistent paralysis ; on the contrary, a perma-
nent anaesthesia is indispensable to its therapeutic
action. When it is directed, as is most frequently
the case, against an exaggeration of the direct, or
reflex sensorj^ — motor irritability of the nerves.

■Most ner\-e stretching has been done for neu-
ralgia, especially sciatic neuralgia, giving more
successes than on other nerves, and for other
affections. Should the first operation of nerve
stretching not succeed, a second one may be done
after a reasonable length of time. Prof H. B.
Sands, of New York, has done ner\'e stretching
the second time for chronic sciatica on the same
patient, having performed the first about six
months previous to the last. A degree of con-
traction may follow a rheumatic, or gouty deposit
in the nerve sheath, and thus affect the nerve
current in the centre of the fibre, which may be
drawn out by the nerve stretching, the normal
function of the ner\-e tubule being thus restored
temporarily or permanently. The success may
be owing to an alteration in the relations between
the nerve fibres, having the effect of improving
their nutrition. (Nussbaum). Nerve stretching
is a less serious operation than nerve section, and
more efiicacious, and should be done in preference
to the latter in chronic sciatica.

Indications for nerve elongation are, first, vio-
lent pain ; .second, continuous and annoying
hyperaesthesia, paresthesia, or causalgia ; third,
anaesthesia ; fourth, paresis and atrophy of the
muscles and limb to cause nutritive changes.
Mild traction on the central end of the ner\'e, for
sensation, and the distal end for mobility ; fifth, !
the prevention of structual changes in the spinal j
cord ; sixth, it may be used as a dernier rcssort.

Nerve stretching is effected by cutting down
upon the nerve trunk, detaching it from its con-
nections for the space of a few inches, laying hold
of it with the fingers, forcibly stretching the whole [
nerve from its origin to such an extent as to afiect ;
powerfully its functions, and then closing up the |
wound. In some instances a certain amount of
loss of sensation or muscular power in parts to
which the nerve is distributed is the immediate
result, which, however, passes away after a cer-
tain interval, and the nerve function becomes
more or less completely restored. When the sci-
atica is due to the pressure of tumors, or neuro-
mata in the ner\-e tract or neighborhood, in ad-
■dition to removing the tumors, the nerve may
require to be stretched on account of its diseased
condition, and the operation would not be com-
plete unless the ner\^e was elongated.

From ten to thirty or fortj^ pounds traction on
the nerve is required ; the amount of traction de-
pending upon whether it is for the relief of pain,
ansesthesia, hj'persesthesia, or to increase the
mobility and nutrition of the limb. Rupture of

a moderately large nerv'e is not to be feared, since
Baum has proven it is impossible to employ a
force of more than 33 lbs. av. in making exten-
, sion with a grooved director.
I The pathological anatomy of nerve stretching
1 consists in a laceration of the sheath, and in rup-
ture of the blood-vessels which are distributed to
its interior.

Schliech says a coagulation of myelin occurs ;
Tarchanoff saj-s immediately after elongation
traces of hyperasmia and capillar)' haemorrhage
and the division of a certain number of nerve
I fibres of the myelin and axis cylinder are found :
f the sheath of Schwann always remaining intact.
Scheving found healthy fibres, especiallj^ at the
centre of the nerve, and fibres in a state of fatty
' degeneration. In fine, nerve stretching seems to
cause most frequently the rupture of a certain num-
ber of nerve faciculi. Forcible elongation of large
nerves does, sometimes, affect even the spinal cord.
Sequelae of nerve stretching are sensory or motor
paresis, one or both, depending upon the amount
of traction employed. If forcible traction on cen-
tral end of nerve trunk has been exercised anaes-
thesia results; otherwise, hyperaesthesia. By slight
traction on the distal end motor paresis or chronic
sciatica may be relieved or cured. To control
I spasm of the muscles supplied by the sciatic nerve,
forcible traction will produce paresis. Rigors with-
in an hour after the operation of nerve stretching
' frequentl}' occur. Should insomnia and neurasthe-
nia not precede the operation they will attend it.
Retention of urine for a few hours maj' supervene.

The treatment of patient after the operation is
of great importance. It is desirable to get pri-
mary union of the wound in order to avoid the
formation of a cicatricial tissue and compression
of the nerve after the operation. For the first few
days after the operation the limb should be kept
extended at rest, and bandaged from the toes
above the wound. After the seventh or four-
teenth day passive motion and massage should be
applied to the limb and affected muscle supplied
bj' the nerve, to prevent adhesions and further de-
generation and atrophy of the nerve, muscles and
limb. The limb should be bandaged from three
to six weeks to prevent oedema, to support the
groups of muscles, and to prevent stretching of
the scar, and to hold the limb in normal position
until the nerve is regenerated, and the limb re-
stored to its normal state. vSayres' artificial rub-
ber muscles, a splint, or a removable plaster-of-
Paris boot may be necessary to hold the limb in
its normal position and prevent torsion and exten-
sion of the foot inwards, until the temporary motor
paresis is cured. During the convalescence of
most cases anodynes, soporifics and nerve tonics
will be indicated. Exercise in the open air and
sunlight on crutches, and in the wheel invalid
chair, are highh' essential, and should be em-
ployed with consistency.

37°

THE ORIGIN OF PUS.

[September 14,

In manj- cases it maj' be necessar}- to use local
and general electricity, or both, to hasten the re-
cover}^ of the motor paresis and the secondary
trophic changes, and counteract and relieve the
neurasthenia that generalh- accompanies the
chronic sciatica before the operation, or which
usually follows it.

The success of ner\'e stretching : In chronic
sciatica, in 168 cases collected from various sources
153 have been cured, 15 cases temporarilj^ bene-
fited. In other neuralgias, out of 1S9 cases, 132
have been cured, and 33 permanently benefited.
Bryant gives 70 operations of nerve stretching for
sciatica ; statistics indicate that in 60 the patients
were either cured or greatly relieved, and that in
the majorit}' of cases the relief was permanent.
The writer is informed that Mr. Calendar and
other English surgeons have had about 60 per
cent, of recoveries from nerve stretching.

As an extreme measure and a last resort, nerve
section has been done for chronic sciatica and
other neuralgias. Neurectomj' has been done by
Sapolino, Brinton, Morton, Hodge, Vance, Gold-
ing-Bird and Wyeth with at least temporary ben-
efit. Cures have been reported of neuralgia that
was cured by resection when nerve stretching had
failed.

THE ORIGIN OF PUS.

Read in the Section of Dental and Oral Surgery at the Fortieth

Annual Meeting of the American Medical Association,

June, l88<p.

BY WJI. ATKINSON, M.D.,

OF NEW YORK.

It is the gift of genius to foresee discoveries
even for centuries. Such a genius was John
Hunter, of London, who toward the end of the
last centurj-, merelj' upon the ground of specula-
tion and ratiocination, made the assertion that
inflammation is nothing more than a return of
the tissues to embryonic condition. And our
present knowledge of the process of inflammation
and suppuration is a strong proof, supported by
careful researches of good pathologists of Ger-
many and England, that Hunter's theorj' was the
correct one.

Since microscopy became a science (a period
covered by half a centurj') the views concerning
the intimate nature of the inflammatory' process
have been greatly at variance. These views largely
depend upon the general ground taken by pathol-
ogists in reference to the pathological processes
at large. We have three marked phases in the
development of pathology within the last fifty
years. The fir.st is the standard of humoral pa-
thologj' promulgated b}' the late Rokitansky, of
Vienna. The second is the phase of cellular pa-
thology established mainly by Virchow, of Berlin.
The third phase, still in vogue with many pathol-
ogists, is the doctrine of emigration of colorless

blood corpuscles or leucocj-tes, as propounded by
the late Cohnheim, of Leipsic. I personally
went through all these phases and am willing to
admit that each meant progress, and still I have
grown old enough to convince mj'self that neither
of the views mentioned contained the whole
truth. I have witnessed researches going far to
prove that it is mainly a combination of the pre-
vious views that makes us approach the truth. I
say approach, for there is no reason to deny that
coming decades will bring us forward still more
in our understanding of the intricate nature of
the process termed inflammation and suppuration.
During the past five j^ears bacteriology has held
swaj' of the minds of the majority of the pathol-
ogists, proving what was just stated. To-day no
one will be rash enough to neglect the influence
of bacteria in producing suppuration. And have
we not learned through excellent observers that
it is not the microorganisms themselves, but
rather their chemical products, the ptomaines,
that plaj' an important role in the causation of
suppuration and possibly of inflammation. I
here allude to the latest researches of Seber, of
Goettingen, who maintains that it is a ptomaine,
called by him phlogestein, that stands in causal
relation to inflammation.

The task I have undertaken is to bring before
you a review of the theories held in the last fifty
j'ears, closing mj' historical remarks with a de-
scription of what I consider to be the truth to-
daj'. The review of such a history is instructive
in many respects. It teaches us that none, be he
of the most gifted talent, is able to emancipate
himself from preconceived ideas and accepted
notions. It furthermore teaches us that we are
the subjects of general theories extant for the
time in which we make our investigations. It
teaches the great lesson of modesty and humility.
If a man of my age must confess in the seventh
decade of his career that he has been misled in
his younger days bj- books and teachers and must
tr>' hard to unlearn what he thought he knew be-
fore, it is certainly proof of human frailty, and
goes far to prove that we are obliged to consider
the truth to be truth only pro tempore, viz.: so
long as we do not know better. Our successors
will surely step over our shoulders and will esti-
mate our work onlj- by considering the amount
of time, honesty and acuteness of mind spent in
bringing forth new facts and new revelations.

In the fifth decade of our century humoral pa-
thology was thought to hold the full truth in the
explanation of inflammation. The older of us
will remember which facts the humoral pathologj-
was based upon. The web of the foot of a living
frog was expanded over a cork ring and the web
touched with an irritating agent, such as a drop-
let of ammonia, an acid, or with a pointed, red-hot
iron, and the subsequent changes observed under
the microscope with the comparatively low powers

1889.]

THE ORIGIN OF PUS.

371

at the disposal of investigators of the time. The}^
saw around the irritated portion of the web an
undulation of the currents of the blood within
the vessels, shorth' afterwards a slacking of the cur-
rent, and still later a standstill of the stream. The
last phenomena they called ' 'stasis, ' ' and this stasis
was thought to be the essential feature of the in-
flammatory process, Many and animated contro-
versies arose over the question, what is the stasis
due to ? Most obser\'ers agreed that a paralysis
of the capillar}' blood-vessels, after a few preced-
ing contractions, was to be considered the cause
of stagnation. At the same time an inundation
was seen to take place in the affected tissues with
a liquid which of necessitj- must have come from
the general blood column, and was termed " exu-
date." According to the nature of the exudate
different varieties of inflammation were set up,
such as the "serous," the "fibrinous," the
" albuminous," and should blood have been ad-
mixed with the exudate, the " hsemorrhagic. "
Corpuscular elements seen in the affected terri-
tories and apparently' suspended in the exudate
were thought to have originated from the exudate
itself, therefore the pus corpuscles would have
originated from the exudate, the latter from the
blood, hence the definition of pus, "dead blood."
No stress was laid upon the structural changes of
the affected tissue itself, except so far as the exu-
date saturating this tissue was concerned. The
ultimate cause of inflammation and suppuration
was sought in chemical mixtures of the blood,
termed dyscrasia, which means bad mixture of
the blood. If a person became affected with
lobar pneumonia the cause surely was surplus of
fibrin in the blood, or fibrinous dyscrasia. If a
person produced a number of abscesses in his or-
ganism the cause was denominated purulent d)'s-
crasia. All diseases were, in this d3'scrasic view,
essentially diseases of the blood. The blood in
its mixture caused the diseases simply by being
overloaded with obnoxious or effete material.

The man who dug the grave of humoral pa-
thology was Virchow, in the beginning of the
sixth decade of the present century. To him the
phenomena of alterations in the circulation of
the blood were of secondarj- importance. The
stasis he would not admit as a cardinal sj-mptom
of inflammation for it would mean rather death of
the ti.ssue, gangrene or necrosis. The exudate
also played but a secondary- role, serving onlj' as
a pabulum to the living corpuscular elements of
the tissues, the so-called cells. Inflammation was,
in Virchow's opinion, a structural change of the
affected tissue, mainly morphological changes of
the cells themselves. The cells being the seats of
life would attract and, as it were, imbibe the exu-
date, swell up, divide and come to a state of pro-
liferation, in which a number of cells would arise
from an original single cell, and the large number
of newly- formed cells would replace the intercelular

substance lost by liquefaction. A formation of cells
out of a previous liquid or semi-solid exudate was
declared to be impossible, since all newly-formed
cells must have arisen from preexisting cells. Dys-
crasias were done awa}' with. The main causes
of inflammation were peculiarities of the tissue
itself, and a certain weakness of the tissue was
proposed to explain the predisposition to inflam-
matory processes. The word suggested for this
supposed local weakness of the tissue was " dia-
thesis." If a man suffered from articular rheu-
matism the cause was said to be "rheumatic dia-
thesis." Tuberculous persons were predisposed
to cheesy degeneration simply because they were
afflicted with tuberculous diathesis. In the same
sense hsemorrhagic purulent diatheses were spoken
of. The pus corpuscles were without exception an
offspring of the previous cells of the ti.ssue, and
in this sense pus was considered dead tissue.
Cellular pathology has made a verj' strong impres-
sion on the minds of observers. Even the stalwart
humoral pathologist Rokitansky yielded to the
novel views and accepted the doctrine that no cell
will grow in an exudate unless previous cells be
there. Cellular pathology even in our day gov-
erns the minds of most pathologists over the civ-
ilized world. Proliferation of the cells accounts
for all tissue changes, either newly-formative, the
so-called hyperplasia, or destructive, that is, sup-
puration. Proliferated cells being present in
either of these instances, cellular pathology is at
a loss to explain why a certain tissue, owing to
proliferation of its cells, becomes augmented and
hyperplastic in one instance and is destroyed by
suppuration in the other. Still, in spite of all
weaknesses of this doctrine, we must consider it
an advance in comparison with the teachings of
humoral pathology. The cell being supposed to
be the only center of life, inflammation and sup-
puration were for the first time considered as the
phenomena of life, and the idea began to dawn
in the minds of pathologists that inflammation
and suppuration were morbid processes occurring
in tissue elements endowed with life, the so-called
cells.

The third period arose in the middle of the
seventh decade of our centurj', when Cohnheim
observed a migration of colorless blood-corpuscles
through the walls of the capillaries and small
veins of an exposed and expanded mesentery of
a frog. Several years before S. Strieker, in \'ienna,
obser\'ed the red corpuscles pass through the
walls of the capillaries of the nictiant membranes
of the live frog, so-called diepiesis. Even in
1848 the emigration of leucocytes had been seen
in England by Walker and Wallace. The facility
with which the emigration of leucocytes could be
seen under the microscope has induced many
German pathologists to accept the view of Cohn-
heim, that inflammation and suppuration are but
an emigration of colorless blood-corpuscles.

372

THE ORIGIN OF PUS.

[September 7,

These accumulating in a tissue whose cells would
remain inert and whose intercellular substance
would become liquefied and destroyed, furnish a
representation of both inflammation and suppur-
ation. With this view there was nothing aliv^e
in the body but the leucocytes. At first Cohn-
heim denied the participation of the so-called
stable cells in the process of inflammation, but
later he admitted that in reparative inflammation
the tissue cells do proliferate and furnish their
share for the benefit of newly-forming tissue, ex-
actly in the sense of cellular pathology. That
pus corpuscles should be emigrated colorless
blood- corpuscles was intelligible, as were isolated
corpuscles nearl}' identical in appearance. How
new tissue could form from leucocytes remained
a deeply-shrouded mysterj', as no observation has
as yet proved that through coalescence of leuco-
cytes new protoplasmic masses and new tissues
can arise. The observation of Zeigler, of Tiibin-
gen, that multinuclear bodies, so-called giant
cells, are invisible between thin glass plates intro-
duced under the skin of an animal lacks the proof
that such giant-cells arose b}' coalescence of leu-
cocytes. On the contrarj-, later observations
made especially upon deciduous, replanted and
implanted teeth, go far in proving the giant-cells
to be an oSspring of the myxomatous granulation
tissue, sprouting in all directions, filling the bay-
like excavations on the deciduous and other teeth
and carrying blood-vessels into places where there
had been none before, leading to the vasculariza-
tion of a new tissue, seen, for instance, in sponge
grafting.

S. Strieker immediately sought to overthrow
the teachings of Cohnheim. In his investigations
he used almost exclusively the cornea (chiefl}- of
frogs, cats and rabbits); in which he brought in-
flammation by introducing a thread. The changes
were faithfully watched up to the formation of
abscess around the foreign body. The observa-
tions enabled him to prove the established views
of cellular pathology to be correct, namely, that
these so-called cells divide and subdivide, but
also that the coarser offshoots of the cornea cor-
puscles split up, and by division produce new cor-
puscular elements. Strieker also held, up to 1874,
(Ashurst's International Surgical Cyclopaedia),
that pus corpuscles were products of proliferation
of the cornea corpuscles and their coarser oflf-
shoots. Unfortunately he calls all the products
of cells originating from proliferation of previous
cells pus corpuscles. Indeed it was impossible to
di.scriminate between inflammatory corpuscles
and pus corpuscles, since all of these appeared
isolated under the microscope. Clinically it is
well established that every inflammation does not
terminate in suppuration. Particularly do we
know of a termination which instead of causuig
destruction of an affected tissue, as suppuration
does, brings about a new formation, an increase

of the bulk of the tissue, the so-called hyper-
plasia. How shall we explain such marked
differences by the theor)' of cellular pathology,
which claims all corpuscular elements are isolated
from the start? However, since 1880 Strieker is
a convert to the views of C. Heitzmann, estab-
lished in 1873, which doctrine I advocate, having
studied specimens, illustrative of inflammation
and suppuration, under the microscope in that
investigator's laboratory'.

Let us recapitulate in a concise way the views
held by the said C. Heitzmann concerning the
normal or physiological structure of tissue. He
holds that there is no isolated or individual cell
in any variety of tissue in either the anjmal or
vegetable organism. Such individual corpuscleg
are met with only in the fluids of the body, such as
the blood, where they are named red corpuscles ; iq
the lymph, called lymph corpuscles ; in the
saliva, called salivar}- corpuscles : in the sperujj
called spermatazoids, etc. Neither the bloo.4 Hox-
the lymph, nor anj- of the fluid, semi-so^it^ secrer
tions deserve the name of a tissue. Tissue w§
call a continuity of not only orgapized materialj
but a materia! endowed with all the properties of
life, such as mobilit}^ and the capa.city of repro-.
duction. Tissues hold at certain inter\-als proto-
plasmic bodies, so-called cells, the vast majority
of which are in continuity with the living matter
held bj' those substances, previousl}- termed "interr
cellular" and to-daj' they are known by the names,
of basis and cement substance The greatest
amount of living matter is present in the center^
of protoplasmic bodies, wliere they appear ag
nuclei and nucleoli. The surrounding protoplasm,
in full development, holds the living matter in a
reticular arrangement and s\ich a reticulum i§
traceable throughout the surrounding basis sub-
stance, hitherto considered as entirel}- inert.
Thus an uninterrupted connection is established
from one ' ' cell ' ' to another by the iuter\'eniug
bridges of living matter. This same arrangement
being present throughout all tissues of the ani-
mal organism, a continuity of all the tissues com-
posing such organism is established. Recent
researches of botanists go far to prove that even ii]
the plants there exist no individual cells, but the
intervening cement substance, or cellulose, i§
traversed by minute bridges of living matter,
rendering the plant an individual from the tips of
the leaves to sporacles of the rootlets. Recent
observers in animal and vegetable microscopy
have drawn attention to the fact that by means of
certain reagents the nucleus will be split up into
loop-like threads, a process which they consider
precedes the division of the nucleus and indirect
division of the protoplasm. This process is
termed karyokinesis, or mitosis — -"fibrillation,"
" thread making." This observation is had only
with certain reagents and is not visible in the
fresh specimen or in one preserved in a chromic

1889.

THE ORIGIN OF PUS.

373

acid solution. Suspicion naturally arises that
the loop-like figures of the nucleus are artificially
produced and thereby their connections are ren-
dered invisible. The threads forming loops are
called "chromatin," because readily stained by
analine dyes, whereas the inter\'ening substance
and the protoplasm itself stain but little, and
therefore are "acromatin." Facts rendered con-
spicuous by staining appliances only are of doubt-
ful correctness. The fact that there are threads
and loops in the star-point form arrangement in the
nucleus rather proves the latter to be made up
largely of living matter, which is known to
change shape any moment. Coarse formations of
living matter readily stain with analine dj'es,
whereas delicate formations of the same substance
will not stain. The connections between the
loops of the nucleus and the surrounding radi-
ating reticulum of the protoplasm are plainly
visible in fresh specimens, and also those preserved
in liquids which we know will not alter the struc-
ture of protoplasm, such as a solution of chromic
acid of one-tenth to one-half of i per cent. Al-
cohol as a preserving fluid is far inferior, owing to
the shrinkage it efiects.

Let us analyze the construction of dentine
(most important to dentists, since it builds up the
main mass of the tooth) in the light of this novel
doctrine, for which the late Louis Elsberg, one of
its most enthusiastic advocates, suggested the term
bioplasson theory. Dentine has no cells, but is
composed of a dense, firm basis substance (not
cartilaginous as formerly thought but glue yield-
ing, similar to that of bone tissue) thoroughly
infiltrated with lime salts. This basis substance
is traversed by the canaliculi which radiate from
the surface, occluding the pulp chamber toward
and join the cement and enamel. Each canaliculus
holds in it a delicate fibril, the so-called Tomes
fibre, around which exists a minute space filled
with a liquid, obviously the carrier of nutrient
and denutrient substance. Fine thorn-like off-
shoots were known, especially in transverse sec-
tions of dentine, to emanate from the fibril, tra-
verse the surrounding space and fade ijpon ap-
proaching the wall of the canaliculus. Now in the
light of the bioplasson doctrine the Tomes fibres
are formations of living matter. From them
arise transverse conical ofi^hoots penetrating the
walls of the canaliculi and in connection with a
delicate, nearly rectangular reticulum traverse the
whole of the basis substance and connect the
tenant of one canaliculus with the neighboring
tenants directly, and therefore all the others indi-
rectly. The presence of this reticulum was first
established by C. F. W. Bodecker, in 1878, who
saw light rents in the basis substance and assumed
them to hold living matter without being able to
directly prove its presence.

This proof has been quite recently furnished by
Wm. Carr, who after decalcification of the dentine

by means of a 6 per cent, solution of acetic acid
rendered the reticulum visible by staining with a
chloride of gold solution, and also osmic acid.
These last results have not as yet been published
by their obser\-er. I have seen his own specimens
through lenses of i,ooo to 1,200 diameters with
good immersion, and am convinced of the pres-
ence of the reticulum throughout the dentine.

Thus we understand how dentine can grow and
be nourished, and realize it is a tissue endowed
with sensibility prominently at those places which
abound with living matter, such as the periphery
toward the enamel and the cementum at the neck
of the tooth. Therefore we can appreciate that
living dentine, if irritated by a foreign body, such
as a mass of gold filling, or chemically by acids,
will react upon this injury, become inflamed and
produce a new tissue, called osteo-dentine, which
sometimes is more compact than the original.
This process of the inflammation of the dentine,
called " ebuniitis," was carefully studied by Dr.
Bodecker a few years ago, and although he has
not 5-et completed his studies upon teeth which
had been filled with different materials for months
and years, every intelligent dentist knows that
such a reaction exists. This fact is utilized by
all of us in introducing highly-irritant agents,
such as oxyphoshate of zinc, into otherwise
poorly calcified, so-called soft, teeth. The result
after some months is a compact wall of the cavity
made up of osteo-dentine, or secondary dentine,
and better fitted to tolerate a gold filling than it
was before this temporary' filling. How can we
understand these changes aud the toleration of
highly conductive filling, unless the tooth sub- •
stance be a veritable living tissue throughout its
extent ? Whenever irritation is brought to bear
upon a living tissue reaction will follow, and this
is inflammatory process. The first that occurs i.s
liquefaction of the basis — or cement — substance,
probably induced bj- the presence of an acid,
mainly lactic, thus the living matter previously
concealed (held) in the basis — or cement — sub-
stance becomes liberated and the protoplasmic
form of the basis substance reappears. This con-
dition has directly been observed by S. Strieker
on the cornea of frogs, as before stated. He saw
the basis substance in motion, changing the
configuration of its living matter, under the mi-
croscope, much like clouds changing on the face
of the skj'. Next the protoplasm furnishing the
substratum of previous basis substance becomes
split up into small bodies, known as medullar^', or
embrj'onal, or inflammatory corpuscles. Any
portion of living matter of .such indifferent bodies
ma}' grow to the size of a nucleus, owing to the
presence of an excess of pabulum beyond the
physiological requirements of these bodies, an ex-
cess essential to the inflammation. Not only the
original "cells," but the inter\'ening basis sub-
stance will participate in the formation of new

374

THE ORIGIN OF PUS.

[September 14,

elements or inflammaton- corpuscles. Here is the
distinguishing feature between modern and an-
tique pathological views, for according to the
latter only the "cells" themselves were consid-
ered active and capable of proliferation. The
sum total of the newly-formed inflammatory
corpuscles is known under the term inflammatory
infiltration, which means that a certain amount of
a tissue, be it connective, muscular or ner\-e
tissue, is replaced by and transformed into
newly-appearing protoplasmic bodies in the
stage' of indifference, that is, being purely proto-
plasmic tissue bodies without any distinctive
character either as to origin or destiny. So
long as the inflammaton,- corpuscles remain in
continuity by their delicate offshoots they repre-
sent a tissue, though in a condition of indiffer-
ence, or embr\-onal state. Such a tissue by new
formation of a basis substance will either return
to the previous normal state, terminating the
inflammator3- condition in "resolution," or, being
considerably augmented itself, Will produce a
tissue much greater in bulk than the one origi-
nally inflamed and we will have hyperplasia. In
neither instance will the inflamed tissue cease even
for a moment to be tissue. The tissue which is the
bearer of the blood and lymph vessels is the con-
nective tissue, and connective tissue is the only
bearer of these vessels. And here is the starting
point of inflammation in almost ever3- instance.
This we understand from the fact of the rather
low dignity and activity of the connective tissue.
We look for the greatest reaction on irritation at
the sources of nutrition, obviously the blood-
vessels. Muscle, ner\'e and epithelial tissue react
in rather a secondarj- manner on inflammation of
connective tissue. Virchow proposed the name
"parenchymatous inflammation," for the desig-
nation of the inflammator}' process, which term
may be retained if restricted always to a secondarj-
manifestation upon the primarj- inflammation of
the "interstitial" connective tissue. A gland, for
instance, is a compound organ composed of par-
enchyma according to Virchow, which is the
epithelial glandular tissue. This is surrounded
with and accompanied by connective tissue bear-
ing many blood-vessels. It is impossible that the
glandular tissue could be the primary- seat of the
inflammatorj' process. This process will be
present in the connective tissue first and more or
less rapidly invade the glandular epithelial tissue.
If the connections of the inflammatorj- corpuscles
be severed we shall have a certain number of i.so-
lated medullary or embrj-onal corpuscles suspend-
ed in an albuminous liquid.

Pus is therefore the resultant of destroyed tissue,
but quite unfit for the production of any form of
tissue. How much the emigrated blood corpus-
cles contribute to the formation of pus may not
yet be positively stated. However, we do know
positively that upon the approach of suppuration

in a certain tissue its blood-vessels are destroyed
without exception in the territory involved. The
blood-vessels, by outgrowth of their endothelia,
become at first solidified and afterwards split up
into medullary and pus corpuscles, the same as
all the other elemental constituents. Even the
smooth muscles of an arter}' will partake in this
pus-forming process. The amount of migrated
leucoc}'tes cannot be great, considering the loss
of the vessels which have supplied them. Pus
is destroj-ed tissue, first originating in a closed
cavity bearing the name of ' 'abscess, "or, secondly,
coming from the walls of physiologically shut
cavities, termed "empyema," or, thirdlj', spring-
ing from exposed tissue surfaces, viz., such as
granulating surfaces of wounds, termed ' ' pyor-
rhoea." In the two latter instances, namely,
empyema and p5-orrhoea, the emigration of color-
less blood corpuscles plays a far more important
role than in the case of ' ' abscess. ' ' In granu-
lating surfaces of wounds, especiallj-, the source
of the pus corpuscles must be sought mainl}- in
the capillaries, which abound in the myxomatous
granulation tissue, producing loops therein, upon
the grouping of which depends the raspberry
look of the so-called " proud flesh." Around an
abscess a dense laj'er of fibrous connective tissue
is formed verj' soon — beautifuUj^ displayed in
alveolar abscess at the apices of diseased roots of
the teeth. This newlj-- formed layer represents
the productive activity of inflammation, being
h3-perplastic, fibrous connective tissue, more or
less well supplied with blood-vessels. Old pathol-
ogists termed this layer " membrana pyogena,"
which signifies that the membrane itself produces
the pus. This view was abandoned long since,
and to-day the membrana pyogena is known to
be a secondary,' formation in the appearance of an
abscess, as it were, a protective wall to the healthy
tissues. After the evacuation of the pus from an
abscess or an empyema, either bj^ spontaneous
rupture of the covering layer toward the surface,
or artificially by knife or caustic, the membrana
pyogena changes its character and becomes the
seat of an acute inflammation, which leads to the
formation of a freely-vascularized myxomatous
tissue. This is what is called " proud flesh," or
granulation tissue. In all instances in loss of
tissue by suppuration the final result is the for-
mation of a scar. This consists of a dense fibrous
connective tissue whose bundles freely interlace
and which is, as a rule, scantily supplied with
blood-ves.seIs. It is an outcome of myxomatous
granulation tissue and is covered with epithelium
whenever the pus has been discharged through
the skin or a mucous membrane, which them-
selves appear in a normal condition with an epi-
thelial layer.

Pus, therefore, is a tissue disintegrated and
broken up into indifferent or medullary corpus-
cles which are suspended in a liquid more or less

1889.]

THE ORIGIN OF PUS.

375

rich in albumen. How much the emigrated leu-
cocytes share in the formation of pus corpuscles
may not be determined. The pus corpuscles re-
main alive as long as the liquid surrounding them
is sufiBcient for the support of their nutrition.
Even fatty degeneration of the pus corpuscles, as
seen in chronic abscesses, will not altogether de-
prive them of their vital phenomena, such corpus-
cles, if transferred upon a slide, remain amceboid,
and thej' die only by exposure to a low tempera-
ture, or after the addition of chemical reagents,
or within the body by being deprived of their
nourishing liquid. The last condition is noticed
in cheesy degeneration of the pus so often met
with in tuberculosis. A question now arises.
What is the cau'se of the formation of pus ? Ever
since the famous experiments of Cohnheim and
Counselraan, who introduced vials filled with
croton oil under the skin of rabbits, with anti-
septic precautions, and after healing was complete
cracked the vials, subcutaneously, thus producing
an abscess, this is a much mooted question. A
host of experimenters who have repeated these
trials have taken views pro and con of the ques-
tion. I consider the experiments of P. Grawitz
and W. de Bary, published in Virchow's Archives,
1887, the most valuable testimony towards set-
tling this question. They found that the subcu-
taneous injection of concentrated solution of
chloride of sodium in rabbits and dogs was fol-
lowed by oedema, a swelling of the facia, but no
suppuration. It makes no difference whether the
solution be mixed with a large number of staphy-
lococci. Staphylococcus, with its three varieties,
the staphylococcus pj'Ogenes, aureo-albus and
citreous, first discovered by Rozenbach, was
thought to be essential to the production of pus.
And even H. Knapp, of New York, maintained
that a small quantity of Croton oil mixed with
olive oil will not produce suppuration if intro-
duced into the anterior chamber of the eye of the
rabbit, whereas the same mixture if contaminated ;
with pure culture of staphylococcus aureus will
invariably be followed by suppuration under like
circumstances. Grawitz and de Bary, on the con-
trarj-, have proven that not only the coccus named,
but certain irritating reagents and different pro-
ducts of microorganisms, not necessarily the
staphj'lococcus, different alkoloids, or ptomaines,
are productive of pus. Solutions of nitrate of
silver, if injected under the skin of dogs, rabbits,
rats and mice, will be harmless if weak, not
stronger than .005 of i per cent., but when 5 per
cent, in strength v.'ill invariably be followed bj'
abscess in dogs. Neither acids nor alkalies cause
suppuration, except the liquor of caustic ammonia,
which if introduced in full strength is followed in-
variably by suppuration. In neither of these in-
stances were there anj- microorganisms discover-
able in the pus freshly removed from the abscess,
or transferred upon nutritive gelatine as a culture

medium. Oil of turpentine in rabbits and guinea
pigs did not induce pus, even though injected in
large quantities, but onlj- inflammation ; whereas
in dogs oil of turpentine, which is a strong germ-
icide, after subcutaneous injection was always
followed b}' suppuration.

From these experiments it follows that chemi-
cal substances entirel}' free from bacteria and
cocci tend to induce the suppurative process in
different animals. On the other hand it was ex-
perimentall3' proven that in dogs and rabbits the
injection of cultures of staphylococcus into the
normal subcutaneous tissues will not induce in-
flammation or suppuration. It is necessary that
a tissue first be irritated to a condition of inflam-
mation, by traumatism or by chemical irritants,
to have a soil favorable for the development of
staphylococcus, which under these circumstances
will produce an abscess. Lately P. Grawitz has
shown that the subcutaneous injection of a pto-
maine derived from putrescent organic material,
called cadaverine, will always lead to the forma-
tion of an abscess. From the practical stand-
point it is of the utmost importance to work
aseptically, or in other words, with such degree
of cleanliness that the introduction of micro-
organisms or their ptomaines becomes impossible.
It is well established that even open fresh wounds
if aseptically dressed with gauze saturated with
a i:iooo solution of corrosive sublimate and left
alone for a few weeks will kindly heal without
one single droplet of pus. Corrosive sublimate
and carbolic acid are still most reliable germicides.
We are not 3'et prepared to assert that micro-
organisms alone cause suppuration, since there
are irritating chemical substances whose intro-
duction into the body may likewise be followed
by this process. Recent observers have main-
tained that there is a marked difierence between
a mere accumulation of leucocytes and an abscess
proper. In the first instance there may be present
a serous or fibrinous exudate entangled with a
number of emigrated leucocytes, without a loss
of tissue, without, therefore, suppuration. In the
latter instance a certain amount of tissue is de-
stroyed and directly transformed into pus. If
this view be correct, it certainly stronglj' supports
our present notions of the process of suppuration
herewith laid before j'ou in this resume of my
paper.

1. Inflammation is a disturbance of nutrition
of a tissue causing a recurrence of the embryonal
condition of the tissue involved.

2. The embr}-onal condition is established bj^
the breaking up of the tissue into those medullary
or indifferent corpuscles which, at an earl\- stage
of normal development, have built up the tissue.

3. The medullary corpuscles arise not only
from the protoplasmic bodies of the tissue, the
so-called "cells," but also the intercellular or
basis substance is productive of such corpuscles,

376

CLIMATE OF SOUTHERN ALBERTA.

[September 14,

as these have shared in the formation of basis
substance in the process of normal development.

4. The medullary or indifferent corpuscles will
still represent a tissue so long as they remain in-
terconnected and continuous. B}- a simple reap-
pearance of basis substance the most favorable
termination is established, so-called " resolution." \

5. If the inflammatorj' or medullary corpuscles
have largely augmented, a number thereby re- !
maining in original connection, the result will be !
productive, viz.: with a newly formed tissue of
increased size, a so-called "hyperplasia."

6. If the inflammatory corpuscles springing from
previous ' ' cells, ' ' basis substance and blood-ves-
sels break asunder and become isolated, they will
be suspended in an albuminous liquid, they will
henceforth represent pus corpuscles.

7. Pus, therefore, is a destroyed tissue broken
up into its cortstituent elements, and as such unfit
for production of a new tissue, although the sin-
gle pus corpuscle will remain alive and amoeboid
almost indefinitely as long as they are sufiBcientlj-
nourished.

8. The emigration of colorless blood corpuscles
certainl}^ participates in the formation of pus and
in the purulent discharge of proud flesh or gran-
ulation tissue, and is probablj- the main source of!
the pus,

9. Suppuration is caused bj- the presence of
certain microbes, mainly the three varieties of
staphylococcus, only when a previous inflamma-
tion be present in the tissue, furnishing a favorable
soil for the development of the before mentioned
microbes.

ID. Staphylococcus is not the only antecedent
of suppuration, it having been proved b}- experi-
ments that the introduction of certain chemical
agents, unfavorable to the development of mi-
crobes, may likewise be followed by suppuration.

THE CLIMATE OF SOUTHERN ALBERTA

AND ITS RELATION TO HEALTH

AND DISEASE.

Abstract of a Paper read at the Annual Meeting of the Canada Medi-
cal Association, Banff, Alberta, August 16, rS8g,

BY G. A. KENNEDY, M.D.,

OF MACLEOn, CANAn.\.

It appears to me that no apology is necessary
in introducing the subject of this paper. It is
only a few years since the opening of our great
National highway brought the Northwe.st Terri-
tories into touch with the rest of the world ; and
only a few yea.TS further back since these vast i
plains and mouiitains, which are now so quickly
becoming the homes of civilized man, were re- \
garded as an inhospitable desert, fit only for tlje i
buffaloes which roamed their solitudes and the
Indians subsisting on the cha.se. The past five
years have been epoch-making so far as our great i

West is concerned. Coincident with, and follow-
ing on the building of the Canadian Pacific Rail-
way, a flood of light began to illumine the Eastern
intelligence, and as a consequence .settlement has
steadilj- and in a gradually increasing stream
poured into the Territories.

It will be readih- understood that a country
almost equal in area to Russia must have many
diversities of climate. As I cannot undertake to
speak for the whole of the Northwest, I have lim-
ited mV remarks to that part with which I am
best acquainted, viz. : that strip of countn,- h'ing
along the eastern base of the mountains, and more
particularly the southern part of this — bounded,
sa}', on the north by the C. P. Ry. I make the
eastern limit a line drawn north and south through
Letheridge, although for all practical purposes this
line can be extended as far east as Medicine Hat.
On the south is the International boundary line,
and to the west the summit line of the Rockies
and British Columbia. This Southern Alberta
comprises an area of 150 miles square, of moun-
tains, foothills and prairie. It is intersected everj-
few miles by mountain streams as j-et unpolluted
by the filth and garbage of more thickly settled
communities. Its general character is treeless
save along the valleys of these streams, which
are fringed bj- the willow and Cottonwood, and
on the sides and bases of the mountains. To the
outside world this is known as Canada's grazing
country, whence England will draw a large part
of its future beef supply. As a sort of corollary-
to this, it has also been known in a general way
that it was reputed to have a milder climate than
the rest of the Northwest Territories, To most
of you the following description will be not only
interesting but necessary to a proper understand-
ing of what follows. It is taken from an admir-
able paper by Mr. C. C. McCaul, of Letheridge,
published in the August number of the Aiiiciiaxn
Meteorological Rcvic'n'. After noticing that winter
only really sets in about the middle of December,
he goes on to say :

It is characterized by a maximum of bright,
still, cloudless days, a scantj- snow fall, and fre-
quent and prolonged breaks of warm weather,
heralded by the Chinook wind, of which more
hereafter. Occasionally a bad snow storm will
cover the prairie and hill to a depth of 18 or 20
inches. This, however, is very exceptional. The
winter generalh- breaks up in Fel)ruar\- by a grand
blow from the west, followed by a period of from
one to three weeks of warm, bright weather, which
may fairly be called the beginning of spring.
Spring, here as elsewhere, is the most variable
and capricious sea.son of the year. On the whole
it may, perhaps, be described as cold and damp,
with frequent rainfalls, varied by bursts of the
most gloriously bright warm weather, lasting
sometimes a fortnight or three weeks.

May is generally fine, warm and bright ; June

1889.3

CLIMATE OF SOUTHERN ALBERTA.

377

and the earlier part of July rainy ; the remainder
of July, August, September, October, and gener-
all}' November, warm and very dr}'. The sum-
mer, July to September, is characterized by hot
days and cool nights, with very little rain, but
the warm, lazy daj-s of autumn, often lasting well
into December, are the glory of the year.

The grand characteristic of the climate as a
whole, that on which the weather hinges, is the
Chinook wind. It blows from west to southwest,
in varying degrees of strength, from the gentle
breeze that just tosses the heads of the daisies
and sunflowers, to the howling gale that carries
off contributions of chimneys, barrels, shingles,
hats, and miscellaneous rubbish to our neighbors
in Assinaboia. In winter, the wind is distinctly
warm ; in summer not so distinctly cool. Its ap-
proach is heralded bj- the massing of dark cumu-
lus clouds about the mountain tops, and a distant
wailing and rumbling from the passes and gorges.
Its effect in winter is little short of miraculous.
When a real Chinook blows, the thermometer
often rises in a few hours from 20° below to 40°
above zero ; the snow, which in the morning may
have been a foot deep, disappears before night ;
ever^'thing is dripping ; but before another night
falls all the water is lapped up by the thirsty wind,
and the prairie is so dry that a horse's hoofs hardly
make an impression upon it as you take j'our first
welcome canter, after a prolonged and tedious spell
of " settin' round the stove."

It may be added to this that the elevation above
sea level of the plains here varies from 2,700 feet
at Letheridge to 4,500 feet at the entrance of the
Crow's Nest Pass, which may be taken as the
base of the mountains proper.

The winter and early spring are characterized
by the coughs and colds incident to these seasons
in almost any country'. Summer is very healthj%
and in autumn there are occasional cases of ma-
larial fever of a remittent type, of which more
hereafter.

Rheumatism is remarkably rare when one con-
siders the sudden changes of temperature that
often occur and the fact that most of the male
population have led lives of the greatest exposure.
When it docs occur, it is almost always in the
subacute or chronic form. Affections of the lungs
are also verj' infrequent.

Summer disorders are almost unknown, a fact
which must be attributed partly to the sparseness
of population, but which is largely due, in my
opinion, to the cool nights. About ner\'ous af-
fections I am hardly in a position to speak, but I
judge that the rarefied air and the sometimes high
winds would not be beneficial. During the past
four years I have had three cases of paralysis —
hemiplegia, occurring in patients otherwise per-
fectly healthy, cowboys in the prime and vigor of
manhood, who have had no specific disease and
were quite temperate, and whose family history

the most careful inquiry found irreproachable.
These cases were and are a puzzle to me, and I
can imagine no cause but excessive riding.

I have alluded to the existence of an endemic
malarial fever occurring principally in the fall.
This is general throughout the territories, and
has given rise to much comment and some differ-
ence of opinion among medical men. Its charac-
ter is variously modified by the season, climate,
soil and immediate surroundings of the locality
in which it is present. It has been called remit-
tent, intermittent, malarial, typho-malarial, and
typhoid according as a certain set of symptoms
predominated, and is known throughout all the
West by laymen as ' ' mountain fever. ' ' I have
seen this fever at its highest, characterized by a
chill and symptoms of a heavy cold, and broken
up at once by free diaphoresis and a dose of qui-
nine. On the other hand, I have attended cases
in which all treatment was of no avail, cases badly
affected by environment, that would go on from
bad to worse until they would sink into the ty-
phoid state — too often only the beginning of the
end. Between these extremes all grades of sever-
ity are met with — their most general characteristic
being, however, their atypical character. Routine
treatment is therefore impossible except, perhaps,
at the beginning, when I make it a rule to relieve
the bowels by a calomel purge, promote free dia-
phoresis by pulv. ipecac co. or antipyrin, some-
times a combination of the two, and give two or
three large doses of quinine. Subsequent treat-
ment on general principles.

I have alluded to the different names by which
this fever has been called and the consequent con-
fusion. The cause of this is the tendenc)' to re-
gard it as a distinct tj'pical disease, ivhich it is not.
The cause may be the same (no one, I believe,
has ever questioned its malarial nature) ; but the
variations in the course, symptoms and severity
are important enough to entitle them to be called
almost distinct types. These variations are due
to locality, to the season, to different conditions
of soil, climate, atmospheric moisture, etc., and
to the individual. Another cause of the confu-
sion has been the occasional occurrence of typhoid
fever and the incautious use of the mifortunate
term "typho-malarial." I say unfortunate be-
cause I believe that from the time of its coinage
in 1 86 1 -2, it has never ceased to be a cloak for
uncertainty, an unknown quantity in statistics,
and an added difficulty to the struggling and in-
experienced practitioner. It would be a good
thing, in my opinion, if it were expunged from
the nomenclature of disease ; for, notwithstanding
the care that was exercised in its definition by the
U. S. Commission, wherein it was distinctly point-
ed out that it was " not a specific or distinct tj-pe
of disease, but a term conveniently applied to the
compound forms of fever which result from the
combined influences of the causes of the malari-

378

CLIMATE OF SOUTHERN ALBERTA.

[September 14,

rious fevers and t3'plioid fever, ' ' there has been a
tendency to elevate it into a distinct type of dis-
ease. In the Northwest, while I have often seen
severe cases of malarial remittent falling into
the typhoid state and cases of t3-phoid masked
at first by malaria ; while I confess I have been
sometimes at a loss at first to classify my case, I
can hardly recall an instance in which waiting a
few daj's did not clear up the diagnosis.

In 1886 I made an attempt to have collected
detailed reports of all cases of fever occurring
throughout the Northwest, so that the special
features of each district might become better
known. This attempt was frustrated through
ignorance or misapprehension of my taiotive. It
is a matter of regret to me that mj^ suggestions
were not adopted, for I am not one of those who
believe that we have reached the sum possible of
attainable knowledge with regard to malaria. We
owe much to the researches of Thomanasi, Crude-
11 and Klebs, Laveran, Osier and Carter, in trac-
ing out the life historj' in the blood of the mala-
rial plasmoduino. But I believe the future has
still something to unfold to us of its nature, mode
of action outside of, and entrance into the human
S3'stem. And I believe we have j'et much to
learn of the relations between the paludal and
typhoid poisons. I find it difficult to believe the
story of the statistics which tells us that typhoid
fever pure and simple is three, four and five times
more fatal than the same fever complicated with
malaria, and I believe that more care in the diag-
nosis, which is now rendered somewhat easier by
the application of Ehrlich's test ; more thorough-
ness in the recording of cases, and more attention
to etiology, will help us to clear up these doubt-
ful points which few will question are stumbling-
blocks in our path.

I trust that I have not been misunderstood —
that while remarking on this fever at greater
length, perhaps, than its importance warrants, I
have not led you to the belief that it is a constant
menace to life .and health in Southern Alberta. I
should be sorrj- to have made this impression,
which would be an entirely false one. Some
years the countrj' is entirely free from fever ; and
generally it is mild and readih' amenable to treat-
ment. And severe cases will no doubt become
rarer when greater care is exercised in personal
and domestic sanitation.

I believe I have now said the worst that can be
said of the climate of Southern Alberta, and I
consider that in doing so I have earned the right
to dwell briefly on what appears to me its dis-
tinguishing characteristic. I allude to its free-
dom from diseases of the lungs and its value as a
resort or place of living for phthisical patients. I
have already spoken of the rarity of pneumonia
and other lung affections. I know of two cases
of phthisis occurring in the country — one of acute
tuberculosis strongly hereditary, and which proved 1

fatal, and another of fibroid, the cause of which
I believe to be the fine dust of the corral acting
in the same manner as stone mason's and knife
grinder's disease. This latter steadily- improved
on ceasing work and is now almost well.

On the other hand. I have known of a great
many cases of incipient phthisis that have come to
Alberta, and in some the disease has been arrested
and in others the sufferer restored to perfect health.
These facts will not appear strange when the
prevailing conditions are considered ; for, accord-
ing to the latest consensus of opinion among cli-
matologists, the climatic treatment of phthisis re-
quires :

1. A dry aseptic atmosphere.

2. A dry soil.

3. The greatest possible number of clear, sun-
shinj' days during which the invalid can exercise
in the open air.

4. A certain amount or degree of elevation
above sea level. Equability of temperature with-
in certain limits is not now considered necessary.

I believe I may a.ssert without danger of con-
tradiction that Southern Alberta possesses all
these requisites in the most eminent degree. The
dryness of the atmosphere is insured bv the char-
acter of the country, a great grassy, undulating,
treeless plain, elevated from 2,000 to 5,000 feet
above sea level and distant several hundreds of
miles from any considerable bod}- of water. Ac-
curate meteorological data are wanting, but it is
sufficient to sa}' that Alberta is not different from
that whole strip of countrs- lying at the eastern
base of the continental watershed, and which the
absence of a sufficient rainfall has caused to be
devoted principally to the raising of stock. This
dr>-ness of the air, combined with its elevation,
almost necessarily renders it aseptic in a wonder-
ful degree.

Elevation is not now considered an essential
feature in the climatic treatment of phthisis, The
altitude theory, which Miguel did so much to
bring into favor and which was so great an ad-
vance on the indiscriminate employment of places
like Madeira and Havana — places where warmth
and equability of temperature and a certain degree
of moisture were prevailing features — is now slow-
ly going out of fashion. But it is doubtful if even
the immense power of fashion — which, it is to be
deplored, is almost as great in medicine as in mil-
liner}'— will ever be able to seriously affect in the
medical mind the value of elevation. The reason
it is not so much considered now is that it was
found that the curative properties were the drj--
ne.ss and purity of the air, and not nece.ssarily the
elevation. But it is difficult, almost impossible,
to find a dry aseptic atmosphere' without the ele-
vation being near .sea level, and for this reason,
if for no other, patients in search of a climate will
still throng to the elevated regions. Besides, the

' Kxcepting .\iken, Georgia.

1889.]

MEDICAL PROGRESS.

379

other ph5'siological effects of elevation ; the in-
creased respirator}- activity and expansion of the
lungs and chest walls, the consequent increased
nutrition, the cool nights, almost compelling
sound and refreshing sleep, are features of no lit-
tle value in the altitude treatment. As before
mentioned, the elevation in Southern Alberta va-
ries from 2,000 to 5,000 feet, and the patient can
therefore choose the locality which seems to suit
best his particular case.

Laennec, Bowditch, Buchanan and others hav-
ing made it very clear that soil moisture is one of
the chief causes of phthisis, a dry soil must be
considered a necessity for am- place putting forth
claims to be regarded as a resort or place of living
for consumptives. While I am not able to give
the geological formation of Southern Alberta, I
can assert without fear of contradiction that its
soil must be regarded as preeminently a dry one.

Perhaps a more important point than anj- of the
foregoing — certainly a most necessarj' one — is the
number of days during which patients can take
exercise in the open air. Here the want of mete-
orological observations is again severelj^ felt, but
from a private record kept during the five 5'ears
ending December, 1888, I am able to deduce the
following : The number of days which are re-
corded as overcast, raining and snowing is respec-
tively 51, 49, 56, 53, 44, being an average of a
fraction over 50, all the rest being noted as fine.
Over 50 per cent, of these (fifty) are simply over-
cast, so it is fairly presumable that in the large
majority of them, confinement to the house would
be unnecessary. These observations, moreover,
were taken very close to the mountains, where
local storms are more prevalent than on the plains.

As to the class of cases for which Southern Al-
berta is suitable I am content to take Dr. Knight's
selection, which is, I believe, approved by the
great balance of authoritj- on the subject. It
comprises :

1. Those presenting the earliest physical signs
of tuberculosis of the apex, who have as yet
shown little if an}' general disturbance from the
disease, and who complain only of morning cough
and expectoration. As Dr. Knight very truly
remarks, the prognosis in this class has been
changed from verj' bad to very good by the im-
proved ideas of treatment.

2. Hemorrhagic cases without marked febrile
reaction or much phj-sical evidence of disease.

3. Certain cases of " fibroid " or '" interstitial "
pneumonia.

4. Patients recovering from acute pleurisj' or
pneumonia in whom the irruption of tubercle is
dreaded .

For these classes of cases. Southern Alberta of-
fers inducements hardly excelled by any place on
the continent. I trust I have already satisfied
j'ou that the necessary climatic conditions are
present : the dry aseptic atmosphere, the dry soil.

the clear sunshiny daj'S and the necessary eleva-
tion. There are one or two other points which I
feel compelled to mention. One is that seekers
after health are not obliged to remain for a few
months onh-, and then go awaj' again on the ap-
proach of winter or summer. Another is that,
being a stock-raising countrj', it is easily possible
to spend almost all one's time in the saddle. It
was Sydenham who said that "unlimited horse-
back exercise is almost as good a cure for phthisis
as quinine for ague. ' ' Another is that Alberta is in
Canada, for why should Canadian phj'sicians send
their patients to Colorado when they have a cli-
mate equall)- as good within the confines of their
own Dominion?

The general conditions of life are those of any
new and growing country*. Many of the pleasures
of the East have to be dispensed with, but to
most people, the bright sunny skies, the pure,
bracing, intoxicating air, the exhilarating free-
dom of outdoor life and the unrivaled scenerj- of
Alberta, will amplj^ compensate for the artificial
pleasures they are obliged to forego.

MEDICAL PROGRESS.

Jaborandi as a Parturifacient. — Under
this caption Dr. N. P. Moss reports a few cases
(lY. O. Med. and Surg. Joiirn.) in which jabor-
andi seemed to expedite labor, and his explanation
of the modus operandi of the drug is unsatisfac-
torj-, as he seems to attribute it merelj- to its dia-
phoretic properties. His cases are also not nu-
merous enough to serve as a basis for accurate
deductions. Pilocarpin has been proven bej-ond
doubt to possess a powerful action upon the ute-
rus, and it has been employed to a considerable
extent as an abortifacient. Professor Schauta, of
Prague, has employed pilocarpin in more than
forty cases as a means of strengthening labor
pains. Injected subcutaneouslj' he has found it
active in 2 per cent, solution, although he has
also used it in 3 or 4 per cent, solutions. Schau-
ta went so far as to measure the effects of his doses
\>y means of the manometer, and reached the con-
clusion that the influence of pilocarpin upon the
uterus is a verj^ powerful one, although it varies
greatly- according to individual susceptibilit)-. In
1 88 1 Van der Mey made experiments upon preg-
nant rabbits from which he obtained similar re-
sults. Gigollet has reported the case of a woman
in whom premature labor was twice induced by
the administration of pilocarpin, three injections
at inter\'als of four hours having proved sufficient.
Prof. Schauta gives the following rules for the ad-
ministration of pilocarpin : After careful exami-
nation of the organs of respiration and circulation
I would administer on the first day, if necessary.

380

MEDICAIv PROGRESS.

[September 14,

as many as three injections of a 2 per cent, solu-
tion. If by the second daj' no contractions had
supervened, I would use not more than two injec-
tions of a 3 per cent, solution; and finall}-, on the
third day one or two injections of a 4 per cent,
solution, employing always the muriate of pilo-
carpin. If I obtained no action by the fifth day
I would resort to other measures. It would be
absurd to abandon the use of muriate of pilocar-
pin, which has proved itself such an excellent
ecbolic remedy in some cases, simply because it
has not been found active in all cases when used
in a 2 per cent, solution.

Abdominal Aneurism. — Dr. Wm. F. Drew-
iiY, of Petersburg, Va., reports the following case:
The patient, a negro aet. 60 years, was admitted
into the Central Lunatic Asylum of Virginia on
March 15, 1889. An aneurism of the upper third
of the abdominal aorta was easily diagnosticated.
Iodide of potassium, acetate of lead, anodyne em-
brocations, etc., were prescribed. On May 17 the
patient died while asleep. An autopsy revealed
the following conditions : In the upper half of
the abdominal aorta, in the vicinity of and in-
volving the orifice of the coeliac axis, and arising
from the anterior face of the aorta, a false saccu-
lated aneurism was found, with a mean diameter of
6 inches. It was intimately adherent to the adja-
cent tissues and encroached somewhat upon the
spinal column. The sac had ruptured, perforating
the diaphragm, and the contents had escaped into
the left pleura. The reporter refers to the following
statistics: Of 551 casesof aneurism of the aorta tab-
ulated by Crips, only 59 were abdominal. Of 880
cases collected by Sibson only 177 occurred in the
abdominal portion, and of this number 131 were lo-
cated at or near the coeliac axis. Of 103 cases of
abdominal aneurism collected bj' Lebert only 3 oc-
curred at or near the bifurcation. Biggs, of New
York, has recently reported 33 cases of aneurism of
the aorta, only 4 of which were in the abdominal
pylorus. Regarding the termination of abdominal
aneurisms Sibson says : Seventy -seven per cent,
rupture — 28.5 per cent, into the peritoneal cavity;
22 per cent, into the subperitoneal tissue in the
left hypochondriac region. — VirgtJiia Medical
Monthly, July, 1889.

Peptonuria in Pregnancy. By Dr. Wil-
liam FiscHEL. — In my work on puerperal pep-
tonuria, I reported casuallj' the occurrence of
peptone in the urine of pregnant women. I wish
to add that the pregnant women referred to were
kept under obser\'ation up to the time of their
confinement and even beyond, and that they re-
mained healthy and especially were free from skin
eruptions and .syphilides. They all bore healthy
living children. Inasmuch as I found peptone in
one-fourth of the urine examined, I cannot at all
agree with Dr. Koettnitz (Dent. Mid. Woch., 1888,
p. 613), who, as the result of his observations, re-

ported that the peptonuria of pregnancy is fol-
lowed by death and maceration of the foetus. Pep-
tonuria certainly does occur in cases where the
foetus does not die. I cannot say whether Koett-
nitz's negative results of examination depend
upon the reaction adopted by him, or whether it
was a matter of chance that he always found the
urine free from peptone. The positive results
which I obtained by careful analyses according to
approved methods, in Prof Huppert's laboratory-,
cannot be set aside, whether they appear plausible
or not.

I also wish to direct attention to the fact that
the conditions explained by Dr. Koettnitz, under
which alone he conceives the peptonuria of preg-
nancy possible, would be explained by me in the
same manner. But it must be remembered that
the pains of pregnancy do not occur merely at the
end of gestation, as Dr. Koettnitz says, but dur-
ing the entire period thereof and accordingly, on
the basis of this hypothesis, peptonuria may oc-
cur at any time during pregnancy. That this
hypothesis is not proven, appears from my former
reports ; as does also the fact that it is not the
only conceivable one. — Ccntialbl. fi'ir Gyn.

A C.\SE OF FcETus Papyraceus. — Dr. E. W.
Mulligan, of Rochester, N. Y., reports a case
of this kind. He first saw his patient in Novem-
ber, 1888, when she was apparently having labor
pains. She considered herself to be in the sixth
month of pregnancy, although the large size of
the abdomen seemed to -indicate a more advanced
pregnancy. Patient was not seen again for three
months, when she was found in labor ; the abdo-
men, curiously enough, was much smaller than it
was three months before. Patient soon gave birth
to a child weighing 10 lbs. which was immedi-
ately followed by the expulsion of a dead foetus.
This was flattened out and .seemed to correspond
to the sixth month of foetal development. The
cord was slightly attached to the border of the
placenta. The woman now said that .soon after
the physician's previous visit the membranes
broke and almost a pailful of clear fluid escaped,
after which the pains subsided and she went about
her duties as usual.

Double l^agina and Uterus. — Dr. Mulligan also
reports for Dr. Jonas Jones the case of a well de-
veloped woman 25 years old, married two years
without children. External genitals normal.
There are two vaginae situated side by side, the
opening of the left one being a little above and to
the right in relation to the other. They appear
to be about the same size, but the right one, hav-
ing been used, received the speculum more read-
ily. Each uterus is 2'j inches in depth, the os
being normal in each. The patient has had two
miscarriages in the past three years, miscarrying
each time when two months pregnant. — Buffalo
Med. and Surti. Journal, August, 1S89.

i889.]

EDITORIAL.

381

Journal of the American Medical Association

PUBLISHED WEEKLY.

Subscription Price, Including Postage.

Per Annum, in Advance $5.00

Single Copies 10 cents.

Subscription may begin at any time. The safest mode of remit
tance is by bank check or postal money order, drawn to the order
of The Journal. When neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
betters.
Address

Journal of the American Medical Association,

No. 68 Wabash Ave.,

Chicago, Illinois.
All members of the Association should send their Annual Z)ites
to the Treasurer, Richard J. Dunglison, M.D., Lock Box 1274, Phila
<lelphia, Pa.

lONDON Office, 57 and 59 Litdgate Hill.
SATURDAY, SEPTEMBER 14, 1889.

GRAILEY HEWITT' ON THE SEVERE VOMITING
OF PREGNANCY.

Dr. Grailey Hewitt's most recent communi-
cation " On the Severe Vomiting of Pregnancy,"
read at the last meeting of the American Gyneco-
logical Society, merited critical attention and ade-
quate discussion. But it is a somewhat remarka-
ble fact that neither the presence of the distin-
guished author himself, nor the valuable nature
of his essay, was sufficient to draw out livelj' de-
bate. The explanation, however, of this apparent
slight put upon a foreigner is not hard to find.
The surgical aspects of obstetrics and the diseases
of women received the attention that ought to
have been devoted to equallj' weighty matters of
internal medicine.

Dr. Hewitt's paper relates chiefly to etiology —
undoubtedly the topic of greatest import. He
writes: "The conclusion suggested is _ substan-
tially in agreement with the opinion of Desor-
meaux, expressed .some years ago, that the vom-
iting is due to interference with expansion of the
uterus. The cases related in this paper appear to
show that there are two factors which principally
contribute to this interference with uterine ex-
pansion : I. Incarceration of the uterus in the
pelvis a.ssociated with flexion or version : and 2.
Undue hardness and rigidit}- of the tissues of the
cervix and around the os internum. Also that
these two factors are in most cases associated."

Those familiar with the earlier utterances of
Dr. Hewitt will recognize a material change of

' Transactions of the American Gynecological Society. Vol. xiii.
18SS. British Medical Journal, 1S89,

opinion in this most recent expression. Flexions
and versions, in general, and anteflexions in par-
ticular, no longer exercise dominant power in de-
termining hN'peremesis. But this amended hy-
pothesis is no more equal to the explanation of
all recorded cases of the uncontrollable vomiting
of pregnancy, than were its less pretentious ante-
cedents.

In the limited space at our command, it is im-
possible to enter into a detailed criticism of Dr.
Hewitt's analj'sis and elaborate classification of
recorded cases. In passing, however, it may be
remarked that in the construction of his premises,
he has assumed the question at issue, while he
treats with a certain insular arrogance the opin-
ions of other obser\-ers. Indeed, his treatment
of the entire subject can hardlj' be regarded as
candid.

In a number of ca.ses, quoted in his paper, and
in a still larger number of examples described in
the literature of the subject, the vomiting and
prostration either appeared for the first time, or
became marked, after the uterus had passed up-
ward out of the pelvis into the abdominal cavitj-.
In other words, the symptoms presented them-
selves at a time when the operation of the factors
mentioned bj' Dr. Hewitt must have been physi-
cally impossible.

There are scarcelj^ six cases of incarceration of
the ante-flexed pregnant uterus on record. Then
the symptoms of incarceration of the pregnant
uterus, whether it be bent or turned forward or
backward, or fixed by exudates and the like,
make up a clinical picture essentially different
from that we see in the uncontrollable vomiting
of pregnancy. Incarceration causes pronounced
local disorders, in connection with the function, of
the bladder and rectum, that are more or less
acute. These disturbances commonlj' attract
the patient's attention to her own condition.
When vomiting occurs it is usually the vomiting
of ileus, not of pregnancy. The clinical char-
acters of the vomiting from incarceration of the
pregnant uterus are not identical with the ap-
pearances of hyperemesis gravidarum. The former
is a subordinate phenomenon, appears late, and
lasts necessarilj- but a brief period. The latter
rules the situation from the first, constitutes the
complete clinical picture of the disease, and runs
a chronic course.

Dr. Hewitt does not mention a considerable

382

MEDICAL ORGANIZATION.

[September 14,

class of cases, in which the determining cause of
the vomiting is found in some morbid state of the
gastric mucous membrane, often existent be-
fore conception. It is well-known that preg-
nancj' not onlj- often exaggerates physiological
processes into morbid activity, but also that it
seriouslj- aggravates conditions of little moment
in the non-gravid woman. The adjuvant cause
of hyperemesis gravidarum is not uncommonly
discovered in latent chronic gastritis, or in acute
gastritis arising during pregnancy. Gastric ul-
cer is of more common occurrence and attended
with greater significance in pregnant women than
is generally believed.

The causation of the uncontrollable vomiting
of pregnancy constitutes a most intricate problem,
and while etiological research has cleared up
some obscurities, there still remain cases in which
the autopsy fails to disclose any adequate objec-
tive changes. Under such circumstances is it not
better to admit ignorance, rather than to force a
favorite hypothesis ?

MEDIC.A.L ORG.^NIZATION.

At a recent session of the California State Med-
ical Society, a resolution was adopted declaring
that continuous membership in a local society,
where one exists, is essential for membership in
the State society. In pursuance of this action,
the Sacramento Society, regarding this as an im-
portant step in the maintenance of the local
organization, adopted similar action.

We are glad to note this as a real advance in
the proper direction. In a number of States, the
State society only exists as the parent head of
the count}' or other local societies. This we be-
lieve to be the only proper means to secure the
organization of the profession and to control those
who are inclined to irregularities. In the earlj-
days of medical societies, especially in the new
States, it was not always possible to wait on the
local bodies prior to the formation of the State
body. In fact, in some instances it was necessarj'
to combine the members of the profession in a
State medical society' at the outset, and by means
of organizing committees to cause the local
societies to radiate from it as a centre.

But medical organizations have now become so
well known and their workings so well understood
that this plan is no longer needed. Every county

should have its own society, or where the mem-
bers of the profession are extremelj' few in num-
ber, let them join with one or more adjoining
counties and form a district society, which should
annually send its delegates to the State societj-
and to the American Medical Association. By
the amendment to the laws of this latter body,
providing for " Members by Application," every
regular physician has an opportunity to become
a full member of the general body. This should
be embraced bj- all and the admission of "Mem-
bers by Invitation" should be of rare occurrence.
This latter privilege should only be accorded to
distinguished strangers, and never to those who
are able to join by application, or who do not
feel sufficient interest in their local society to aid
it by their money and influence.

Although the next session of the American
Medical Association will not take place until
May of 1890, yet it is none too earlj- for the pro-
fession of the South and West, in whose midst
that session is to be held, to take steps toward
the thorough organization of everj' portion. The
session at Nashville should be one of the grandest
gatherings ever assembled. As the securing of
rates on the railroads will on that occasion be
solely confided to the hands of one person, and
as he is the one to whom application is usually
made by those who desire to obtain these re-
ductions, we feel confident that on this occasion
it will, if possible, be secured in abundance of
time for all to avail themselves of the reduction.

The organization of a medical societj' need not
be a difficult task. In districts not yet provided
for, let the phj'sicians assemble at the call of one
of their number. There is always a central
figure around whom the rest will cluster ; let
him issue a call and see to it that no worthy
member is omitted. In medicine there is no creed
or politics. Every physician should be admitted
to the local society against whom there is no
charge of irregular conduct. Let the assemblage
adopt the simplest laws for its government, place
the fees of whatever kind as low as will be
sufficient to provide for the maintenance of the
society, .select the best members for officers, par-
ticularly for president and secretary, for upon,
these two officers the whole usefulness of the
body will depend. This done, let the .society
apply to the State Medical Society for recognition
by representation, as upon such recognition de-

1889.]

EDITORIAL NOTES.

383

pends its right to send delegates to the American
Medical Association. Such an organization will
continue as an integral part of the medical
fraternity with but little effort on the part of its
members.

To make the sessions useful and attractive, it
would be well to have a committee on essays,
whose duty will be to provide for each meeting
some literary entertainment in the form of an
essay, clinical report, or similar matter, and the
hour of meeting will soon come to be regarded
as a pleasure and its coming anticipated by all.

In many such meetings we have known them
to be looked forward to as an opportunitj- to
renew friendly greetings, to make new acquain-
tances, as well as to learn what was new in the
profession.

In a very large experience of this kind, we
have known the warmest friendships to have been
formed, mutual misunderstandings explained, a
feeling of sociability to be established, which has
done much to cause the entire profession of the
locality to gain the respect of the community.
In conclusion, let us urge these points upon the
profession everywhere ; organize, and where
societies already exist, make them stronger, bring
in every one who is eligible ; thus you will elevate
the profession at home, in your State, and in the
whole country.

EDITORIAL NOTES.
HOME.

Typhoid Fever in Indiana. — Typhoid fever
prevails at Dundee and Connorsville. It is of a
malignant type and is spreading rapidly.

A Peculiar Cattle Disease. — Cattle are
dying in the vicinity of Dallas City, Hancock
county, 111., of a strange disease. They become
stiff in the hindquarters and suddenly drop to the
ground, dying in great agony.

The American Association for the Ad-
vancement OF Science, which concluded its
sessions in Toronto last week, decided to hold
its next meeting at Indianapolis in August,
1890.

Woman's Medical College of Chicago. —
The Woman's Medical College celebrated the
opening of its twentieth year of instruction on
the 3d inst. at the College building on South

Lincoln street. Dr. William H. By ford. Presi-
dent, and Professor Mary Mixer made brief ad-
dresses. Already over one hundred students
have been enrolled for the present year, a very
large increase over the former attendance.

The American Society of Microscopists
held their twelfth annual meeting at Buffalo dur-
ing the third week in August. There was a large
attendance of members and the following officers
were elected : President, George E. Fell, M.D.,
Buffalo ; Vice-Presidents, W. H. Seaman, Wash-
ington, D. C, and F. W. Kuhne, Fort Wayne,
Ind. ; Treasurer (to fill the unexpired term of Dr.
Mosgrove, resigned), C. C. Mellor, Pittsburgh,
Pa.; Executive Committee, W. P. Manton,
Detroit, Mich.; Dr. Frank L.James, St. Louis;
W. H. Walmsley, Philadelphia, Pa. The time
and place of next meeting is not yet announced.

The Association of American Physicians,
as previously announced, will hold their Fourth
Annual Meeting at Washington on the i8th,
19th and 20th insts., under the presidency of Dr.
Francis Minot, of Boston. Papers will be read
on the following subjects : "The Early Stage of
General Paralj-sis," by Dr. C. F. Folsom, of
Boston; "Tetany," by Dr. James Stewart, of
Montreal ; ' ' Tetany and a New Theorj^ of its
Pathology," by Dr. John T. Carpenter, of Potts-
ville ; ' ' Thrombosis of the Cerebral Sinuses and
Veins," by Dr. A. B. Ball, of New York;
"Chylous Effusions into Serous Cavities," by Dr.
S. C. Busey, of Washington; "Substitutes for
Opium in Chronic Diseases," by Dr. J. F. A.
Adams, of Pittsfield ; " Remarkable Case of Slow
Pulse," by Dr. D. W. Prentiss, of Washington;
Discussion on the Relation between Chlorosis,
Simple Anaemia, and Pernicious Anaemia, in-
cluding Leucocythsemia and Hodgkins' Disease,
Referee, Dr. Frederick P. Henry, of Philadelphia,
Co-Referee, Dr. F. Forcheimer, of Cincinnati ;
"Primary Cancer of the Duodenum," by Dr. E.
N..Whittier, of Boston ; " Primarj^ Cancer of the
Gall Bladder and Ducts," by Dr. John H. Musser,
of Philadelphia; "Gastric Neurasthenia," by
Dr. G. M. Garland, of Boston ; "Specimens from
Two Cases of Cretinism, by Dr. W. F. Whitney,
of Boston ; "The Anatomical and Physiological
Relations of Lesions of the Heart and Kidneys,"
by Dr. H. F. Formad, of Philadelphia ; "The
Contagium of Diphtheria," by Dr. P. Geri'ais

384 EDITORIAL NOTES. [September 14,

Robinson, of St. Louis ; " A Supplementary In- . did reveal a clot in the left lateral ventricle. la
quirj- into the Frequency with which Lead is view of the fact that such reports are often re-
Found in the Urine," by Dr. James J. Putnam, I corded and that opium is an unsafe remedy in
of Boston ; Discussion on the Relations of Rheu- cases of threatened apoplexy, the physician cer-
matism to Rheumatoid Arthritis. Referee, Dr. ^ tainly acts the part of prudence when he with-
William Osier, of Baltimore, Co-Referee, Dr. holds the use of morphine in delirium tremens-
Morris Longstreth, of Philadelphia ; " How Far | and trusts to more reliable sedatives.

may a Cow be Tuberculous before the Milk Be-
comes Dangerous as a Food Supply?" by Dr.

Loreta's Operation for Stricture of the:
Pylorus. — Dr. T. W. Huntington, of California,.

Harold C. Ernst, of Jamaica Plain ; "The Bacillus , j-gports a case where he performed Loreta's opera-
Tuberculosis," by Dr. J. T. Whittaker, of Cin- 1 ^^j^^ f^j. stricture of the pylorus in a patient who
cinnati ; "Hot Air Inhalations in Tuberculoses,"
by Dr. E. L. Trudeau, of Saranac Lake.

had suffered from gastric derangement for three

j^ears. After dilation of the constricted portion

,, .,.^ „ _ <<T^ „^ the former svmptoms disappeared, and five weeks-

More Experience with the " Euxir ofi - K , . ,' , , .

,, _ 1 rA CM. 1^ f -rv * ,^1 •„ after the operation the patient had resumed his

Life. — Samuel C. Showalter, of Dayton, Ohio, , ,. ^ , . ^ ,

, , , , -, 1, -^i. J 4. • • ^- r usual diet and is pronounced practically well.

aged 60, voluntarily submitted to injection of t- f :>

elixir of life three weeks ago, hoping for relief Met.\l Removed from the Eyeball by an

from rheumatism, and died on the 2d inst. from , Electro-Magnet. — Dr. W. E. Briggs, of Sacra-

the effects of the treatment. Immediately after I mento, reports, in the Occidental Medical Times,

the injection was made his limbs began to swell nine cases of operation for removal of metal from

and his whole system was permeated with blood the eyeball by means of the electro-magnet.

poison. There were two successful cases of removal from

m T-v_ „„T>.^^ „. r>A^^T,^r,-.,r, ^u ^ thc auterlor chambcr, thrcc of removal from the

The Death-Rate in California. — Ihe, , ^ , .,.

. . .,,.„.„ ,i:^..„-„f^ ^r n„u vitreous, and one of removal from the ciliary

deaths registered in 81 town districts 01 Call- r r ■■, , . \.

.^, 1 *• r „ „^ i regions. In two cases of failure, enucleation of

forma, with a population of 790,700, correspond- & , ,, r „ j ^ ■ r r -,

, r ,, 4.1. r T 1 <-„ „..,.,i ,of.^ ^f the ej'eball followed, and in one case of failure

ed, for the month of Julv, to an annual rate ot i -' . ' , .

., ^, 1 J 4.-U i- I the patient refused enucleation and passed from

IT, 1,-t, per mil. The average annual death-rate | ^ .. . '^

^ ,, • tu * 1 „„^ „;^; observation. Dr. Briggs summarizes his conclu-

from all causes occumng in the ten largest cities ^, ,

.,, 1 ..• r £ , sions as follows : The electro-magnet is generally

and towns, with a population of 620,000, was; . r. ■ r r

12.57 per mil.

a safer instrument for the extraction of frag-
ments of steel from the anterior chamber, from
Meteorological Reports from San Diego the iris, or from the anterior portion of the lens,
and San Francisco for June, 1889, furnish the i than the forceps. It is practically our only re-
following data: Mean temp., San Diego, 64° ; ^ source when the steel has penetrated the vitreous
San Francisco, 58, 1°. Highest temp., San Diego, j chamber. It is safe to retain, quite extensively,
72° ; San Francisco, 75°. Lowest temp., San injured eyes, if the offending body be promptly

Diego, 56° ; San Francisco, 52°. Mean daily
range of temp., San Diego, 10.5° ; San Francisco,
12.1°. Total rainfall, San Diego, o. 10; San
Francisco, 0.03.

The Use of Morphine in Delirium Tre-

removed and thorough asepsis observed.

An Army Medical Board will be convened
in New YOrk City, New York, October i, iSSq,
for the examination of such persons as may be
properly invited to present themselves before it as
MENS. — Another one of those cases (unfortun- candidates for appointment in the Medical Corps

ately by no means rare) where a patient suffering
from delirium tremens dies after the administra-
tion of moderate doses of morphine is reported
in the Occidental Medical Times. In this instance,
as often happens, the press dispatches reported
that death occurred from an overdose of morphine

of the Army. Application for invitation should
be addressed to the Secretary of War, stating date
and place of birth ; place and State of permanent
residence, and accompanied hy certificates, based
on personal acquaintance, from at least two per-
sons of repute, as to citizenship, character, and

administered by the physician. The autopsy moral habits ; testimonials as to professional
showed no evidence of morphine poisoning, but I standing, from the professors of the medical col-

1889.]

EDITORIAL NOTES.

385

lege from which the applicant graduated, are also
desirable. The candidate must be between 21
and 28 years of age, and a graduate from a regu-
lar medical college, evidence of which, his diplo-
ma, must be submitted to the Board. Further
information regarding the examinations and their
nature may be obtained by addressing the
Surgeon-General, U. S. Army, Washington,
D. C.

FOREIGN.

To Inspect Drainage Systems. — Ellis Clark,
President of the Association of Municipal and
Sanitary Engineers of England, will sail on the
Servia on the 21st inst. for the purpose of ac-
quainting himself with the methods adopted in
large cities in the United States for the disposal
of sewage and refuse, and also with internal san-
itary arrangements.

Collective Investigation. — It is to be re-
gretted that the Collective Investigation Commit-
tee of the British Medical Asssciation, from whom
so much was expected, feels obliged to recommend
the abandonment of the work of collective inves-
tigation. The Committee reports that the returns
received upon the subjects which have been taken
up have been so few that they do not feel justified
in continuing the inquiries further or in entering
upon fresh ones.

The Tercentennial of the Microscope. —
Preparations are being made in several German
towns to celebrate next j^ear the three hundredth
anniversary of the invention of the microscope.
Zacharias Janssen, of Madgeburg, is credited with
having constructed the first microscope in 1590.

Dr. Eustgarten. — -It is announced that Dr.
Lustgarten, of Vienna, is about to remove per-
manently to this country. Dr. Lustgarten will
be remembered especially by reason of his discov-
ery in 1885 of the bacillus of syphilis. At the
time his report was received with a great deal of
incredulity, but it was not long in obtaining the
recognition of the highest authorities. As As-
sistant to Prof. Kaposi (the successor of Hebra)
Dr. Lustgarten became personally known to many
of the American physicians who have visited Vi-
enna within the last few years.

Profs. Breisky and Ultzmann. — The Vien-
na Medical Faculty has recently suffered severe
losses in the death of Prof Breisky, the distin-

guished obstetrician, and that of the no less emi-
nent professorof urinary diseases. Prof. Ultzmann,
both of whom were well known in this country
for their valuable contributions to medical litera-
ture. Prof. Ultzmann, from his longer residence
in Vienna, was particularly well known to us, and
numbered his American pupils by the score.
Those who were so fortunate as to have attended
his admirable clinics at the Policlinic will long
retain pleasant recollections of his skill as well as.
liis kindly demeanor toward his patients.

An Inquiry into the Management of
Medical Charities. ^The following resolution
will be moved at the next session of the British
Medical Association : "That this meeting of the
British Medical Association views with great
pleasure the action of the Charity Organization
Society of London in presenting a petition to the
House of Lords praying for an inquirj' into the
management of the metropolitan medical chari^
ties, and earnestly hopes that the scope of the
inquiry will be extended so as to include pro-
vincial hospitals and dispensaries, with the view
of obtaining as complete information as is possi-
ble upon this important subject ; that a copy of
this resolution be forwarded to the Lord President
of the Privy Council, and that he be requested to
receive a deputation ; that the Council be re-
quested to appoint a special committee to deal
with the question, and request the Charity Or-
ganization Society of England to form a similar
committee to act in conjunction with it."

In Great Britain a new wing is about to be
added to the Leeds Infirmary. Dr. Thomas King
Chambers, honorary physician to the Prince of
Wales and a member of the General Medical
Council, is dead. An epidemic of typhus fever
has been prevalent in the Marshalltown division
of the Mitchelstown district, Ireland. Londoners
have been alarmed over an alleged outbreak of"
typhoid fever in the West end. The Glasgow-
Town Council have been considering the neces--
sity of making new arrangements for meat inspec-
tion, and have decided to place the inspection of'
meat in charge of the sanitary department, atid
have appointed a committee to consider what fur-
ther legislation is necessary to secure the public
against the sale of tuberculous and infected meat.
At the recent quarterly meeting of the Royal Col-
lege of Surgeons of England Mr. Jonathan Hutch-
inson was elected President, a.nd Messrs. Bryant,
and Croft Vice-Presidents..

386

TOPICS OF THE WEEK.

[September 14,

TOPICS OF THE WEEK.

THE HYGIENIC USES OF THE IMAGINATION.

In a recent editorial entitled " Considerate Judg-
ment," we endeavored to emphasize the necessity of
basing conclusions upon well ascertained facts, and stat-
ed that only those theories which could be thus substan-
tiated would be found enduring. But in the attainment of
truth we are by no means debarred the full and free play of
a well disciplined imagination; indeed, it often points the
way to undiscovered truths; it is by no means infallible;
its suggestions always need verification; but imaginations
verified become with us accepted facts. Under the above
heading, at the recent meeting of the British Medical As-
sociation, Sir James Crichton Browne presented a very
able address which is reported in the British Medical
Jourtial of August 24, and from which we make the fol-
lowing abstract;

The cultivation of the imagination, then — and it can
be cultivated and disciplined to agility and steadiness of

action is of high importance to us as medical men; for

it can be serviceable to us in collecting materials, in solv-
iuo- difficult problems, and, by the analogies it suggests,
in truiding us in our life-long search after truth. The
precise character which medicine is happily assuming, as
its several departments merge into the exact sciences, and
which demands of its cultivators a physico-mathematical
and chemical training of ever increasing stringency, does
not in any degree abrogate the necessity for the employ-
ment of the imagination. On the physical side of medi-
cine that still holds its own, and on its psychical side it is
indispensable in dealing with phenomena that are beyond
the province of physical and chemical research. Medical
men and medical students, then, need not fear that they
are altogether wasting their time when they turn aside
now and then from their professional tasks to ramble for
a little in the green pastures of literature, or climb the
pinnacles of art. True, their imagination may be fully
trained for its professional duty, as it is exercised, in con-
junction with observation and judgment, in the scientific
sphere; but it will be braced, invigorated, and have its
resources multiplied, by recreating occasionally in its
native air. Even if imaginative pursuits did not strength-
en the hands of medical men in grappling with disease,
or quicken their scientific vision, these would still be
commendable, because of the refreshment they bring to
jaded brains. To turn from the fatigue and anxieties of
practice into realms where rivalry is no more and night
bells never ring is to plunge into one of the most sooth-
ing and depurative of " tired Nature's " baths. Members
of our profession are, I suspect, generally aware of this,
and resort to imaginative literature, music, and art more
than any other class of professional men, except, of
course, artists and men of letters, and to an extent that
is remarkable, considering the engrossing claims made
on their time and the scant leisure they enjoy.

The contributions of medical men to the departments
of imaginative work have been far from insignificant.
At least four eminent members of our profession now
living might be named who have found leisure, amidst

absorbing occupation, so to use the pencil and brush as
to gratify not only their private circles but the public,
and a list of medical poets would be a long and goodly
one, including such names as Akenside (the gifted singer
of the pleasures of that imagination whose usefulness I
am attempting to extol). Garth, Blackmore, Goldsmith,
SmoUet, Armstrong, Erasmus Darwin, Crabbe, Moir (bet-
ter known as Delta, John Brown, whose Rab and His
Friends is id^-llic, and Oliver Wendell Holmes. Nay,
even one or two of the greatest names in poetical litera-
ture might not improperly be added to such a list. Keats
was apprenticed to a surgeon at Edmonton, and after-
wards attended St. Thomas' Hospital. It has been ar-
gued, I am afraid not very convincingly, that Shake-
speare's extensive medical knowledge proves him to
have been engaged in the study of medicine during one
or two of those years of his life that are unaccounted for,
but it is indisputable that Dante was enrolled amongst
the inedici c speziali (leeches and druggists) of Florence,
and that he attended their council meetings for several
vears. But it is not as producers but as consumers of po-
etr}- and imaginative literature that medical men derive
from them their restorative influence; and as consumers
they are, I feel sure, amongst the bookseller's best friends.
Sydenham, when asked by Sir Richard Blackmore what
course of study he would recommend for a medical stu-
dent, replied, " Let him read D071 Quixote, it is a very
good book; I read it still." Connolly, the apostle of that
non-restraint system to which we owe everv'thing that is
most excellent in the treatment of the insane in this coun-
try, and with which I trust professional opinion and pub-
lic sentiment will permit no tampering — Connolly told
me in his latter years that he took ever renewed delight
in Gulliver's Travels. I know hard-working doctors in
town and countrj- who hold habitual converse with some
of our great imaginative writers. Two of the most dis-
tinguished and busiest physicians of this day are, to my
knowledge, inveterate novel readers. I have heard one
of our great surgeons deliver an address betraying a deep
stud}' of the poetry of Keats; and another of our great
surgeons, present at this meeting, told me receutl}- that
on his way to and from every serious operation he dips
into Shelley.

But it mav be objected that the imagination, if some-
times stimulating and restorative in its influence, is often
morbid in its tendencies, and that its indulgence is to be
guarded against by those who desire to possess well reg-
ulated minds. " No habit can be more opposed to a
healthy condition of the mental powers," says Aber-
crombie, "than that which permits the mind to wander
in a mere vision or waking dream from scene to scene,
unrestrained by reason, probability or truth;" and the
answer to Abercrombie is supplied by Tyndall, who says
that those who have deuounce<I the imagination because
thev have seen its disastrous effect on weak vessels,
"might with equal justice point to exploded boilers as
an argument against the use of steam." But the weak
vessels wrecked by imagination are really fewer than is
commonly sujiposed. Now and again some erratic gen-
ius, of highly strung nervous temperament, gives himself
up to the pleasures of imagination till he becomes intox-

1889.]

TOPICS OF THE WEEK.

387

icated with them, and staggers over the boundary of san-
ity. Now and again an intense!}- imaginative child, like
Jerome Cardan or Hartlej' Coleridge, so indulges in day
dreams that his fancies grow into phantoms that haunt
him ; but I do not hesitate to say that for one case of
insanity caused by excess of imagination, there are a
dozen caused by the want of it. Apathetic dulness and
torpor of mind are apt to deepen into dementia ; and
those entirely given up to " the care of this life and the
deceitfulness of riches " are more likelj- to be choked by
them than those who can surmount them, and breathe
the free and ample air of aesthetical emotion. A vulgar
error as to the nature of insanity has perhaps conduced
to exaggeration as to the dangers of imagination. Vis-
itors to asylums invariably arrive expecting to find
growths of morbid invention and belief, wild, tangled,
and luxuriant as a tropical forest, and leave much disap-
pointed by the barrenness of the land, for the insane are
the least imaginative of beings. At rare intervals a mad-
man is encountered — a Blake or a Swedenborg — whom
two intrepid doctors have certified, who dazzles all
around him by the meteoric brilliancy of his concep-
tions ; but, as a rule, the lunatic is as dull as a stone.
He is the victim of a fixed idea, or his delusions pursue
a treadmill round, or occur in groups so unvarying that,
if }-ou have ascertained one of them, you can predict all
the rest. His mind is a blank or a blurred and unread-
able page, or his fancies, if they come thick in the tu-
mult of mania, are so disjointed or huddled together as
to defy recognition. Idiocy is the absolute negation of
imagination, and insanity undermines and destroys or
enfeebles it more or less, and, when we try to drive out
insanity, the first thing we do is to invoke imagination's
aid, for moral treatment consists mainly in appeals to
this faculty, and fully acknowledges its hygienic uses.
The first recorded cure of melancholia was bj- the harp
of David, and to-day in every lunatic hospital worth the
name persistent efforts are being made by music, by pic-
tures, b}- poetry and the drama to stimulate the imagina-
tion, and thus " cleanse the stuffed bosom of that peril-
ous stuff that weighs upon the heart."

Imagination seems to have a trophic influence on the
brain. When it is absent tard}- growth goes on ; when
it is more or less in abe3-ance, weakness exists ; when it
is active, there is vigorous development ; and the imme-
diate effects of imagination in causing exhileration and
preventing sleep when it is excessiveh- indulged almost
suggest that the states of the cortex which accompany it
have some control over metabolic changes in the body.
We now know that, besides alkaloids exercising a poison-
ous effect, which owe their formation to microbes, and
are called ptomaines, there are others which are produced
by the cells of the living organism themselves in break-
ing down albuminous matter, and which are called leuco-
maines. Now Bouchard has shown that the alkaloids of
the latter kind formed during sleep have a stimulating
action, so that, when they accumulate to a certain
amount, they excite the nerve centres and cause awaken-
ing, while those formed during waking hours have a de-
pressing action and tend to induce sleep. And it is just
possible that in the formation of leucomaines of different

classes, under varying conditions of the supreme nerve
centres, a key may be found to the curious fact that cer-
tain emotional moods, after having persisted for a time,
tend to induce their opposites — excitement, depression ;
appetite, disgust — and also to the influence of imagina-
tion, when very active, in causing exhileration and wake-
fulness. It is just possible that under such circumstances
it may arrest the formation of those leucomaines, usually
manufactured during waking hours, which are depressing
and lead up to sleep, or so modify decomposition that
other leucomaines of a stimulating character are pro-
duced. There can be no question that, in insanity, cer-
tain states of the highest nerve centres are accompanied
by rapid disintegration of the tissues and emaciation,
while in other states of these centres metabolism is re-
duced to a minimum, so that prolonged starvation may
be sustained with comparatively little wasting.

But it is only an inordinate indulgence of the imagina-
tion that produces excitement and interferes with natural
slumber ; its reasonable and regulated use causing only
a certain buoyancy of spirits with which a sense of sooth-
ing is associated. Imagination, indeed, legitimately
used, combines to some extent the pleasurable effects of
both morphine and caffeine, without any disagreeable
after-consequences, such as headaches, despondenc)', or
confusion of thought. On the one hand, it may heighten
happiness, and on the other afford solace in suffering and
sorrow. It may give zest to appetite and allay the pangs
of hunger, brace to exertion, or lessen the sense of fa-
tigue. It would not be wrong to speak of it, when
rightly used, as a true physiological stimulant, and anal-
gesic, capable in some degree of taking the place of those
crude agents drawn from herbs and trees, with which in
all quarters of the globe mankind has sought to mitigate
the dulness or assuage the pains of life. Moreover, its
massive pleasures have a distincth' sedative effect in con-
nection with those petty but exasperating animosities-
and jealousies that are the thorns of social intercourse,
and fret and fray fine-textured brains. Lifting us above
the turmoils and worries of the moment and opening up
wide and distant prospects, they promote altruistic feel-
ing, lull to rest our wounded sensibilities, and allay
feverish excitement.

SENILE CHANGES IN ARTERIES.
In discussing the nature of constitutional susceptibil-
it}- to disease in his recent address at Leeds, Dr. Joseph
Co.\TS, of Glasgow, makes reference to senile changes in
arteries in the following language :

'Turning to susceptibilities to disease, I believe that
senile changes constitute a very important element in the
commoner diseases of arteries. Atheroma of arteries and
aneurysms, arising as these do for the most part from
atheroma, are conditions in which we can distinctly trace
the two elements in the causation which I alluded to at
the outset of this address. These are diseases of middle
life and old age, that is to say, senile changes in the
arteries constitute the predisposing cause or susceptibil-
ity, but the determining cause is the impact of the blood
on the wall of the artery. This is evident from the fact
that atheroma is commonest where that impact is greatest^

388

SOCIETY PROCEEDINGS.

[September 14,

namely in the aorta. It is not common in arteries of
comparatively small calibre, but there are two situations
in which it frequently occurs even in small vessels, and
these are situations where the impact of the blood is apt
to be greater than in other arteries of a similar size. The
coronary arteries of the heart, coming off directly from
the aorta, are exposed to a high blood-pressure, and thev
are ver\- often atheromatous. The arteries of the brain
also, coming off as the anterior and middle cerebral do
from a large artery which passes up directly from the
aorta, are presumably exposed to unusual blood-pressure,
and they are very frequently affected with atheroma.
Perhaps also the soft character of the brain substance,
causing the arteries to be less supported than most others,
may have to do with the frequency' of atheroma here.
In this disease, then, the changes of constitution in the
arteries consequent on man}- years of activitv induce a
condition which renders the tissues of these vessels in-
capable of resisting, as before, the effects of the blood-
pressure. This change of constitution we may infer to
he a diminished vitality in the living structures forming
the walls of the vessels. That it is so is almost demon-
strated by the fact that atheroma is often associated with
a condition of the middle coat, which implies greatly
diminished vitality, namely, calcification of the muscle
cells of that coat. Before a living structure allows of the
deposition of lime salts in it, it is alreadj' so much re-
duced in vitality as to be almost dead.

Now it is interesting to observe that these senile
changes in the constitution of arteries are subject to very
great variations in different individuals, and in like man-
ner the occurrence of atheroma varies, both in the age at
which it occurs and in its extent. This is of great im-
portance when we consider what an important part this
disease plays in causing death in old people. A large
proportion of the deaths in the latter part of middle life
and in old age are from haemorrhage or softening of the
brain, presenting itself in the various forms of apoplexy,
paralysis and brain weakness. These conditions of the
brain mostly depend on atheroma of the arteries, and so
we may say that the tendency to death is greatly in-
fluenced b}' the occurrence or the premature occurrence
of the senile changes which render the arteries suscepti-
ble to atheroma. The constitutional condition of the
arteries as regards vitality of their tissues in advanced
life exercises thus a very important influence on the
duration of life. I may venture to say that the constitu-
tional powers of the heart and of the arteries are the
principal factors in determining longevity. The abilitj-
of the heart varies greatly in different individuals, and
survival when attacked by an acute disease will largely
depend on the power of the heart to resist the debilitating
influence of the morbid agent. If a man passes through
middle life and has escaped from acute di.seases, or has
survived them, then the condition of his arteries is prob-
ably the most important factor in determining his chances
of life. It is thus that the local constitutional peculiari-
ties of the vascular system influence the duration oflife.
These constitutional conditions, like others, are largely
the sulyect of inheritance, which thus again is seen to
determine local peculiarities.

, KIND TRE.\T>IENT FOR THE CURE OF DEMENTI.i.

During the past week the American Social Science As-
sociation has been in session at Saratoga. A good com-
mon sense paper on " Training Insane Women in Domes-
tic Industry " was read by General Secretary Sanborn,
who prefaced his remarks by saying that in the general
interest now aroused by industrial education he had
thought the success of Miss Alice R. Cooke, of Sandwich,
Mass., author of the above paper, in restoring to indus-
trious habits insane persons who had become idle through
loss of mental power and the lack of mental direction,
would be of value, and this paper was the result. Miss
Cooke said she took three women from asylums where
they had been five years or more, all of Irish extraction,
the youngest being about 30 years of age, aud the oldest
about 60. All were suffering from dementia, character-
ized by melancholia and delusions. Her treatment was
simpl}' kindness with thoughtful care, aud her success in
restoring them to constant usefulness in household ser-
vice was made the basis of an argument showing the de-
sirability of placing the chronic and quiet insane in pri-
vate families rather than in the noise and confusion of
public hospitals, where their disease is aggravated by the
quarrels and violent outbreaks of different classes of pa-
tients. She thought what she had accomplished with
these middle-aged women could be done still more effec-
tively with the younger ones and those of more vigorous
bodily health. This was followed by a general discussion
relative to the training of defective classes in labor.

SOCIETY PROCEEDINGS.

Medical Society of the District of Columbia.

Slated Meeti7ig, February 20, i88p.

Charles E. Hagner, M.D., President,

IN THE Chair.
Dr. I. Hermann read a paper on

THE POSSIBILITY OF L.\TENT SYPHILIS CArSING
INFECTION.

(Discussion Concluded frotn page 355.')

Dr. Smith : All men and women who contract
syphili-s will lie about it. Unless Dr. Berniann
could swear that this man did not contract the
disease since his marriage and that this woman
did not cohabit with anybody else, he could not
help doubting infection from such a long latency.
He then gaYe the history of a ca.se where the wo-
man told scYcral stories aud protested her inno-
cence, and several years after she admitted that
she had been indiscreet a number of times with
several men. If Dr. Bermann could get the true
history of his case he might find that there had
been a little lying going on.

Dr. Thompson : The que.stion of infection
through the semen is a very interesting one

1889.]

SOCIETY PROCEEDINGS.

389

Most syphilographers agree that infection must
be through the foetus. Could this man, at this
length of time since primary infection, infect his
■wife ? He thought not. There were secondarj'
manifestations, and not tertiary, after eleven years
latency, according to Dr. Bermann's diagnosis.
He questioned the correctness of the diagnosis.
He had not proved syphilis. The man could not
infect his wife from glandular enlargements. The
•diagnosis was false. He did not believe this
man had syphilis. He had seen a young man
to-day who had an eruption resembling the sec-
ondar)' manifestations of sj'philis, with glandular
enlargements ; but there was no evidence of local
lesions, and he declared that he had never had
intercourse with a woman. Five years ago he
had treated a man for the mildest form of s\'phi-
lis ; he afterward traveled and returned to perfect
health. He came to him a few days ago with a
suppurating gland, similar to a venereal bubo,
and still he declares that he has not been ex-
posed. According to the theory advanced to-
night this man could infect his wife and children.
Dr. Thompson did not believe that this }-oung
man could give his wife sj'philis by copulation,
or could infect his children through his wife.

Dr. Berm.^nn : The cases cited by Dr. Thomp-
son and his own are not at all alike, and, there-
fore, not comparable. Dr. Bermaun was certain
of his diagnosis. He could make as good a di-
agnosis as any one, and when he did diagnosticate
syphilis he was as competent to do so as any one
in this country or anj'where else. He had .seen
enough cases of sj-philis to be sure of it when he
made his diagnosis ; and when he said a man had
syphilis he felt sure it could be relied upon.

Dr. Thompson : The cases were similar. Both
"had syphilis and were said to be well, but years
afterwards developed symptoms resembling the
secondarj- manifestations of sj'philis. He was
surprised at the w-ild statement of Dr. Bermanu
as to his powers of diagnosticating a disease sur-
rounded by as many uncertainties as syphilis. He
was surprised to hear a gentleman get up in a
body of intelligent men and utter such an opin-
ion. Dr. Thompson had visited the clinics of
men with large experience in syphilitic diseases,
and never heard one of them make such a rash
statement. Thej' are constantly- changing their
opinion. He had seen many cases in which they
could not tell with certainty what the disease was
•due to, but suspected syphilis ; but suspicions are
not facts, and are not reliable in correct diagnos-
ticating. If Dr. Bermann had not obtained the
history in his cases he did not believe that he
would have attempted to diagnosticate sj-philis
from such meagre manifestations. He had not
proved that either of the.se patients had syphilis
by one positive sign ; until he did, then the diag-
nosis would be questionable. We all see ulcera-
tions that resemble sj-philitic ulcerations, but we

' would not make a diagnosis from these alone at
such a remote period after primary' infection.

Dr. Busey was seeking information. It had
been definitely stated by Dr. Thompson that syph-
ilis would not remain latent for so many j^ears.
The question is, did either of these patients have
syphilis? The point seems to be settled that if
the man had syphilis it did not remain latent so
long, and if the woman had it the infection was
more recent than claimed bj- Dr. Bermann. As-
suming that the latency was not as long as it was
said to be, the diagnosis is not positive. He did
not believe the woman could have contracted the
disease through the pregnancy and not have man-
ifestations for so long a time. He coincided with
the view expressed bj' Dr. Thompson, that if the
woman had syphilis she contracted it long after
the time stated in the report.

Dr. Bermann was very glad to hear Drs.
Thompson and Busej' testif}' to the absolute ne-

I cessity of making an exact diagnosis, and felt
verj' much relieved, consequent!}', as that ab-
solved him from having been too arrogant in tak-
ing a firm stand regarding the exactness of a di-
agnosis he had made in a case fullj- as important
as that of extra-uterine pregnancy, and much
easier to make. A fair and scientific criticism of
the subject brought before this Societj' for dis-
cussion can onlj' be welcome to all members ; but
such objections as those made b}^ disputing with-
out giving any reasons, the correct diagnosis of a
case they have never seen, and which had been
under his observation for a long time, he could
not consider either fair or scientific.

Zeiss says : Repeated observations, however,
have taught us that persons affected with latent,
feeble syphilis, though having no syphilitic ef-
fects on any part of their bodies, maj' communi-
cate the disease to their wives, although it is not
possible to discover any initial sj-philitic lesion
in the latter, and have not become pregnant. In
these women .sj'philis manifests itself by extreme-
ly rapid emaciation. In the further course of the
disease they lose their hair ; sometimes periosteal
swellings come on in some of the bones, and sub-
sequently the menses become profuse and recur
frequentlj'. On becoming pregnant they will
often abort. In what manner the syphilitic con-
tagion in such cases has gained an entrance into
the system is not 3'et clearly known. We know-
just as little in what manner a woman who suffers
from latent sj-philis is capable of communicating
the disease to her husband. Possibly in such
cases the blood has served to transmit the infec-
tion, some bleeding erosions or excoriations hav-
ing occurred on the genital organs.

Neumann, to whom Dr. Thompson refers, says:
Though it is not possible to draw the line abso-
lutely between secondarj' and tertiarj- symptoms,
still experience teaches that some forms of syph-

1 ilis show soon after infection, that means in more

390

SOCIETY PROCEEDINGS.

[September 14,

acute fashion, while others appear onl)' several
years after infection. The tertiary symptoms be-
gin not before seven or eight months have elapsed.
Not infrequently it can be observed that the so-
called tertiary symptoms develop after the lapse
of several years, without any secondary symp-
toms having been observed.

In regard to Dr. Thompson's statement about
the use of mercury and iodine in such cases, a
well known author states :

' ' Mercury as a rub is advantageous in propor-
tion to the nearness of the symptoms for which it
is given to the primary lesion, while iodine is
nearl}^ a specific for the later manifestations. The
intermediary symptoms require both medicines
combined.

" Syphilis may manifest itself as a mild erup-
tion after chancre, disappearing possibly without
treatment, and then, exceptionally it is true, lie
latent for many years, as long as 52 years, to re-
appear with characters due only to syphilitic dis-
ease."

Bumstead and Taylor say: "It has been
proved that the semen is not an infecting fluid,
as are syphilitic blood and the excretions of spe-
cific lesions ; moreover, every physician with ex-
perience has met with many instances of syphi-
litic men cohabiting for 5'ears with healthy women
who never show any evidence of syphilis.

"The physiological secretions of syphilitic per-
sons, the milk, saliva, urine, perspiration and
tears, most probably are not vehicles of sj'philitic
poison. They may probably contain it, but in
such an exceedingly dilute state as to be innocu-
ous. However, one of the phj'siological secre-
tions, the semen, seems to form an exception to
this rule.

"Whether the semen of a man affected with
latent syphilis may be the medium of contagion to
the wife remains yet an open question. Von Bar-
ensprung claims that this can be so only when
the wife conceives. Others, as Porter and I^ang-
ston Parker, have reported cases which tend to
show that infection of the wife may take place
without conception, solelj^ through the direct ac-
tion of the semen, and at the same time without
the production on her part of any discoverable
primary lesion. The difficulty experienced in
ascertaining the real facts in such cases is ma-
terially increa.sed from the fact that the primary
lesion upon the internal genitals of the female is
often very superficial, and lasts but a short time.
H. Lee is of the opinion, however, that in these
cases the semen does not cause the infection it-
.self, but only through the admi.xture with it of
syphilitic virus from the urethral mucous mem-
brane.

"On the other hand, the virulence of the .semen
of a syphilitic father for a child he begets is an
unquestionable fact."

The point that Dr. Smith made that people

with syphilis will lie even to their physicians is
unquestionablj' true, but in his case the man's
word could be relied on, as he had every reason
to know and there was no reason for him to con-
ceal anj^ facts after he had acknowledged to
having been treated for syphilis. The wife, when
she came to him, had tertiary^ manifestations, as
is suiEciently proved by the specific effects which
iodide of potassium had in her case. If she had
contracted the disease illegitimately, she would
have been more likely to have come under obser-
vation long before it had come to the manifesta-
tion of tertiary symptoms. Furthermore, ex-
perience teaches, as Foumier in his works on
Syphilis and Marriage shows, that the rule is that
the wife is infected by the husband, and his au-
thority, he thought, would not be questioned.

Dr. Thompson said his one idea in all dis-
cussions was to consider matters brought before
this society simply from a scientific standpoint,
in order that a thorough, satisfactory, and at the
same time impersonal discussion might be possi-
ble. He believed that the other members of the
society would agree with him in saying that the
extracts read by Dr. Bermann were admirably
adapted to support the views expressed by him,
and rather weakened than strengthened those of
Dr. Bermann. He thought that no competent
authority of the present believed that a woman
could acquire syphilis by the semen unless through
the foetus after impregnation. Foumier has in-
oculated with the semen of syphilitics without
effect. The point which he would emphasize
was that rather than believe that the patient had
acquired syphilis from the semen of a syphilitic
he would doubt Dr. Bermann's diagnosis. It is
true that if an individual had a specific sore in
the mouth the saliva which came in contact with
it might infect another, and so could the semen
passing over a sore in the urethra ; but saliva and
semen as such did not and could not infect.
Further, while secondarj^ syphilitic lesions were
inoculable, tertiary were not.

In regard to the diagnosis of the primarj' lesion,
if Dr. Bermann meant that some syphilitic sores
were so characteristic that no one could possibly
make a mistake, he agreed with him : but the
true Hunterian chancre does not represent one-
half the infecting sores. Sometimes these are so
slight that the patient would not di.scover their
existence, and this has repeatedly occurred, even
in the person of physicians. Many slight erasions
or abrasions may occur which are not the least
characteristic, and which readily disappear upon
simple treatment. But, nevertheless, it is possible
for even these to infect with syphilis, or a person
may become infected through them. There are
no hard and fast lines to be drawn between the
appearances of the chancre and chancroid — the
I infecting and non-infecting sore. Characteristic
! examples of each are met with, but again other

1889.]

SOCIETY PROCEEDINGS.

391

sores occur which it is impossible to refer definite-
\y to either category sirapl)' from their naked-eye
appearances. The woman in Dr. Bermann's case
was exposed constantly throughout her married
life to infection from her husband, but who could
tell when it occurred ? If syphilis were present
inoculation must have occurred in this way ; for
supposing that even the sore in the man's mouth
was a gumma, infection from it was not possible.
Dr. Bermann had said that it was possible to
differentiate in ulcers of the throat between specific
and non-specific. This was always difficult. At
the present time he had under observation, in an
elderly maiden ladj' — where the existence of
syphilis was out of the question- — a leg ulcer
which had all the appearances of being specific,
but which was healing rapidly under the simplest
general and local treatment.

Dr. Busey expressed his surprise that Dr.
Bermann should have believed that he had made
an attack upon him.

Dr. Bermann had referred to Baumler's opin-
ions in regard to the subject in hand which on
being rehearsed seemed to support the stand
taken by Dr. Thompson.

Dr. Busey asked if Dr. Bermann now said
that he did not know when the woman was in-
fected with sj'philis why he had presented the
case as one of latent syphilis of long standing ?

Dr. Bermann reiterated his belief that his case
was one of infection bj' latent syphilis.

I

Stated Meeting, February 2j, i88q.

Dr. H.'i.GNER IN THE ChAIR.

Dr. D. S. Lamb presented
SPECIMEN OF ti;bercui.ar peritonitis.

Uterus and appendages and left lung. Peri-
toneum covering uterus and appendages was
everj'where studded with small flat tubercles
about 2 lines in diameter. The lung was com-
pressed so that there was no air in it. Specimens
from a colored woman who had had fever, night-
sweats, brown tongue, cough, brownish expec-
toration, emaciation ; diarrhoea and constipation
alternated ; tympanites ; severe abdominal pain,
especially in epigastric, umbilical and right iliac
regions. The post-mortem examination showed
the peritoneum everywhere as in the specimen ;
the parenchyma of the organs, the mucous mem-
brane of the intestines, and the lymphatics of
the abdomen not affected. Right lung (Edema-
tous ; left lung as described ; was compressed bj'
a large serous effusion in pleura ; pleura of lung
thickened. Abdominal organs adherent every-
where ; some adhesions slight ; others, especialh'
in the right iliac region, old and firm. Liver
small and fatty ; spleen small. Kidneys normal.
Brain and heart normal.

Also, a specimen of extra-uterine pregnane}-.

The mother, a colored woman, age 27, had been
married one year when she began to show signs
of pregnancy in October, 1888. After a time she
had colicky pains, and towards Januar}-, 1889,
had, at short inter\'als, some haemorrhage pei
vaginam ; a tumor also appeared in right ilio-
lumbar region. In January the hemorrhages
were more profuse and frequent. She died sud-
denly February 20th. The post-mortem exam-
ination showed the right Fallopian tube converted
into a large sac, with placental wall ruptured at
one end, where a four-months' foetus had escaped ;
left tube much distended with watery fluid ; small
corpus luteum in left ovarj^ ; some old adhesions

j around right tube and to omentum. Lungs nor-
mal ; slight thickening on one aortic segment.
Abdominal organs normal, except as mentioned.

1 Abdomen full of blood-clots and serum.

Dr. Busey was extremely interested in these
cases, and in the extra-uterine pregnancy he was

' desirous to obtain a correct record of knowing if
he had understood Dr. Lamb to say that the pa-
tient had had symptoms in the second, third, and
again in the fourth month.

Dr. Lamb remarked that there had been pain
in each of the three months, and the discharge
spoken of had occurred one month before
death.

Dr. Busey thought that the patient had not
been examined carefully, and that in all proba-
bility operative interference at the right time
might have saved her life. Referring to the
case reported sometime since to the Washington
Obstetrical and Gynecological Society, by Dr.
Smith, he observed that the case had onlj' been
seen after death \>y Dr. Smith, but the symptoms
seemed bj' him to have been sufficienth- pro-
nounced to have excited the suspicion of her
attending physician. Here then were two speci-
mens, presented within a short time of each other,
removed post-mortem from patients who had
died of a ruptured extra-fcetation sac, and in
both cases it was fair to suppose that if the diag-
nosis had been made, and abdominal section per-
formed, a fatal termination might have been
averted.

Dr. Smith asked Dr. Busey if he had ever
seen a case of ectopic pregnancy. He reviewed
the histor}^ of the case alluded to by Dr. Busey,
which had previous!}' been reported by him. The
patient was pregnant three months, but there had
been no symptom pointing distinctly to the ex-
istence of an extra-uterine foetation before those
presented themselves which immediately preceded

\ and accompanied the fatal issue. Four days be-
fore her death the patient sent for Dr. Smith, and
she then complained of intense abdominal pain,
most marked in the epigastric region. The temper-
ature and pulse were normal but there was some
vomiting. The next day the symptoms were the
same, but were somewhat mitigated by the treat-

392

SOCIETY PROCEEDINGS.

[September 14,

ment pursued. On the eveuing of the fourth da}^
he saw her again and left her comfortable. There
was no pain or tenderness in or over the abdomen,
nor any symptoms of hsemorrhage or shock. At
his next visit he found the woman dead. Through-
out the whole history of the case there was noth-
ing to indicate the existence of an anomalous
pregnancy. The only thing which produced dis-
turbance was some frequency and painfulness in
micturition. At midnight, a few hours after Dr.
Smith's visit, she awoke her sister — who was
sleeping with her — and told her she was dying.
She was anxious to have her feet elevated. Dr.
Holden, who lives in the neighborhood, was
hastily summoned, and reached her about half-
past one. He gave her stimulants h3-podermat-
ically, but without avail, as she soon died.

Dr. Smith, continuing, said that Dr. Busey was
of the opinion that the diagnosis should have
been made in" this case, and in that reported bj'
Dr. Lamb, but the inherent difficulties of the di-
agnosis in this condition should not be forgotten.
At a recent society meeting in Philadelphia Dr.
Par\'in had said that, after all, the diagnosis in
such cases of ectopic pregnancy was a happy
guess. Many others, whose names are familiar
to us as active and intelligent gynecologists, had
participated in this discussion, but the general con-
sensus of opinion was that the whole question of
diagnosis was be.set with the utmost difficulties.
Indeed, even after operation, it is notalwa3^s easy to
decide that an ectopic pregnancy really existed ;
and in one case, to which attention was called, in
New York, the specimen had first to be submitted
to a microscopist before this decision could be
arrived at.

So far as the historj' of ectopic pregnancy in
this city was concerned, there were eight or ten
specimens in the Army Medical Museum, all of
which had been removed after death.

In any woman where the menses have ceased
and the uterus on ej^amination proves to be en-
larged, the inference is that normal pregnancy
exists. In his own case the uterus was of the
size to correspond with the existing term of utero-
gestatiou. This being ascertained, there having
been nothing to point to the existence of anything
abnormal, the examination was concluded.

The symptoms of ectopic pregnancy are really
those of pregnancy plus abortion ; and if an ex-
amination is made and no abortion is found to be
taking place then the suspicion of extra-uterine
pregnancy is at once excited. Suppose, under
these conditions, a tumor is found at the side or
behind the uterus, are we justified in performing
abdominal section and removing it ? Dr. Smith
thought that we were, and would go farther and
say that anything less than such a procedure was
an injustice to the patient. It would be more
excusable to fail to make a diagnosis than having
made it fail to remove the abnormally-seated pro-
duct of conception.

Dr. Busey remarked that, having trusted ta
his memory when first speaking of Dr. Smith's
case, he had made an error in believing that Dr.
Smith did not see his patient until the time im-
mediately preceding or coincident with the fatal
termination. It now transpires that he saw her
four days before this and, without desiring to cast
any blame upon Dr. Smith, he thought most as-
suredly the diagnosis should have been made.
Even although he could not have made the diag-
nosis completely and accurately he should have
discovered the tumor. He differs again with Dr.
Smith as to the unvarying employment of lap-
arotomy even if the diagnosis is assured, for even
as great an authority as Thomas conceives lapar-
otomj- to be the last, not the first resort. He be-
lieved that laparotomy may be but is not invari-
ably best. Yet, in either of these cases laparotomy
would not only have been justified, but was im-
perative, when symptoms of impending dissolu-
tion appeared. At the time of rupture abdominal
section was imperative, but not always before this.

Dr. Smith asked Dr. Busey if not laparotomy,
then what other method of treatment was indi-
cated before rupture?

Dr. Busey : Electricity is the alternative.

Dr. J. Ford Thompson referred to the impor-
tance of the subject under discussion and urged
its exhaustive stud}' and thorough elaboration.
His own opinions were not in perfect consonance
with those of Dr. Smith or those of Dr. Busey.
He thought that in the vast majority of cases of
ectopic pregnane}' the diagnosis ought to be made.
When the surgeon is called upon to decide the
nature of an abdominal or pelvic tumor coexisting
with pregnane}', and in connection with the symp-
toms which have already been alluded to, he must
confess that there is little ground for confusion.
He was anxious that not too much weight be
placed upon the opinion of accepted authorities,
for upon these matters any one of surgical expe-
rience is entitled to entertain and express his in-
dividual opinion.

He was in accord with Dr. Busey as to the lim-
its he puts upon abdominal section. Tait has re-
ported forty-two cases of abdominal section for
ruptured ectopic fcEtal sacs with but two deaths ;
and if such a result can be achieved at such a
time, and under such unfavorable conditions of
shock, etc., why not earlier? If early laparotomy
is not performed the surgeon may never have the
opportunity of operating at the time of rupture,
for death may ensue before he reaches her bedside.
It is the bounden duty of the surgeon to first make
his diagnosis and then perform laparotomy. He
regarded the sound as a valuable aid in diagnosis,
although its use was deprecated by some. He con-
sidered electricity, or any other means of killing
the fcetus, as inferior to laparotomy. Such a pro-
j cedure does not save the woman ; even though it
I averts immediate danger many accidents may sub-

?•]

SOCIETY PROCEEDINGS.

393

sequently ensue, such as breaking down of the
sac, and all the evils attending and following this
process.

Laparotomy is best performed earlj', for then
the operation is easy, no adhesions or other com-
plications existing. He expressed himself as op-
posed to any method of killing the foetus provided
it was allowed to remain within the abdominal
cavity.

Dr. G. W. Johnston obser\^ed that it gave
him great pleasure to listen to the preceding dis-
cussion of the subject of ectopic pregnancy, and
he was glad that a matter so important was called
so forcibly to the attention of the Society as had
been done by the presentation of the specimen
from one fatal case, and the narration of the his-
tory of another. Tait's views as to the nature
and mode of origin of ectopic pregnancy were
well known and needed no comment ; and Dr.
Lamb's specimen, in which there was tubal ges-
tation on one side and grave disease on the other,
would aid in the support of Tait's opinion as to
the etiology of the condition. Dr. Johnston hoped
that the tube which was diseased would be sub-
mitted to careful microscopic examination in or-
der to ascertain the character of its lining mucous
membrane, particularly with reference to the ab-
sence Or presence of cilia upon its epithelial invest-
ment.

So far as the difficult}' of the diagnosis before
rupture was concerned, he believed that this was
universally acknowledged, and while we all agreed
that a diagnosis should be made it was not always
easy to make it. The classical symptoms of this
condition at this time were quite distinctive, but
from a study of those cases where the diagnosis
previously attempted or made had been confirmed
by abdominal section during life or autopsy, he
was convinced that many of the distinctive symp-
toms might be wanting although, in a certain pro-
portion, so characteristic was the picture presented
that it was hardly possible to see how one could
have gone astray. While it appears, therefore,
that in some cases of extra-uterine foetation, be-
fore rupture, many significant features of the af-
fection may be absent, so that we are, as Tait puts
it, rather confused than enlightened by the historj'
of the case; on the other hand it is equally worthy
of remark that certain other affections of the pelvic
contents may be accompanied bj' sj^mptoms, both
subjective and objective, so like those which are
said to accompany extra-uterine fcetation that it
is with surprise, on opening the abdomen, that
the operator finds that it is not with an ectopic
pregnancy, but with something entirely different,
that he has to do.

In spite of the manifest difficulties which sur-
round this subject we will all agree that nothing
exceeds or, perhaps, even equals it in importance.
It is a subject which is of the most vital impor-
tance, not only to the specialist, but the general

practitioner, and its importance has been im-
measurably enhanced b}' the wonderful record of
Tait's operations at the time of rupture, which
are set forth in his work on "Ectopic Pregnancy,""
recently published.

America has just cause to be proud, however,
not only for the work which her physicians have
done in the development of electricity in the
treatment of this condition, but more especially
because two of its members have proven conclu-
sively, by three cases, that the diagnosis could be
made and the sac and its contents be successfully
removed before rupture had taken place. To Dr.
Joseph Price, of Philadelphia, who reported the
first case, and to Dr. J. S. Hawley, of New York,
who operated upon the others, too much credit
cannot be given for this solution of a verj' diffi-
cult problem.

It would appear from the remarks just made in
discussion that the use of electricity was attended
by no danger. That this was not the invariable
rule Dr. Janvrin's case (heretofore reported)
proved very conclusively.

Dr. Sjiith desired to make some further re-
marks in regard to his own case. The daj' be-
fore his patient had been seized with the illness
which proved to be her last, she had been actively
engaged in washing clothes and hanging them
on the line. She had, at the conclusion of this
work, gone out to a neighboring .store to make
some needful purchases, and on her return at-
tempted to castigate one of her children, a large
boy. It is likely, therefore, that the rupture of
the sac was immediately the consequence of her
own indiscretion. He had previously treated
this patient for retroversion of the uterus, and
when he had first been called after her sudden
attack he supposed that the gravid uterus, which
he previously replaced, had again become dis-
located. Examination showed the uterus to be
occupying its normal position, and he presumed
that it had fallen backward, but had subsequently
spontaneously assumed its normal position.

Beside this there was a fibroid in the uterus,
and the discovery of this body in the womb of a
woman with signs of pregnancy ser^^ed still fur-
ther to complicate the diagnosis. He was thor-
oughly in accord with Greig Smith, who regarded
laparotomy as imperative as soon as the diagno-
sis was made. He was opposed to the u.se ot
electricity, as after the foetus had been killed the
woman was by no means free from danger. He
referred to a case in which Dr. Mann, of Buffalo,
had supposed that he had killed an ectopic foetus
by electricity, while Dr. Kelly, of Philadelphia,
who subsequently operated upon the patient,
proved the supposed ectopic gestation sac to be
an ovarian tumor. He quoted Dr, Formad, of
Philadelphia, as saying that the majority of cases
of extra- uterine pregnane)' were diagnosticated
by the coroner. He referred also, in speaking- of

394

FOREIGN CORRESPONDENCE.

[September 14,

the use of electricitj% to the opinion of Reeve,
-expressed in the words : ' 'One should never em-
ploy electricity in this condition unless his lapar-
otomy instruments were at hand."

Dr. Ford Thohpson observed, in speaking of
the usefulness of the sound for purposes of diag-
nosis, that when all other means of diagnosis had
been exhausted, and the symptoms pointed to
the existence of ectopic pregnancy, the introduc-
tion of the sound was perfectly justifiable, and in
Dr. Smith's case this procedure might have led
to the making of a correct diagnosis, and the sav-
ing of the patient's life.

Dr. Busey asked if Dr. A. W. Johnstone, of
Kentucky, had not been the first to remove an
ectopic foetation sac before rupture ?

Dr. G. W. Johnston replied that Dr. Joseph
Price was the first to put such a case on record.
The history of his case was very brief, and per-
haps might be called incomplete. The second
and third operations had been performed, as had
been said, by Dr. Hawley, of New York, and the
•description given left nothing to be desired. Dr.
Price's case appeared in the Annals of Gynecology
and Dr. Hawley's in the N. Y. Afedical Journal.

Dr. Busey was convinced that in every case
of ectopic pregnancy the diagnosis should be
made. Heretofore, in speaking of ectopic preg-
nancy, he had had in mind only the tubal varie-
ty. To make -his views upon treatment clear he
would say that: i. When rupture has occurred
laparatomy is the sole and imperative operation ;
and 2. When an assured diagnosis has been ar-
rived at previous to rupture, laparotomy is again
the operation of election ; but in that large group
of cases where the existence of ectopic pregnancy
is probable, but where an accurate diagnosis is
impossible, electricity is preferable to laparotomy.
While it is true that bad results have attended
and followed its application in some instances,
this was by no means most frequently the case ;
and the vast majority of instances nothing un-
toward had occurred, and success had followed
its application.

Dr. Lamb said that in his case a corpus luieum
was noticed in the left ovary, while the pregnancy
was in the right tube. He asked if any explana-
tion could be offered for this state of things ?

Dr. G. W. Johnston remarked that the intro-
duction of a sound into the uterus for diagnostic
purposes was by no means devoid of risk ; the
contraction of the uterus, and of the foetal sac,
might thereby be induced, and fatal rupture was
known to have occurred. In reply to a question
of Dr. Thompson's, he said that he was not pre-
pared to state definitely where he had seen such
an a.ssertion, but would endeavor to give him the
desired information.

Dr. S. S. Adams reported a case of
fracture ok skull and laceration of brain.

B. F. C, white, N.Y., consulted me in Augu.st,

1887, for epilepsy, inherited from father. Full
habit and addicted to use of alcoholic liquors. A
seizure preceding night. Two or three slight
paroxysms since. Feb. 22, 18S9, was thrown
from a carriage and sustained a number of con-
tusions. Was confined to house till Feb. 26th,
then returned to work in land ofiice ; at noon,
while ascending inside stairs on north front, he
fell backward. Was attended by Drs. Darby and
Littleford. Dr. J. Ford Thompson called at once,
and sewed scalp wound on right frontal eminence.
I met Dr. T. at 5 p.m., when he made an explor-
atory incision on the right temporal region.
Fracture detected, but no depression. Prognosis :
Death would take place in a few hours, as it was
believed that the brain had been lacerated.
Active convulsions from time of accident till 7
p.m., after that profound coma until death, at
midnight, 26th.

Necroscopy, b}' Dr. D. S. Lamb, twelve hours
after death, limited to the head : There was a
large swelling in the right temporal region, due
to haemorrhage into and under the scalp. In this
swollen part an angular incision had been made
above and in front of the line of the ear. On the
right side of the forehead was a lacerated wound
of the skin corresponding to the frontal eminence,
beneath which the bone was normal.

The right parietal bone was fissured longitud-
inally, the fissure crossed the coronal suture at
the right temporal ridge and took an angular
course to the left for a short distance over the
frontal bone ; posteriori}' the fissure approached
the occipital apex within 2 inches, and bifurcated
into two branches, one extending downwards to
the occipito-parietal suture, the other to the left,
across the median line and a short distance be-
yond.

The brain was covered with dark blood-clots
ever3'where ; there was a longitudinal laceration
involving the lower part of the frontal and parie-
tal lobes, and communicating with the surface in
line of the lower end of the fissure of Rolando.
The fractured bone showed manj' extravasations
in the diploe.

FOREIGN CORRESPONDENCE.

LETTEK FROM EOXWOX.

(FROM ODR OWN CORRESPONDENT.)

London Hospitals and their Management — The
Metropolitan Water Companies' Filter Beds — Spi-
rone in the Treatment of Consumption — The use of
Poison for Criminal Purposes in India — The Death-
rate of Londo7i — Miscellaneous Topics.

The Government has pledged itself to take into
consideration the whole question of the London
hospitals and their management. Lord Sandhurst

1889.]

FOREIGN CORRESPONDENCE.

395

in a speech showed that ample rooai exists for
searching inquir}-. It is undoubtedly the case
that the multiplication of "special" hospitals
during recent years has seriously diminished the
incomes of the older institutions. This is a grave
matter in itself, but it becomes graver still if it be
true that the "special" hospitals are prone to
extravagance. Sir Andrew Clarke's fancy sketch
of the "Hospital for the Treatment of the Dis-
eases of the Great Toe " has a good deal of truth
at the back of its irony. It is not easy to see what
the Government can do to stop this state of things,
but even the knowledge that it hopes to do some-
thing may produce a beneficial effect for a time.

Major General Scott, the official water exam-
iner, in his forthcoming report gives a favorable
account of the condition and working of the Me-
tropolitan Water Companies' filter beds. A nor-
mal limit to the rapidity of filtration has now been
adopted, being at the rate of 2 ' j gallons through
each square foot of the filtering surface, which
consists of layers of sand and fine and coarse
gravel. The local companies' filtration during
last year appears to have been well within this
limit. Sand is the efficient medium. Turbid
water, however, after floods is difficult to deal
with. The solid impurities in suspension chiefly-
consisting of cla)', marl, and chalk in ven,- fineh-
divided state, can be got rid of only by long sub-
sidence previous to filtration. Turbid water must
of necessity be sometimes admitted, and filters are
then overtaxed. Great stress is laid in the report
upon the necessity of having cisterns properly
covered so as to exclude both light and dirt, and
they should be so placed that the water may be
kept cool in summer withou't being in danger of
freezing in the winter.

Spirone is the name given to a fluid which is
claimed to be of great use in the treatment of con-
sumption and a variet}- of pulmonary affections.
It is also stated to be verj- eflScacious in corj-za.
The quantity used is y^ oz. during the twenty-
four hours, and this is best taken by inhaling
about one-fourth of the total quantity for the
twenty-four hours, as soon as the patient awakes
or immediately after getting up. Another fourth
should be taken before going to bed, and the re-
maining half should be used at intervals in drib-
lets during the day, especially if at any time there
be a feeling of dryness, itching or tingling. The
spraj- should be applied by blowing it somewhat
vigorously against the back of the throat, making
the jet strike successively the different parts of
that region, the patient drawing it into the lungs
at the same time. Two whiffs in succession should
be given up each nostril, the head beiug thrown
well back, and kept in that position, so that the
spirone can trickle down the back of the throat.
The first whiff is often very painful, especially
for the first few days ; the second is less so — the
sensitiveness diminishing rapidly as the condition

of the mucous membrane improves. If two in-
halations up each nostril are sufficient to produce
entire relief thej' had better not be repeated dur-
ing the day. If, however, at any time the nos-
trils, back of the nose or throat again appear irri-
tated or uncomfortable, the application may be
repeated. It is found, however, well not to use
it for the nostrils more than four times altogether
during the twenty-four hours, and the spray must
not be delivered too forcibly, as in hay fever the
mncous membrane of the nostril may easily be
made to bleed, owing to its state of irritability
and congestion. In ha}- fever the treatment
should begin a few days before the expected at-
tack. Even if the remission of the sj'mptoms is
complete, the treatment must not be left off, or
even decreased for a week or ten days after the
expiration of the period during which the disease
generally lasts.

Some interesting reports are to hand relative
to the employment of poison in India for criminal
and other purposes during the j^ear 1888. It
would seem that the total number of such cases
dealt with in the Government of Bombay for the
twelve months was 360, while there were only
282 the preceding )-ear. This enormous increase
is accounted for partly from the fact that the use
of poison for criminal purposes is becoming in-
creasingly frequent each 3-ear. Vegetable poisons,
which were most extensively used a few years
ago, have been rapidly giving place to metallic
poisons. This is ascribed by Dr. Lyon, the ana-
lyst to the Government, to the ease with which
drugs such as arsenic are procurable at the pres-
ent time, there being practically no restriction on
their sale. Out of eighty-four undeniable cases
of human poisoning, arsenic was employed in
forty-one, copper iu six, mercur)- in five, pow-
dered glass in three, and red lead in three, while
of the remaining twenty-seven cases opium ap-
pears to have been used in fifteen, datura in five,
alcohol in two, prussic acid in one, and oleander
and other plants in four. According to Dr. Lyon
poisoning by means of powdered glass is, com-
parativeh- speaking, quite a recent innovation,
and hence the number of cases which had come
under his notice was smaller, probably, than it
otherwise would have been. The return points
irresistibly to the conclusion that deaths from
criminal administration of metallic poison are not
only common, but are in fact of increasing fre-
quency in India at the present daj\

Among the large towns of the United King-
dom, London during the past month, with a
death-rate of 18.6, holds an honorable place in
the latest returns of the public health. It is far
behind Huddersfield, which reports only 10.7,
and Derby, 12.2 ; but these are both ver>' excep-
tional returns. Next in order comes Brighton,
14.6, and Bristol, 16.4. Absolutely the most un-
healthy large town is Preston, with a death-rate

396

MISCELLANY.

[September 14, 1889.

of 48.6. In the metropolis the most serious zv- j troit, Mich
motic disease at present isdiohtheria, from which Advertisins Agency Boston Mass.; Dr. T. A^ Marcha
, ^ ^- 1 ^,' o 1 ^ r • Ciucmuati, O.; Dr. A. N. Bell, Brookh-n, N. \.; W.

there were forty-four deaths. Scarlet fever is ciearv, New York; Medical College of Ohio, Cincinn
prevalent, but the epidemic is of a mild form. O.; D'r. P " ' ' "■ -

Dr. J. G. Carpenter, Stanford, K}-.; Dodd's

Marchand,

P.

ati,

O. Hooper, Little Rock, Ark.; Dr. S. Solis-

Dr. Norman Kerr, who was first drawn to the Cohen, Philadelphia, Pa.; J. H. Bates, New York; Loug-

studyof inebriety as a disease while working as ™^"^'?''fV'^ ?,? ■ ' ■^'''T; ^''"', k' ^'^'l^,'^- ^'""J. "^'■^^'

-' r . ^ ^ ^^ ^ ^ ■ New \ork; Dr. W. E. Casselberrv, Chicago; Dr. C. O.

a temperance reformer, points out that certain ,.j,„lj.^._ jiadelia, Minn.; Dr. G. B. Dunmire, Philadel-
periods of life are accompanied by a special crav- ; phia. "

ing for stimulants, which disappears along with I

the physiological circumstances that caused the |

disturbance of the system. The habit of drunk- Official Lisi 0/ Changes in the Stations and Duties 0/

Officers iterving in the Medical Department, U. o.

Army, from August si, tSSg, to September 6, iSSg.

By direction of the Secretary of War, a board of medical
officers, to consist of Col. Edward P. Vollum, Surgeon;
Major Henry McElderri*, Surgeon; Major Washington
Matthews, Surgeon ; Capt. James C. Merrill, Asst.
Surgeon, is constituted to meet in New York City on
the ist day of October, iSSg, or as soon thereafter as
practicable, for the examination of Asst. Surgeons for
promotion and of candidates for admission into the
medical corps of the Army. The board will be gov-
erned in its proceedings by such instructions as it may
receive from the Surgeon-General. Par. i, S. O. 203,

enness, he asserts, ma}' also result from some ac-
cident— may, indeed, be a symptom of some ob-
scure brain disease.

Aix-les-Bains is grateful to British medical
men for their appreciation of its mineral waters,
and the municipality has recenth' determined to
honor the profession in the person of a distin-
guished London phj'sician, by giving to a new
avenue the name of Sir Alfred Garrod.

In view of the excessive prevalence of infant

mortality a select committee has recommended , ^ r. c ^♦^„i,=, -; ,qo

, -„ . ,, ^ . ,. . . I , , 1 1 A. G. O., September 2, 1009.

that the Friendly Societies Act should be so al- ^^^^^ p j ^ cieary. Surgeon U. S. Army, is hereby
tered that the age for the insurance of juveniles granted leave of absence for two months on surgeon's
be extended from 10 to 16 years, but that the' certificate of disability. S. O. 59, Hdqrs. Div. of the
total amount of insurance be absolutely limited, ^ Pf 'f^'^' San Francisco, Cal August 27, 18S9.

Capt. Joseph \ . Porter, Asst. burgeon, resignation has
been accepted by the President, to take effect August

and for the securitj- of infantile life suggests that
the Registrar-General .should add to the form of
medical certificate of death a column demanding ;

29, 1889. Par. II, S. O. 200, Hdqrs. of the Army, A.
G. O., August 29, 1S89.

MISCELLANY.

particulars of insurance on the life of deceased, ' Capt. Charles B. Ewing, Asst. Surgeon, granted leave of
^ , (.,, . i_ ^1 1 i • .,.i J ii. i absence for twentv-one days, to commence on or about

to be filled up by the doctor m attendance on the September 21, 1889, provided that at that time the post
family. surgeon, now on leave, has returned to duty. Par. 5,

S. O. 201, Hdqrs. Div. of the Atlantic, Governor's Is-
land, N. Y., September 4, 1889.
First Lieut. W. B. Banister, Asst. Surgeon, granted leave
of absence for fifteen days. Par. 2, S. O. 82, Hdqrs.
Dept. of Ariz., Los Angeles, Cal., August 23, 18S9.
The garrisons of Ft. Laramie, W. T., Ft. Hays, Kan.,
and Ft. Lvon, Col., will be withdrawn and the posts
named will be abandoned as soon as it can be done
with due regard to economy. By G. O. 6g, A. G. O.,
August 31, 18S9.

Official List of Changes in the Medical Corps of the U. S.

Navy for the Week Ending Scptemh'r 7, i8Sg.

P. A. Surgeon F. S. Nash, detached from the "Dale"
and ordered to duty in the Bureau of Medicine and
Surgery.

P. A. Surgeon A. C. H. Russell, ordered to naval hospi-
tal, Yokohama, per steamer of September 28.

P. A. Surgeon C. H. H. Hall, detached from naval hos-
pital, Yokohama, on reporting of relief, and return
home.

Asst Surgeon S. S. White, detached from naval hospital,
New York, and ordered to the "Minnesota."

Asst. Surgeon E. P. Stone, detached from the " Minne-
sota," and wait orders.

Asst. Surgeon P. H. Bryant, detached from the ".\jax,"
and ordered to naval hospital, Norfolk, Va.

Asst. vSurgeon A. R. Wentworth. detached from naval
hospital, Norfolk, Va., and wait orders.

American Academy of Medicine. — The Annual
Meeting of the Academy, for 1889, will be held at
Chicago, 111., November 13th and 14th, being postponed
to that date liy authority of the Council.

Richard J. Dunglison, Secretarj'.

Philadelphia, Sept. i, 1889.

LETTERS RECEIVED.

Dr. S. O. Bowen, Eastford, Conn.; B. Westermann &
Co.. New York; Dr. Jno. G. .\mes, Marblehead, Mass.;
Dr. W. H. Ashley, Shelburne Falls, Mass.; Dr. J. A. Hin-
ton. Friendship, Tenn.; Shelby Morgan, Shelby, Ind.;
Dr. John S. Marshall, Green Spring, O.; Dr. Samuel A.
Fisk, Denver, Col.; Dr. John B. Hamilton, Surgeon-Gen-
eral U. S. M. H., Washington ; Dr. Herbert H. Judd,
Galesburg, 111.; Dr. J. G. Carpenter, Stanford, Ky.; Dr.
H. R. vStorer, Newport, R. I.; Dr. J. B. Lawrence, New
York; E. J. Hirsh, Ann Arbor, Mich.; Dr. Hubert S.
Johnson, Lowell, Mass.; Dr. C. S. Pixley, Elkhart, Ind.;
Dr. Wm. C. Bane, Cannonsburg, Pa.; Dr. D. Mason, Spo-
kane Falls, Wash. Ter.; Dr. F. Terrier, Paris, France,
Surgeon-Major Chas. D. Greenleaf, Washington; Dr.
Marv Green, Charlotte, Mich.; Dr. C. T. Keniniurer,
Eldr'idge, la.; p;. Steiger & Co., New York; Hon. W. P.
Sheffield, Newport, R. I.; National Surgical Institute;
Indianapolis, Ind.; Dr. Wm. Perrin Nicholson. Atlanta,

CORRIGENDUM.

In the address of the Hon. Wm. P Sheffield, appearing in The
JotRN.M. of .August 24. the closing sentence of the third paragraph.

second colnnin.'page Jsi. should'read : " He came while the court
Ga. ; W. M. Thayer & Co., Chicago; Geo. S. Davis, De- 1 wasin session, and afterthe^nVi/nnrfsentenceof Mrs. Hutchinson '

THE

Journal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.
PUBLISHED WEEKLY.

Vol. XIII.

CHICAGO, SEPTEMBER 21, 1889.

No. 12.

ORIGINAL ARTICLES.

NASAL BACTERIA IN HEAI^TH.

Read in the Section of Laryngology and Otology at the Fortieth An-
nual Meeting 0/ the American Medical Association , June, iSSg.

BY JON.\THAN WRIGHT, M.D.,

OF BROOKLYN. N. Y.

The position which microorganisms will ulti-
mately take in their relation to the morbid pro-
cesses of disease has not been determined as yet.
Indeed, we seem now only at the beginning of
an unknown region in which, possibly, lies hid-
den the mj'stery- of the etiologj' of man}- patho-
logical changes. Encouragement in the region
of preventive medicine, under which head we
must include all that Listerism has done for sur-
gery, lends zest to the attempts to follow the mi-
crobe into the human organism and there annihi-
late. The almost complete failure thus far has
given professional cj'nics an opportunity for a
somewhat galling criticism. These failures are,
no doubt, in a large measure due to our as yet
very incomplete knowledge of the varj'ing con-
ditions and influences which complicate the rela-
tions of microbes to the human organism. What-
ever opinion the clinician may have of the part
played bj- them in the etiologj' of the diseases he
observes, even the most skeptical must admit that
the burden of disproof must have been thrown
upon the doubters.

With the increased probability that many pul-
monary and nasal diseases owe their origin, in a
large degree, to microorganisms, it becomes im-
portant that the bacterial contents of the respira-
tory tract, in a state of health, should be known.
Before we are in a position to investigate a pa-
thological process, we must have a firm physio-
logical basis on which to stand. Before we seek
for a pathogenic microorganism in disease we
should know what exists in the situation in a con-
dition of health. The ingress of all infective
agents must, in the vast majority of cases, be
through the nose or the mouth ; those of the
respirator)' tract, as a rule, through the former :
those of the alimentan,' tract, as a rule, through
the latter. The bacterial contents of the mouth,
in health, have been so thoroughly investigated
by Biondi,' Vignal," Netter,' Fraenkel' and others,

that further researches would seem superfluous
when our knowledge of the nasal microorganisms
in health is so slight. As laryngologists we are
becoming more and more impressed with the ne-
cessity of normal nasal respiration and the harm
of mouth breathing. In the further advance of
nasal bacteriology we may find another reason
to urge the importance of pureh' nasal respira-
tion. When we remember the apparatus of
Hesse* for air anal5^sis, the configuration of the
internal nose would seem admirably adapted to
arrest the progress of microbes carried into it by
the air current ; and still further, it has been
conclusively proved that bacteria never rise from
a damp surface, however strong the blast may be
over it, unless carried along by some particle of
water, or mucus, or solid matter. Hence we
should expect to find innumerable varieties of
bacterial forms derived from the air, and might
well despair of reaching an}' definite conclusions
in the matter. Besides the bacteria of phthisis
and pneumonia and the microbe of diphtheria,
whether it be the bacillus of LofSer or the strep-
tococcus of Prudden, there seems good evidence
that some purelj^ intra-nasal diseases depend
upon microorganisms for their origin or their
subsequent course. A perusal of the researches
of Lowenberg," Klammann," Thost,* Seifert,'
Strauch,'" Valentin," Hajek,'- Reimann," and
others into the etiology of ozsena and coryza
must convince us of the truth of what Walb" says
of ozaena. "I am convinced," he says, "that
the way opened by L,6wenberg will lead to the
discovery of the nature of ozsena. Whether the
Lowenberg coccus or some other is the cause ot
ozasna is of no consequence ; it must exist and it
is to be hoped that it will be found."

Whether there is a bacterial connection be-
tween corjza and pneumonia as claimed by Thost^
and further urged by Cardone,'* it is impossible,
with our present knowledge, to form anj- opinion.
Notwithstanding the abundance of literature to
be found on the bacteria of nasal diseases, there
is ver>^ little, in fact no, sj'stematic examination
of the normal nasal secretions for bacteria record-
ed in the somewhat extended range of literature
to which I have had access. However instruc-
tive the staining of nasal secretions for bacilli and
cocci, as a matter of technique, maj' be, there is

398

NASAL BACTERIA IN HEALTH.

[September 21,

little or nothing else to be learned from it with-
out the aid of the improved methods of culture
tests. I have therefore omitted extended refer-
ence to this class of work. The mere presence of
microorganisms in nasal secretions was estab-
lished many j-ears ago. Bernard Fraenkel, in
Ziemssen's Encyclopaedia, in 1876, in his article
on "Acute Coryza," saj's : "A large number of
these little structures recently so much spoken of
and called micrococci, ma}- generall}' be seen also
covering the cells." And he refers to Hueter'" as
claiming these bodies to be the source of irrita- 1
tion in cor3-za. Herzog'" in iSSi found many ba- '
cilli and cocci in normal and abnormal nasal se-
cretions, more abundant in the latter, and espe-
ciallj' in foetid nasal catarrh. Eugen Fraenkel,'*
on the other hand, in 1882, stated that he could
find no bacteria in the normal nose, and his work
on Ozsena, in the secretions of which he found
four kinds of bacteria, has been widely- quoted,
but in the light of our present bacterial knowl-
edge it possesses on this point only historical in- 1
terest. Later observations have all been made ,
incidentally in connection with bacterial investi-
gations of disease. Bernard Fraenkel," in 1886,
found in the normal pharynx, besides the staphy-
lococci pyogenes aureus and albus, a micrococcus
which often appeared as a diplococcus, and did
not fluidify gelatine. Probably the same coccus
was found in the normal retro-pharynx by Hack,="
and fulh- described by his pupil, Strauch.-" The
latter asserts that it is also found in the nose, but
less frequently and in fewer numbers. Both Low-
enberg" and Hajek'- failed to find microorganisms
at all constant or abundant in normal nasal se-
cretions. Reimann,''on the other hand, described
two forms as nearly always found ; one a plump
round ended bacillus, and the other a little coccus
which occurred usually in pairs but often in longer
chains. Considering the extensive and very thor-
ough work done upon the bacterial contents of
the mouth in health, it is singular that there
should be such a lack of it in the nose.*

My own obser\^ations were made during the
last two j-ears in the laboratory of the Alumni
Association of the College of Physicians and Sur-
geons, under the direction of Dr. T. M. Prudden,
to whose kindness and careful oversight the little
which may be of value in them is due. The ma-
terial was drawn from the Dispensary of the
Roo.sevelt Hospital. Although a luimber of other
cases were examined, it is mj- purpose to record
here only those investigations made in fairly nor-
mal cases, leaving the examinations in the other

* At the l.TSt meeting of the Russian Congress in .St. Petersburg.
Besscr reported having examined the nasal secretions of 8i pa-
tients, the l>ronchial secretions of lo, and the secretions of the
frontal sinuses in 5. Out of the nasal and bronchial secretions he
cultivated the Fraenkel-Weichselbanm diplococcus of pneumonia
in 14 cases, the staphylococcus i>yogenes aureus in 14 cases, and
tile streptococcus pyogenes in 7 cases. I'nfortnnately. I have not
been able to procure the original article and the reference in the
Cfnttalbtatt /iir Itac/frio/ut^u', Bd. V, No. 21. is incomplete, not giv-
ing the conditions under whicli they are found.

cases for further amplification and another occa-
sion. The method of work was as follows : Por-
tions of the nasal secretion were removed from
the mucous membrane covering the turbinated
bones and adjacent portions of the septum, in the
loop of a long platinum needle previously steril-
ized in the flame. This was immediately plunged
into two gelatine tubes and streak cultures were
made upon two agar-agar plates. Thus four in-
oculations were made from different portions of
the nasal chambers in each case. Besides this a
number of drj- cover-glass preparations were made
of the nasal secretion in each case, and stained
by Gram's method and by simple double stain-
ing. These last frequently showed no bacteria
when the culture-tests proved their presence in
great abundance. The gelatine tubes were plated
according to Koch's method, and pure cultures
obtained and transferred to culture media tubes
of agar-agar, 5 per cent, glj-cerine-agar, gelatine,
bouillon, milk and potatoes. The same was done
I with pure cultures obtained from the streak cul-
1 tures on the agar-plates. The growth character-
istics were noted and compared with description
j in the works of Fliigge, Fraenkel, Eisenberg, and
others, and where close correspondence was ob-
; served their denominations were accepted. Those
forms found not to correspond to anj' description
were, as a rule, carefulh' worked out and the rec-
ords preserved, but it is unnecessary to describe
I them here, as they were onh' found in isolated
1 cases. All the usual precautions were taken
against contaminations, and, in addition, only
I those colonies selected from the plates which were
in sufficient immbers to preclude the possibilitj^ of
contamination and to eliminate, as far as possi-
ble, those microbes which had only recently be-
come nasal inhabitants and had not yet grown in
the nasal secretions to any considerable numbers.
When one remembers the multitude of air bacte-
ria which would naturally lodge against the nasal
mucous membrane, and be onh- accidentally vis-
itors to a soil unsuited to them, this precaution
will not seem uncalled for. In all cases care was
taken to ascertain that no nasal douches of any
kind had been previously used. An\' one, even
! those unfamiliar with the technique of bacterial
analysis, will appreciate the amount or work re-
j quired where so many different forms had to be
carefully worked out ; and that maj- be pleaded
as an excuse for the limited number of cases
brought forward. In the ten cases mentioned
the condition of the mucous membrane was as
nearly normal as possible, and even where insig-
nificant changes were observed they are noted.
The class of cases were not as diversified as could
be desirable, as they were all dispensary patients.
I made several bacterial analy.ses of the air of the
Dispensarj- from time to time by Petri's and Sedg-
wick's methods, and by exposure of agar plates.
At no time was there anj- growth but those of

1889.]

NASAI. BACTERIA IN HEALTH.

399

simple air bacteria noted. The nasal bacterial
forms were found to vary markedl3' with the state
of the weather and of the streets. High winds
and dry and dusty streets were sure to fill the
noses with air bacteria. In rainj^ weather, or
after several days of calm, or when snow was on
the ground, aerial forms were much more rare.
It seems to me there can be only one cause for
this, viz. : They tend to disappear because they
have found a soil unfitted for their growth, and,
according to the universal law of natural selec-
tion, give way to microbial forms more favored
by the conditions, It certainly is not because
they flow away in the secretions, because it is not
only their absolute frequency which varies, but
their frequency relative to other forms. The re-
action of the secretion of the normal nose was
found to be neutral or slightly alkaline.

Case I. — Young man in fair health with excep-
tion of slight cough. No pulmonarj- lesion ;
slight hypertrophy of one turbinated bone ; nose
otherwise normal. A short plump bacillus, look-
ing at times like a diplococcus ; slow white growth
on gelatine, which it does not fluidif}'. Same on
agar, spreading slightly on surface.

Case 2. — Young girl with slight tonsillar en-
largement ; nose normal ; general health good.
Bacterial analyses were made on three separate
occasions, and twice was found a nearly pure cul-
ture of the staphylococcus pyogenes aureus. The
tonsils were examined and the same growth found
there. Inoculations of pure bouillon cultures in
the jugular of rabbits set up purulent pericarditis
and endocarditis, of which the animals died. The
pus swarmed with the cocci.

Case 3.. — Boy of 17, who had a perforation of
the septum and hard palate from a syphilitic pro-
cess. All ulceration had long healed and the
mucous membrane was normal in appearance.
The staphylococcus pyogenes aureus was found
in large numbers, and a moderate growth corre-
sponding to the bacillus lactis aerogenes.

Case 4.. — Man of 35. A few weeks previously
had been discharged from Roosevelt Hospital af-
ter a severe operation for the removal of a thyroid
tumor. The wound had healed by first intention.
Left laryngeal paralysis resulted. The nose was
perfectly normal in every way. The staphylo-
coccus pyogenes aureus and albus were both
found and abscesses caused by the injections of
pure bouillon cultures of each beneath the skin
of rabbits. From these absce.sses new cultures of
the same growths were obtained in each case.

Case J. — Child 10 years old. No subjective
nasal symptoms, but the mucous membrane of
the nose is slightly hypersemic. In this case also
both the staphylococcus aureus and albus were
found, and positive results obtained from animal
inoculations.

Case 6. — A seamstress aged 16. She had had
considerable post-nasal catarrh but no purulent

secretion. Nose normal and health good. Two
examinations six weeks apart were made. Each
time in the nares was found abundant growth
of the ordinarj' mould, the pencellum glau-
cum. Each time pure cultures were obtained
from the post-nasal space of the streptococcus py-
ogenes, A pure bouillon culture was injected
beneath the skin of rabbits' ears and an erysipel-
atous inflammation produced, from the sanious
pus of which cover glass preparations were made
showing abundant cocci in chains. At the sec-
ond examination a culture of a gas-producing ba-
cillus was also made from the tonsils. The most
careful questioning could elicit no history of ex-
posure to contagion of any kind. She herself
was in the best of health except the discomfort
from her post-nasal catarrh.

Case 7. — Girl, aged 16; cigarette maker. There
was slight hypertrophy of the nasal mucous mem-
brane and some tonsillar injection. The staphy-
lococcus pyogenes citreus was found in the nose.

Case 8. — Child, aged 4. Slight post-nasal ca-
tarrh and slightly enlarged tonsils. Nose normal.
In it was found the micrococcus flavus desidens.

Case g. — Man, aged 19, with follicular tonsilli-
tis and post-nasal catarrh. This case presented
considerable structural change, and I insert the
record here because, in spite of the large amount
of secretion present, onlj' aerial forms were found.
They were the micrococcus flavus desidens and
micrococcus cereus flavus, and an undetermined
coccus with a curious growth on agar and gela-
tine, a description of which would be out of place
here.

Case 10. — Woman, aged 20, with slight attack
of laryngitis. She was recovering from corj^za,
and there was some mucus .secretion in the nose.
The bacterial contents were as follows :

1. Staphylococcus pyogenes aureus.

2. Micrococcus flavus desidens.

3. A tetrad resembling closely the descriptions
of the micrococcus tetragenus.

4. An undetermined coccus, with a white non-
fluidifying growth on gelatine and agar.

o <u « aj

cn u cc rt

Total, 10

y tn a

o 3 u

3 ifl a

3 a

T^ 3

a 3

a c3

3 3

U 3

u a>

3 VI

Si!

3

The three last cases were examined during
windy, dusty weather, and illustrate well, espe-

400

NASAIv BACTERIA IN HEALTH.

[September 21,

daily in the last case, the unreliability of cover-
glass preparations alone of the nasal secretions in
determining bacterial species, as the morphologi-
cal appearance in four out of the five organisms
was the same.

To summarize :

In six cases, the staphylococcus pyogenes.

In three cases, the micrococcus flavus desidens.

In one case, bacillus lactis aerogenes.

In one case, pencellum glaucum.

In one case, micrococcus cereus flavus.

In one case : Micrococcus tetragenus.

Once in each of three cases : Different unde-
scribed forms.

The air forms may be dismissed without fur-
ther consideration. The micrococcus tetragenus
found in only one case and in few numbers, need
only receive a passing mention. In Case 6 the
only organism in the nasal chambers proper,
which was made out by two careful examinations
at different periods, was the ordinarj' mould, the
pencillum glaucum. It was in such great num-
bers that it possibly may have overshadowed the
growth of other forms. Considering its great
aerial frequency, it is singular that it was not
more often found. In this case the streptococcus
pyogenes was twice found in the naso-pharynx,
which was the seat of a chronic catarrhal inflam-
mation, but which showed few changes in the
mucous membrane besides the reddening of the
surface and the increased secretion of mucus.
For its pathogenic significance in the air-passages
the works of Netter,'-'"' Prudden" and others may
be referred to.

Our attention is therefore directed to the staph-
ylococcus pyogenes ; the three varieties, aureus,
albus and citreus, need only be considered as one
in their pathogenic significance. We know as
yet too little concerning the conditions under
which this organism exerts its characteristic in-
fluence, to draw conclusions. It may be well,
however, to refer to the statements of a few of the
various workers in this field.

UUmann'" found the staphylococcus in the air
in different situations and under varsing condi-
tions, as well as in the water of the river Spree.
He and others found it in the earth, on the streets
and on the walls of various rooms and buildings.
As to man, he says, " Fiirbinger found it in the
dirt under finger-nails, and Bumm in the folds of
the nipples. Biondi obtained cultures of it from
the saliva, and Fraenkel from the tonsils. I have
found it not only on the buccal mucous mem-
brane, in the saliva, the tonsils, the pharynx and
vagina of healthy people and of animals, but in
the oesophagus, intestinal tract and bladders of
recently killed animals. Lustgarten and Manna-
berg found it constantly in the urethra. These
investigations .show that the staphylococcus is
ver3' widely distributed, and that it is found wher-
ever living beings are."

From this we see that its verj- frequent occur-
rence in the nose forms no exception to the rule.
It will require investigation of man}- more cases
than those here cited to prove that it is the most
frequent and abundant microorganism in the na-
sal chambers. Netter,'" in speaking of the influ-
ence of pathogenic microorganisms in the mouth,,
nose and ears, says : ' ' The presence of the mi-
crobes is not enough. It is necessary- that they
should be present in sufficient quantity to triumph
over the resistance which healthy anatomical
structures offer them. It is necessary that their
virulence should be sufficiently great, and we
know that their virulence is not always the same.""

He might have also said that the resistance of-
fered them is not always the same. On this head
the work of Bujwid'' is suggestive. He found
that in round numbers a billion staphylococci au-
rei for a rabbit, a hundred million to a billion for
a rat, and a hundred million for a mouse, could
be injected beneath the skin of a healthy animal
without result, no abscess forming. =•= When, how-
ever, grape sugar had previously been introduced
into the animals' system they succumbed. Rib-
bert^' and his pupils. Fleck"' and Laehr', caused
a catarrhal inflammation of the bronchi, with more
or less a broncho-pneumonia, by injection of pure
cultures of the staphylococcus into the trachea.
Their investigations, as well as those of Wyssok-
owitsch," tend to show that the lungs or the ad-
jacent bronchial lymphatic glands, act as a sort
of filter or as a place of destruction for the mi-
crobe, preventing their further penetration inta
the human organism.

Prudden" repeated the experiments of Fleck
and Laehr with like results ; he also succeeded
in causing broncho-pneumonia bj- injections of
pure cultures of the streptococcus diphtherise and
b}^ injections of ammonia.

Ltibbert^* caused fibrino-purulent tracheitis and
bronchitis bj' injections of a pure culture of the
staphylococcus into the trachea. It is asserted
by man)- investigators, and their assertions are
based upon extensive experiments, that it is the
pavement epithelium which prevents the entrance
of the various microbes into the subjacent struc-
tures and thence into the general sj-stem. The
verj' general experience of larj-ngologists would
hardly bear this out as regards the staphylococcus,
since tonsils and uvulae are cut without fear of
septic invasion, and in all the operations upon
the mucous membranes of the mouth and nose
this is the least danger we fear. If, however, a
patient bites the operator's finger so as to break
the skin, unless the wound is thoroughly washed
out with an antiseptic, local suppuration often

* since this paper was written, the very valuable papers of
Buchncr tCcntralbl. f. Bact., iv. 25. and v, i), and Nissen iZeitsch.
f. Hygiene, vi. 3*. have come under my observ'aliou. They ^ve
convincing proof that it is the albumin' in the blood plasma that
exercises the destructive influence oti bacteria in the circulation.

1889.

NASAL BACTERIA IN HEAI.TH.

401

follows, and occasionally, from this, general
sepsis .

I have mentioned the above facts and observa-
tions in order to show how little we as j'et know
and how vastly much more we have to learn
about this comparatively well-known microbe so
often found in the upper-air tract of healthy peo-
ple. Before closing this already too extended con-
tribution, I wish to make mention of some inves-
tigations, as 3'et very incomplete, which I have
been engaged upon during the last two months,
more in the hope that others with more leisure
and better opportunities will continue them, than
from an expectation of adding much to our
knowledge. I refer to the nasal chambers as a
bacterial filter of the air passing through them.

It has been definitely proven by the investiga-
tions of Grehant,'" Paulsen,'' Aschenbrandt'^ and
Bloch'^ that the nasal chambers are not only
warmers and moisteners of the inspired air, but
act also as a filter for fine dust particles. The
latter observer experimented with many sub-
stances in fine powder, and came to the following
conclusion, as did Grehant and Aschenbrandt :
"A certain part of all kinds of dust, even the
finest, is held back ; the larger part of the formed
substances which float in the air do not reach the
entrance of the larynx, or even the choanas, but
it is impossible for the nose, even with the help
of the uaso-pharynx, to completely free the air
even from the coarser kinds of dust. ' '

Now a bacterium, whatever its relative propor-
tions to other divisions of matter with which we
are familiar, is a ponderable, substance, heavier
than air, water or any of the animal fluid secre-
tions. It is therefore subject to the same physical
laws. It is yet an unsolved mystery how the
bacillus tuberculosis reaches the most frequently
chosen seat of its selective action in the apices of
the lungs and how the pneumococcus usually
reaches the lower lobes before we have lobar
pneumonia. To a bacteriologist it is almost in-
conceivable how a microbe entering the anterior
nasal meatus with the tidal air should go through
the tortuous, moist passage of the nose, past the
broad surface of the palate and the post-phar-
yngeal wall into the larynx, between the false
and true vocal cords, down the long tubes of the
trachea and bronchi, and finally find a lodging
place on the walls of the bronchioles and air-cells.
The chances of its being arrested before it reaches
them seem almost infinite, especially since the
tidal air must stop at a comparatively high point
in the respiratory channel in inspiration, and flow
upwards again on expiration. Neither does it
seem probable that becoming arrested at some
higher point it flows downward with bronchial
.secretions, when we remember the ciliated epithe-
lium and its function. The lymph channels have
been strongly urged as an explanation, but, al-
though our knowledge of the pulmonary lym-

phatics is very limited, there are many objections
to this vague theory which will occur to every
one. The day for theorizing has gone b}^ A
theory now-a-days should be considered as little
better than confession of ignorance. However
small and insignificant an addition to our knowl-
edge, the ascertaining of the capacity of the nose
as a place of arrest for microbes may be, it seemed
so easy of demonstration that I have attempted
it. The technical difficulties were many, but
have been fairly overcome, though it needs a
much more extended and varied research than I
have yet made to draw conclusions. The task is
easily stated : Ascertain the bacterial contents of
the air before and after it has passed through the
nose. Glass tubing of a calibre of ^s to J4 of an
inch in diameter and 6 inches long was filled with
granulated sugar for 3I2 inches of its length, held
in place at the bottom by a piece of rolled copper
gauze, tightly fitting the tube, leaving enough
space at each end for the insertion of a cotton
plug. The sugar grains were of a uniform size
of forty to the inch. This part of the apparatus
was copied from that of Professor Sedgwick and
G. R. Tucker, of Boston, to whom I am greatly
obliged for a description of their method of air
analysis, kindly sent to the College Laboratory'
some time before it was communicated to the So-
ciety of Arts, in whose proceedings for 1887-1888
it may be found. Their rules for sterilization of
the sugar and the apparatus were also followed.
For reasons which I need not stop to explain here
it was found best to vary their procedure consid-
erably and adopt, to some extent, the method of
Petri,'* with sand. After proper sterilization the
glass tubing was attached, by means of stiff rub-
ber tubing, to an air-exhaust apparatus. As there
was a good head of water in the laboratory a
Sprengel's air-pump was principally used, by
means of which one litre of air could be drawn
through the 3>.. inches of sugar in from forty
seconds to one minute. Usually, however, a very-
perfect air-exhausting apparatus may be obtained
by making use of the Allen Surgical Pump, of
the size used for veterinary purposes, which I
show you here, in coiniection with the air filter.
About one hundred revolutions of the handle of
this instrument, which can be made in forty-five
seconds, or a minute, will exhaust one litre of air.
With either contrivance it is perfectly easy to
ascertain the rate at which air will pass, by means
of a litre-flask inverted in water. It has been
proved by Sedgwick, and I have verified the
statement, that air passing at about this rate will
deposit all its bacterial contents in the sugar.

With this apparatus, then, 10 litres of air are
drawn through the filter after the cotton plugs
used during sterilization have been withdrawn.
Then 10 litres of air at the same time and in the
same locality are drawn through the nose and
also through the filter. This is accomplished as

402

NASAL BACTERIA IN HEALTH.

[September 21,

follows : The glass tubing with its load of gran-
iilated sugar, all thoroughly sterilized, is enclosed
by means of a perforated rubber cork in a larger
piece of glass tubing and the space between the
two loosely packed with absorbent cotton. The
■end of the smaller tube does not reach to the end
of the larger. The filter thus protected from the
bucal secretions is put in the mouth and the lips
■closed firml}' around the outside tubing. If held
in a horizontal position in the mouth nothing but
air can enter the filter when the suction is begun.
During alternate periods of fifteen seconds each
the person is directed to hold his breath, making
the thoracic walls rigid. Thus practically all the
air drawn through the filter must have first passed
through the nasal chambers and the post-nasal
space. During the fifteen seconds of respiration
the air-current is shut off" by compressing the rub-
ber tube between the filter and the suction appar-
atus, consequently the time consumed in the ex-
amination of the nasal air is twice that consumed
in the control examination. The plan adopted
by Aschenbrandt and others of drawing the air
up one nostril and down the other before exam-
ination, besides other faults, permits the entrance
of mucus into the air filter, which it is impossible
■to protect from contact with the walls of the nasal
■chambers.

After the 10 litres of air are drawn through in
-each case the sugar is dampened and partly dis-
solved with a few drops of carefuUj- sterilized
•water to facilitate its removal from the glass
tubing. By means of a sterilized, stiff brass rod
the wire gauze is pushed along the tubing, forcing
the wet and partly-dissolved sugar out into shal-
low glass dishes, where it is thoroughly dissolved
and mixed with 10 per cent, nutrient gelatine.
The glass tubing is filled with gelatine and
stopped at both ends with cotton. The gelatine
in the dishes is allowed to solidify slowly, so as to
insure the complete dissolving of the sugar. It
was found that very few, in many cases no colo-
nies developed in the glass tubing, so completely
did the .sugar carry along its bacterial contents
with it when pushed out. I have described the
process hurriedlj- and omitted descriptions of the
routine precautions taken in .sterilizing, control-
ling and guarding against aerial contaminations
which belong to the technique of careful bacterial
analysis.

The colonies developed after several days in
the two .sets of dishes were counted and compared.
As I said before, too few examinations were made
to arrive at hard and fast conclusions. I only
experimented on my own nose, and have suc-
ceeded only recently in getting results free from
errors of technique. Speaking in a general waj',
the nasal chambers in my own case seem capable
of filtering out about three-fourths to four-fifths
of the bacterial contents of the air passing at the
-rate of one litre per minute. The photographs

of an examination made during the presence of
a considerable quantit}- of mould in the air, illus-
trate this fairly well. This particular experiment
was photographed because the white moulds
show the difference in a more striking manner
than bacterial colonies, but the same proportion
seems to hold good with them, as for instance, in
an examination made April 25th of this year :

Ten litres of laboratory air contained 4 moulds
and 125 bacteria.

Ten litres of laboratory air after passing
through nose contained i mould and 24 bacteria.
Of course noses must differ in this respect as
in other ways, and the rapidit}' of the current we
know makes a difference in the number of both
moulds and bacteria deposited in Hesse's appar-
atus. Counting 500 cc. as the tidal air with each
inspiration, we have about nine litres per minute
passing through the nasal chambers in normal
respiration. In the experiments just mentioned
the rate was only a little over one litre per minute.
In spite then of the apparently well-adapted ar-
rangement of the nasal chambers for a bacterial
filter, even at this rate, a really large number of
■ bacterial forms are carried at least into the larynx.
It is to be hoped that further and more complete
and reliable investigations will confirm or refute
i this somewhat premature assertion. Unless we
I throw aside the verj- numerous and careful obser-
: vations made by bacteriologists in pulmonarj-
diseases as useless, it is surelj- of the greatest
importance that we should know something of the
I mode of ingress of microbes into the deeper pul-
i monary tracts.

Dr. John McKenzie, of Baltimore, thought
the solution of manj- points in nasal pathology
bj' bacterial investigation would not be an event
of the immediate future. The problem is an
intricate one, especially in vie%v of the constantly
changing environment of the individual. The
dependence of ozena on micrococci has not been
determined.

> Biondi. Zeitsch f. Hygiene, Bd. ii, 1887, p. 194.
■ Vignal. Coiiiptes rendus de IWcademie des Sciences de Paris,
Tome XV, No. 6, p. 311.

3 Netter. Bull. Med. ii, aun^e No. S9, p. 977.
4E. Fraenkel. Deutch Med. Woch.. No. 6, 18S7.

5 Hesse. Deutsch Med. Woch., Nos. 2 and 5, 1SS4.

6 1,owenberg. Deutsch Med. Woch.. Nos. i and 2, 1S85.
7Klaniniann, AUii. Med. Central Zeit., No. 67, 18S5.
SThosl. Deutsch Med. Woch.. 1SS6.

9Seifert, \'olkmaun's Vortriige. No. 240.

'oStrauch, Monatsch. f. Ohreuheilkunde. Nos. 6 and 7, 1887.
" Valentin, Corresp. lilatt. f, Schw. .\ertxte. No. 51, 1887.
"Hajek. Berl. Klin. Woch., No. .y, i8i>S.
'iKeiman, Inaug. Dissert.. Wiirzbur^, 1887.
'4WaIb, Erfahrungen, auf dem Gebietc der Nase uud Racheu
Krankheitcu, Bonn, is.s.s.

■sCardone. .\rchivi Ital. di Laryngologia. July, 1SS8.

'''Hucter, AUg. Chinirg., Leipzig, 1S73, p. 257.

»:Herzog, Wiener Med. Presse. 1S81, No. 29, ct seq.

'^E. Kraeukel, Virch. Arch.. No. 90.

"jB. Fraenkel, Berl. Klin. Woch., 1SS6, No. 17. p. 367.

-' Strauch, Monatsch. f Ohrenheilkunde, 1S.S7. No. 6, p. 151.

-" Prud<len, .-Vni. Jour. Medical Sciences, .\pril. May, June, 1889.

-Netter, Annnlesdes Mai. de I'Oreville, etc.. Oct., 1S88.

-il'llmanu, Zeitsch f. llvgiene, Bd. iv. Heft I.

-4Iluiwid. ref. Ceutralbl. fur B.ict., No. 9, 1S88.

-5 Kibbcrt, Deutsch Med. Woch., No. 4S. 1884.

-•"Klcck, Dissertation. Bonn, 1SS6.

-rl.aehr, Dissertation. Bonn. 1S87.

1889.]

LOCAL BOARDS OF HEALTH.

40J

THE IMPORTANCE AND ESSENTIAL

NEEDS OF LOCAL BOARDS OF

HEALTH.

Read in the Section of State Medicine, at the Fortieth Annual Meet-
ing of the American Medical Association, June 25, 1889.

BY WILLIAM C. RIVES, M.D.,

FORMERLY SECRETARY BOARD OF HEALTH, NEWPORT, R. I.

Although much has been said and written upon
the subject of local health organizations, the in-
diiference which is still wideh' prevalent in our
country', outside of the large cities, in regard to
the necessity for the formation and proper admin-
istration of such bodies, and the great intrinsic
importance of the question itself, furnish some
reasons for additional remarks.

The protection and preser\'ation of health
through measures taken against those dangers
which threaten it from preventable causes is a
subject which not only concerns sanitarians but
also ever3^ member of a communitj-, and as these
measures must necessarily depend chiefly upon
the local board and its health ofEcer, the value of
efficient boards of health cannot be overestimated
if the advantages of sanitarj' measures are to be
regarded at all. It is, indeed, unnecessary' to re-
mind any intelligent man who has paid the least
attention to sanitan.- science of the importance of
local boards of health ; yet, while all thoughtful
persons appreciate the need of them, there are
manj' communities which are not alive to this
necessitj', as is evinced by their unwillingness to
have a local board, or else by their failure to con-
fer sufficient powers upon it or to contribute their
hearty support after it is established.

It is, notwithstanding, a matter settled bej-ond
the possibility of question, no longer admitting of
argument, that the proper enforcement of suitable
health regulations and due attention to sanitary
requirements have achieved most striking results
in reducing the g'eneral death-rate, and in limit-
ing especially the prevalence of the zymotic dis-
eases and of others whose occurrence is facilitated
by local uncleanliness or unsanitan,- conditions.
Through the exertions thus made for the preven-
tion of disease, other advantages have ensued.
The aid afforded by the application of sanitary
principles in promoting the advancement of Chris-
tian morality by improving the condition of the
wretched abodes of the poor in the large cities
and by the prevention of overcrowding is of in-
calculable benefit ; the saving of expense which
has been often estimated in particular instances,
is perhaps not too strongly expressed in the lan-

-SLiibbert, Der Staphylococcus pyogenes aureus und der Osteo-
niyelitisKioccus, Wiirzbur'g, 1S86.

roWyssokowitsch. Wien. Med. Presse, No. 6, 1S89. p. 231.

^t'Grehant, Recherches Physiques sur la Respiration de
THorame. Paris. 1S64,

3' Paulsen, Separatabdruck aus dem LXXXV, Bd. d. k. Akad.
der Wissenchaft, Abth. 3. 18S2.

'-■ Aschenbrandt. Die Bedeutung der Nase fur die .\thmuug.
Wiirzburg. 18S6.

.»3Blocii. Zeitsch fur Ohrenheilk, Bd. xviii, p. 215.

34 Petri, Zeilsch fur Hvgiene, 18S7, iii, S. i.

guage of Mr. Gladstone in one of his addresses :
' ' There is no greater economy than the saving of
human life. ' '

It is needless for me to quote from the enormous
mass of statistics to show the actual good that
has been done by the carrj-ing out of sanitarj^
reforms. These are particularly striking in the
case of England, the foremost countrj^ in the
world in the care that is taken of the public
health. The action of suitably constituted health
authorities has made London the healthiest large
city in the world, reducing the general death-rate,
which for a number of years during the eighteenth
century is said to have been not less than eighty-
out of every thousand, to twenty to the thousand,,
and has also throughout England accomplished
analogous results. It has effected wonderful im-
provements in the British Colonies, where such
cities as Bombay, Calcutta and Hong Kong have
been freed from the terrible epidemics which for-
merly were liable to devastate them; and in other
countries of Europe, and in our own land, it has
accomplished much, although far from what is-
possible. Owing to the care that is now taken-
small-pox, j'ellow fever and Asiatic cholera are
greatl)' restricted and no longer sweep uncon-
trolled through cities as in former times. Irr
short, some of the greatest achievements of mod-
ern science have been in preventive medicine and,
owing to the remarkable discoveries of Robert
Koch and other bacteriologists, we are on the eve
of restricting in some degree that dread disease,,
pulmonary tuberculosis, by taking precautions
formerly considered unnecessary.

In cities, indeed, the advantages of proper san-
itary' administration are so obvious that they will
not be disputed ; but neither is it of little impor-
tance in smaller places and in rural communities..
The intimate relations -which exist between to-ww
and country at the present day not only render the
sanitation of villages and rural districts a matter
of importance to themselves, but also may be at-
tended with far reaching consequences to others,,
which becomes evident when we recollect that
most disastrous results maj' arise from neglect of
sanitary precautions in some small village or ob-
scure house. It was the disregard of these in the-
case of a single isolated dwelling which was the
cause of the unfortunate epidemic at Plymouth,
Pa. The great epidemic of typhoid fever in the
parish of Marj'lebone, London, in 1873, was traced'
to a single case at a countr\- farm which supplied
milk to a dairj^ in that parish, directly occasioning
no less than 218 cases of the disease, from which
a very large number of additional cases originated.
Since that time as many as eighty-one epidemics
have been traced in various parts of that country
to milk distribution.

Speaking generally, the ultimate object of all

sanitary endeavor is to prevent the spread of in-

! fectious and contagious diseases, and to lessen or

404

LOCAL BOARDS OF HEALTH.

[September 21,

remove influences injurious to health by securing
the highest degree of cleanliness practicable and
bj- exercising supervision over the air, food and
water supply'. In addition to this, there is the
important matter of the registration of vital sta-
tistics. Now, to accomplish all that is needed
for the attainment of these objects, the require-
ments which, in the complex conditions of modern
life, are necessarj', are so verj- numerous that thej'
cannot be satisfied by the action of the ordinarj-
local authorities as such, but give ample and va-
ried scope for the work of permanent independent
organizations, which should be given all the legal
authority and means necessary for the due dis-
charge of their office. While fulh- recognizing
the great value of State Boards of Health in their
proper sphere, it is to local boards that we must
mainl)' look for the actual carrying out of the de-
tails of sanitary- reform and the achievement of the
direct and practical results required for the protec-
tion of the public health; so that the sanitarj' work
of a State maj- be said to be, in the main, the sum
of the work accomplished by its local boards, aud
in so far as the State boards succeed in influencing
them to perform their duties, they will have ful-
filled no small part of the purposes for which they
were created. That there should be, therefore, a
complete system of sanitary administration, boards
of health should be established in ever\' cit}\ town
and incorporated village, and in the le.ss thickly
settled States and where the necessitj- exists they
should also be established for townships or coun-
ties.

Whether or not a single health officer with
all the powers of a board ma)- not in some cases be
more desirable, I will not attempt to discuss. And
yet outside of the large cities, where the necessity
for them is so urgent and imperative that there are
usually well constituted boards of health, although
often suffering for the want of sufficient appropri-
ation, in many of the States there has existed and
does still exist, notwithstanding there has been of
late much improvement, a most unsatisfactory
condition of affairs, as may be seen bj' referring
to Dr. Toner's paper on "Boards of Health in
the United States," ' or the information upon this
subject to be found in the reports of the various
State Boards. It is surprising that the need is not
more keenly felt, and yet it would seem as if an
active board of health is often looked upon as a
set of sanitarj- fanatics who involve a community
in expense, annoyance and useless alarm, frighten-
ing away newcomers and involving every one in
unnecessary trouble, opposition frequently comiug
from the very classes who need it most; for, as Sir
William Jenner says, ' ' the value placed by a com-
munity on individual life is one of the great tests
of the state of civilization. ' ' The obstacles in the
way of boards of health are in fact mainly due to the
indifference, ignorance and prejudice on the part of

■ American Public Health Association Reports, Vol. i, p. 499.

communities and of the authorities upon whom
their appointment rests, which interfere with
proper legislation and with adequate support of
the board after its formation.

One of the principal reasons for this indifference
and apathy is that the work done bj- boards of
health being of a preventive nature, the results
obtained are not at once appreciated by the public
at their full value ; since to estimate and demon-
strate their worth, requires a very careful consid-
eration of all the vital statistics and conditions of
a locality. As Dr, Parkes has stated, "the es-
tablishment of the Registrar-General's office in
183S and the commencement of the sj-stem of
accurately recording births and deaths will here-
after be proved to be, as far as the happiness of
the people is concerned, one of the most important
events of our time. ' ' It sometimes happens, more-
over, that, owing to the great natural advantages
of a place and the absence of any serious epidemic,
the general death-rate may be quite low, even for
a uumber of years, without due attention being
paid to sanitary requirements, and a communitj-
is not slow in seizing upon this as a reason for
neglecting its duty. Sooner or later, however,
there will be disaster, of which there were several
instances in Newport a few j-ears ago, notably as
regards diphtheria, four and even six cases occur-
ring in single houses. The frequent excuse that
the general health of a community has been suffi-
cientlj- satisfactory- without stringent health rules
is of no real weight, -for the question is not so
much how little sickness exists as whether anj-
disease has prevailed that is preventable and
whether, if proper measures had been taken, the
death-rate would not have been still smaller.

Another reason for the prejudice against boards
of health is the refusal to see that expert knowl-
edge is required in sanitary- matters. Instead of
listening to those competent ty give advice upon
such subjects, communities and city councils are
apt to consider themselves fully able to judge
about all questions relating to the public health,
and because the}- themselves are not convinced of
the need of sanitary reform they conclude that the
need does not exist, their attitude towards sanitarj-
science reminding one of the sarcasm of Socrates
regarding political science, that he suppo.sed it
could not be taught, since the Athenians, al-
though asking the opinion of experts upon all
other questions, when it came to politics appeared
to look upon everj- man, however ignorant and
uninstructed, as qualified to give advice. Another
cause for the dislike is an unreasonable fear and
jealousj- that individual rights and personal lib-
ertj- maj- be invaded b%- unnece.ssarj- rules and re-
strictions, but liberty is not license, and no man
has a right to endanger the health and well being
of his neighbors or of the community. Still an-
other cause is that for political reasons the officers
of manj' municipalities object to a separate board

iSSg.]

LOCAI. BOARDS OF HEALTH.

405

of health, being unwilling to relinquish any par-
ticle of power. Thus it unfortunatel3' happens
that at the present time so many of the health
■departments, even of our large cities, are improp-
■erly organized and entrusted with insuflScient
powers.

To promote, therefore, the establishment of lo-
cal boards of health and to render them efEcient
(for an inefficient board of health may be worse
than none at all), there are various needs which
must be satisfied, relating, i, to the appointment
and organization of the board ; 2, the legal pow-
ers with which it is entrusted ; and 3, the means
by which its orders are carried into effect. First,
the State law upon the formation of local boards
should be mandatory, and if certain of the local
officers are designated in it as members of the
board — which, if allowable in small places, is
■certainly objectionable in cities, where the board
should be as far as possible removed from the in-
fluence of local politics — it should be clearly spec-
ified that such boards must be distinct organiza-
tions with their own independent and peculiar
duties and separate officers, who .shall be regular-
ly and formallj' elected. The experience of many
of the States, Rhode Island among the number,
shows that merely ex ojjido boards of health en-
tirel)- composed of the local town or city author-
ities, without regular organization and definite
duties, are incompetent to deal adequatel}' with
liealth problems ; in ordinary times they are in-
active, and when an epidemic comes they are usu- 1
ally unprepared and unable to act as the occasion ■
•demands.

With regard to the method of organizing
an independent board, little or nothing can be
added to what has been already said in the ad-
mirable papers of the late Dr. Leconte' and Dr.
Lee' The appointment of the members, when
uot designated in the State law, will usually rest
■with the City Council or town or village officers, 1
and they should not be chosen by popular vote, i
They should be from three to seven in number
according to the size of the place and, as a board
of health should be a permanent body and may
be expected to increase in efficiency from past ex-
perience, the terms of office should be for long
periods and should not all expire at the same .
time ; so that the membership, if changed at all, !
should only be done so gradually, leaving always
a majority of old members. Those who are se-
lected should be appointed, as far as possible, with
a view to their fitness for the position. Too often
this is utterly disregarded, and from local political
influence the appointment is frequently made of
men who are not only uninformed about sanitary j

-■•Sanitary Problems: The Proper and Rational Method in
■which Municipal Boards of Health should be Organized." By John
L. Leconte, M,D. .-American Public Health Association Reports,
Vol. iv. pp. 131-134.

.^■■The Proper Organization of Local Boards of Health." By
Benj. Lee, A.M., M.D., Ph.D. First Report of Pennsylvania State
Board of Health, p. 135.

matters, but may even be indifferent or antagon-
istic to them and greatly obstruct the board's
work. The words of John Stuart Mill, referring
1 to this country, may well be borne in mind, when
he spoke of the ' ' incompetency and mismanage-
ment arising from the fatal belief of your public
that anybody is fit for anything." The board
should elect a chairman or President and a Secre-
1 tary, and it will be of advantage, when it is com-
posed of five or more members, to appoint stand-
ing committees upon special departments of sani-
tary work. The health officer, upon whose efficien-
cy the successful accomplishment of the measures
directed by the board largely depends, should pos-
sess suitable qualifications, and a good salary
should be attached to the office, that men of suf-
ficient abilit}^ may be secured.- He should usu-
ally be a physician unless none can be obtained,
and should be appointed by the board, not by the
local authorities. He should be present at its
meetings but not vote.

It is an absolute necessity that boards of
health should be given full power to enforce all
sanitary ordinances and laws and have author-
i ity to arrest and punish any persons who may
resist their legal orders or endeavor to pre-
vent their being carried into effect. Various
provisions are made in the different States for the
legal enactment of health regulations. In some
j they must be adopted as ordinances in town meet-
ing or by a City Council, who are, however, not
I always willing to do this. In others, like the
j State of New York, full power is given everj^ lo-
cal board to make regulations which shall be
obeyed as laws. The law of the State of Maine
upon this subject seems to me a very satisfactory'
one, viz. : that such regulations, after being adopt-
ed by the board, become legal on the approval of
a Justice of the Supreme Court of the State. It
is highly desirable that, as has been done in many
States, there should be a general form suggested
by the State Board for local ordinances ; capable,
of course, of modifications or additions. This will
to a great extent silence criticism when it is known
that similar regulations apply to all localities in
the State, It is advisable that the regulations be
not too numerous, as they are worse than useless
if the local board cannot enforce them.

Local boards, even when legally authorized to
enforce sanitary ordinances, do not always in prac-
tice find it easy to do so. In large cities boards
of health have their own legal and police officials,
and so are able to act with promptness. In smaller
places the actual enforcement of the laws must be
done through the ordinary local prosecuting and
police officers, who must be definitely required to
attend to violations of ordinances or regulations
reported to them by the board without unnecessary
delay. In places of sufficient size one or more spe-
cial sanitary police will be of much assistance, and
there should also be, whenever required, a suffi-

4o6

LOCAI, BOARDS OF HEALTH.

[September 21,

cient number of inspectors and other officials for
attending to the various necessary details of the
work of the board. It is needless to say that a
board of health is helpless without a sufficient
appropriation.

It is a far easier task to point out the want of
boards of health and their needs when established
than to provide a remedy, but the main effort
should be directed towards impressing upon the
community in general and local authorities in
particular the value of the results to be accom-
plished through boards of health, and so to edu-
cate the public that a separate health organization
will be looked upon as much as a matter of course
as a fire or police department.

There are several influences which will tend to
create this desirable condition of affairs. First,
as before said, if it can be obtained, let there be
a State law, of which that of New York furnishes
a good pattern, requiring the formation of separate
local boards at least for cities and towns, for noth-
ing short of this will succeed in overcoming the
apathy manifested in some localities. In Connec-
ticut, for example, five months even after such a
law was in force, in 18S7, such was the indiffer-
ence that fifty towns had not organized their
boards and reported their health officers to the
State Board in compliance with the law, notwith-
standing that they had been notified of their duty.
The subsequent effect of the law, however, in that
State has been most satisfactory. Let all the influ-
ence, then, of State Boards, sanitary protection as-
sociations, the press, physicians and clergy be ex-
erted to obtain such legislation, and when this is
unattainable let, at least in the separate towns,
endeavor be made as far as possible to move the
local authorities to action. The State Boards es-
pecially can do much towards securing proper
legislation and can greatly assist the local boards
by providing them with all the information they
need, especially on their first organization. Great
assistance may be rendered by sanitary protective
associations. That of this city, the first organized
in America, has exerted, in spite of a large amount
of abuse and opposition, no small influence in se-
curing a board of health and in interesting the
community in sanitation. The influence and work
of a local board can be greatly aided by the phy-
sicians of the place through their cooperation in
checking the spread of infectious diseases and in
assisting in the proper registration of vital statis-
tics, in calling attention to sanitary requirements
and in general support. In this connection I
would refer to the paper by Dr. Bryant, of New
York.' The press and clergy can also be of great
help ; and finally, the board it.self, by its eflicient
work its tables of statistics, and care not to be un-
reasonably exacting, can gradually elevate the

4 "How can the Medical Profession aid the Board of Health? "
By Joseph D. Brjaut, M.D., Health Commissioner, New York. N.
Y. Medical Record. November 12, 1887, p. 61.^.

public sentiment and attain to the position of im-
portance which it ought to occupy'.

The history of the city of Newport in its health
matters will serve as an illustration of some of
these remarks. Its celebrity and importance as a
place of summer resort render a due attention to
questions relating to the public health of peculiar
importance to its prosperity. Attention has been
repeatedly called to defects in its sanitary- admin-
istration and the nuisances which were suffered ta
exist, by the late Dr. Marion Sims, by Dr. John
C. Peters, bj' Mr. Bowditch in a report of a house
to house inspection published by the National
Board of Health,' by Dr. Storer, and also by the
city Sanitary Protection Association, and'the need
was urged of a separate board of health ; but the
law of Rhode Island not requiring, but merely
permitting the formation of independent health
boards, the power to establish such a body rested
entirely with the city board of aldermen. B}- pe-
titions, representations, and the exercise of influ-
ence of various kinds, the aldermen were at last
brought to see the advisability of a separate board,
and accordingly in 1885 an ordinance establishing'
one was passed. This ordinance is not perma-
nently in force, but requires to be reordained every
year, and gives to the board limited powers, it
having no authoritj^ to make, but only to suggest
sanitan,' ordinances, while the city authorities stilt
retain control over matters over which the board
of health should properly exercise supervision ;
such, for example, as the disposal of garbage.
The executive ofiicer can only be nominated bj^
the board, and is appointed by the City Coun-
cil, The board has legal authority to abate nui-
sances and enforce regulations, but the means of
promptly' enforcing them seem as yet imperfect,
apparently from a want of a thorough understand-
ing and cooperation between the board and the
city legal and police authorities. Nevertheless it
has done good work in preventing the spread of
infection and in keeping the. public informed, by
the tables it publishes, of the state of the public
health. Where it has been least successful is in
remedying the old leaking cesspool system of
drainage and other similar evils, for which the
citj' authorities are in no small degree responsi-
ble, as they have not yet passed an ordinance
making sewer connections compulson,' in the
compact part of the city, notwithstanding this
has been recommended in three successive reports
by the board. The board has thus been impeded
by want of proper legislation, as well as by the
want of means to carr3' out reforms, but it is made
up of competent members possessing the public
confidence, and there are few in the city who
would now wish to return to the old state of affairs.
It is to be hoped, therefore, that as the public
both here and elsewhere become more fully con-
vinced of the importance of the matter, this and

5 Report of National Board of Health, 18S2, appendix C, p. 153-

[889.]

DIOSCOREA VILLOSA.

407

other places in like condition may not long be
■destitute of what are so needful for their welfare,
thoroughly efficient independent boards of health,
with ample powers.

Dr. Hibbard, of Indiana, said that in new or-
ganizations there was generally an attempt to
mark out too extensive a programme at the out-
set, and that in his opinion it was better to ad-
vance more slowl}-, to be active in these matters
but conform to the character of the environments.

Dr. Smart, U. S. A., expressed himself as in
favor of activity and energy in these directions.

Dr. Morris said that for his part he was great-
ly interested in the matter of plumbing and that,
greatlj- to his surprise, he found in the hotels of
Newport abundant evidence of neglect in this im-
portant matter.

Dr. Stoker, of Newport, replying to Dr. Mor-
ris, explained that while the Board of Health of
Newport had done what it could, it was aware
that some of the hotels had not yet adopted the
suggestions of the Board.

DIOSCOREA VILI.OSA— WILD YAM.

Delivetcd in the Section of P}actice of Medicine. Materia Medica and

Physiotogv, at the Fortieth Annual Meeting of the A merican

Medical Association, fune, iSSg.

BY JOHN V. SHOEMAKER, A.M., M.D.,

OF PHILADELPHIA, PA.

It is the writer's purpose in this brief paper to
call attention to dioscorea villosa, a valuable plant,
but one that is seldom employed by reason of the
scant literature upon its medicinal action. It is
my hope that if the short clinical experience
which I have had in the past continues to bring
good results, that in the future it may lead to
further and better investigations upon this
remedy.

Dioscorea villosa, a plant which is commonly
known as wild 3-ain or colic root, is found in pro-
fusion throughout the Southern and to a limited
extent in the Northern and Western States.
Thirty years ago it was eulogized by King, of the
Eclectic School, as a true specific for bilious colic,
no other agent being necessary' in this disease as
it gives, he reported, prompt and permanent re-
lief in the most severe cases. This statement
has been repeated many times since by the disciples
of the Eclectic doctrine, and is undoubtedly true.
The part of the wild yam used is the root, which
is inodorous, but on bruising develops a slight
woody odor. To the taste the root is somewhat
pungent, sweetish and bitterish. It is pulverized
with difficulty, yielding a yellowish gray powder.
The root is soluble in both water and alcohol and
contains an active principle known as dioscorein,
which possesses nearlj^ all the medicinal virtues
of the root. A further analysis of the root would
be of great advantage in studying this plant, as

well as an investigation upon the physiological
and therapeutic action of the active principle.
The want of time has prevented my giving atten-
tion to the all important- consideration of this
portjon of the subject, which I hope to investi-
gate, or see others do so in the future. I therefore
regret I am not able to add in this connection the
physiological action of this plant which still re-
mains to be studied. The scope of the paper is
limited to the clinical results so far experienced
from dioscorea. The preparations of wild yam
usually employed are a decoction, the dose being
from one to four fluid ounces, a tincture, the dose
from ten to sixtj' minims, and the fluid extract,
the dose being about half of that of the tincture.

Earge doses of any of the preparations named
have produced emesis. From its action it has
been classified by King as an anti-spasmodic. It
acts likewise as a diaphoretic and has some ex-
pectorant properties. Dioscorea appears to have
an especial effect upon the liver, as nux vomica
has for the spinal cord. It is a most useful remedj^
in the treatment of the various diseases of the
hepatic S}'stem. In that painful aSection known
as bilious colic, which is the result of the pressure
or impaction of one or more gall-stones in the
biliarj' ducts, dioscorea often affords great relief.
The treatment usually recommended consists of
the administration of copious draughts of hot
water, a prolonged course of phosphate of sodium,
the inhalation of chloroform, heroic doses of
morphine, or a combination of turpentine and
ether, and even with all these remedies we are
told that the disease maj- persist for daj-s and
weeks. Yet as related by King thirty years ago,
and as restated by Dr. Todd in the Atla?ita
Medical and Surgical Joiwnal some two years
past, every case of bilious colic can be cured in a
brief period, varying from a few minutes to a few
hours by the administration of dioscorea alone.

The only qualification necessary to this claim
at present is that the cases must be of pure biliary-
nature due to the presence of a gall-stone or of
thickened, hardened bile in the biliar}' ducts, and
not cases of intestinal colic from other causes.
A good rule in practice is to see if with the
colick}- pains and nausea there be also any yel-
lowish discoloration of the skin or conjunctiva.
If there is, dioscorea will usuall}^ give prompt
relief; if there is not, it may have to be supple-
mented with other remedies. Even when the
stage of incipiency is passed, when the delicate
lining of the ducts are engorged and inflamed, so
that the bile cannot pass through, dioscorea will
be found of infinite value in lessening the en-
gorgement, relaxing the tension of the biliary
channels, and cutting short the course of the
disease. That indefinite complaint known as
hepatic torpor or hepatic indigestion, resulting in
'dull headaches, loss.of appetite, mental inaptitude,
causeless melancholy, and a train of other symp-

4o8

DIOSCOREA VILLOSA.

[September 21,

toms, can be quickly and permanently relieved by
the fluid extract of dioscorea taken in fifteen drop
doses before meals. Of course if there be another
cause at work, such as constipation, improper
hours, ill-prepared food, excessive use of li<juor
or tobacco, etc., they must be removed or counter-
acted. If tonics are needed, they must be given
in addition to the dioscorea. An excellent tonic
containing dioscorea is as follows :

Take of fluid extract of dioscorea villosa, i ounce.
Compound tincture of cinchona, 5 ounces,
njj. Dose: A teaspoonful in water before meals.

In cirrhosis of the liver too much benefit must
not be expected from any remedy. In spite of
all our efforts the inexorable advance of the
fibrous connective tissue, crushing out blood-
vessels, biliary cells and nerves, can be retarded
for only a short time. My experience leads me
to hope that for this purpose dioscorea may
be found more beneficial than the two-edged
mercuric, bi-chloride, which is now so largely
employed. In chronic congestion of the liver,
characterized by fullness of the right side and
an increased area of percussion dulness and a
general impairment of the digestive functions, a
marked improvement and a gradual cure may be
obtained by the administration of from ten to
forty drops of the fluid extract of dioscorea in
water before meals. In those suffering from an
over-indulgence in alcoholic stimulants, and in
alcoholic catarrh of the stomach, no better remedy
can be suggested than dioscorea. The following
combination in the latter disease is of value :

Take of tincture of belladonna, .... 24 drops.

Tincture of nux vomica, . . . i drachm.

Tincture of dioscorea villosa . . 'i ounce.

Sirup of ginger, 2 '4 ounces.

iij;. Dose: A teaspoonful in water every 4 hours.

In chronic malaria great benefit can be derived
from the use of dioscorea alone or in combination
with other remedies. A prescription of ser\'ice
in this affection is appended :

Take of solution of arsenite of potassium, i drachm.

Tincture of dioscorea villosa . . . '4 ounce.

Compound tincture of cardamon, 2'i' ozs.
1^. Dose: A teaspoonful in water after meals.

The following combinations containing dios-
corea will also be of benefit in malaria :

Take of tincture of mix vomica, . . . i drachm.

Tincture of dioscorea villosa . . yi ounce.

Compound tincture of cinchona, 5 ozs.
tR. Dose: A teaspoonful in water before meals.

Take of sulphate of q^uinine, 20 grains.

Tincture of dioscorea villosa . . yi ounce.

Sirup of orange flowers, .... 3 ounces.
itR. Dose: A teaspoonful in water every 4 hours.

For preventing bilious headache, or modifying
the attacks after they have appeared, dioscorea
has proved of value. In intestinal indigestion,
due to the lack of sufficient bile as manifested by
the development of offensive gases, clay colored

stools and general mal-assimilation, remarkable
benefit ma}- at once follow the use of dioscorea
combined with a little capsicum or strj-chnine.

Cancer of the liver is of course an incurable
disease but more relief can be afforded to patients-
suffering from it by adding dioscorea to their
morphine than bj^ administering morphine alone.
It is probable that dioscorea will be found of
great seri'ice in the treatment of man\- other
diseases totally unconnected with the liver. Its
great power in relieving the spasm or contraction
of the biliary ducts would indicate its use in.
various affections where anti-spasmodic remedies
are requisite. Time and investigation alone can
adequately meastire its importance. I hope that
the recital of mj- experience with it and the grat-
ifying restilts it has yielded will induce others
to test the efficacy of this valtiable remedy.
The following cases may be of interest showing
the beneficial results from the use of dioscorea :

Case I. — Mrs. A., aged 35, had been suffering-
from colic at times for eight months. The attacks
lasted from eighteen to twenty-four hoars and
often recurred weekly. The pain was frequentl3r
intense and could only be temporarily allayed by
whiskey and laudanum. Spontaneous relief was
always preceded by vomiting after, as she tersely
expressed it, "she was played out by the pain."
On one occasion the pain was so violent that the
attending physician, becoming alarmed, sent for
me in consultation. On entering the room the
yellowish hue of the patient's face, arms and neck
at once attracted my attention. The conjunctiva
was unchanged. On inquiry I learned that her
color varied similarh- with everj- recurrence of
the colic, and gradually became normal after the
subsidence of the pain. As this was the first case
of biliary colic that I had seen since the publica-
tion of Dr, Todd's article, I determined to try
the merits of dioscorea on it. I accordingly sent
for one ounce of the tincture of dioscorea, and
directed that the patient be given thirt)- to sixty
drops everj- half hour until the pain lessened.
On calling in the evening I was stirprised and
gratified to learn that the pain had disappeared
with the third dose of the medicine and had not
returned. I then ordered the remedy to be con-
tinued in the same doses ever^^ three hours, and
instructed the attendant to search any evacuation
that might occur from the bowels for gall-stone.
When I returned the following moniing I found
the patient had passed a large gall-stone during-
the night and was able to be around attending to
her usual dtities. She continued the dioscorea
for two weeks and has not had a symptom of
colic or of ill-health from that time.

Case 2. — Miss M., aged 22, while lifting a tub
of clothes was suddenly taken with a sharp pain
in the right side which was greatly increased by
attempts to take a full breath. Thinking that
she had suffered some internal injury, she sent

1889.]

CAUSES OF BLINDNESS.

409

for me. After making an examination of her
chest I was unable to discover any indication of
pleurisy or of a deep seated sprain, but as in the
preceding case a peculiar brownish or yellowish-
brown discoloration of the skin was found to be
present. On being given a looking glass the
patient admitted that there was something wrong
with her complexion. It was then mj- opinion
that this was a case of sudden obstruction from a
gall-stone and would furnish a good opportunity
to further test the value of dioscorea. I directed
the patient's mother to give her thirtj' to forty
drops of the tincture even.- two hours, and left
the usual directions about having the evacuations
searched for gall-stone. The pain disappeared
after the second dose of the remedj', and during
the night she passed two good sized gall-stones.
In neither of these cases was the discoloration so
marked as to simulate or resemble jaundice.

Case

-Mrs. C, aged 45, after exposure to

wet and cold was seized with a sharp pain in the
right side. The next da}' her ej'es and skin had
a 3'ellowish-green appearance. I was sent for
and pronounced the case jaundice, due to the
presence of a gall-stone in one of the biliary
ducts. I ordered her 30 to 40 drops of the
tincture of dioscorea ever>' two hours. On re-
turning in the morning I found her much im-
proved and inclined to doubt the correctness of
vsiy opinion that she had jaundice, for, as she
truthfully said, she "had never heard of anybody
being cured of jaundice in a daj-." Notwith-
standing this good lady's opinion, I believe that
there are manj- cases of jaundice due to the
arrest and detention of gall-stones in the ducts,
which if treated properly may be dissipated as
promptly as followed in this case.

Case 4. — Mr. A., aged 25 years, has been sub-
ject for several months to "bilious attacks,"
lasting for three days and characterized b}- violent
frontal headache, great loathing for food and
obstinate constipation. On applying for relief on
Christmas eve, he stated that all his symptoms
were aggravated by the knowledge that he would
not be able to eat any Christmas dinner. I as-
sured him that his fear was unnecessary, that the
attack would be cut short long before the dinner
was prepared. I directed 'him to take three 30-
drop doses of the tincture of dioscorea during
the evening and two compound cathartic pills on
going to bed, and to resume the dioscorea in the
morning. He returned about a month afterwards
stating that the medicine had worked like a
charm, and asked for some more to ward oflf
another attack. I renewed the same prescription
and he has not had the slightest headache or any
digestive trouble since that time.

Case J. — Mrs. D., aged 37, informed me that
she was suffering from "cramps of the womb,"
due to falling of that patient and long suffering
organ. She was without doubt having severe

pain as the expression of her face and the con-
! tortions of her limbs gave evidence, but doubting
her ability as a diagnostician, I asked her how
; she knew the cramps were caused by her womb
being out of place. She replied that she had
similar attacks on two previous occasions, for
which she was treated, and that the cause of her
suffering was prolapsus or falling of the womb.
She added that on the first instance she was in
bed for two weeks, and on the second for thirteen
days. I made a vaginal examination and found
, that the uterus was markedly prolapsed, but that
it was also free from pain, and I therefore con-
cluded that her opinion of the former attacks
was incorrect, and the seat of the disease was in
some other portion or organ of the body. Upon
looking at the patient's countenance again I
detected a slight yellowish discoloration which,
as in the former cases, suggested to my mind a
favorable biliarj- origin of the colic. The tinc-
ture of dioscorea was then ordered, in 30-drop
doses, with the gratifying result of yielding com-
plete relief within si.x hours and enabling the
patient to get up two days afterwards and
attend to her household duties. The evacuations
were carefully searched for a week but no gall-
stones discovered.

WHAT CAN WE DO TO INDUCE THE
GOVERNMENT TO MAKE THE CEN-
SUS OF 1890 CONTRIBUTE EFFI-
CIENTLY TO A CLEAR CON-
CEPTION OF THE CAUSES
OF BLINDNESS.

/^cad in the Section of Qphlhalmology at the Fortieth Annual
Meeting of the American Medical' Association, Jnne^ 1SS9.

BY ROBERT TILLEY, M.D.,

OF CHICAGO, ILL.

The disinterested efforts which have been made
bj- different individuals who have embraced the
study of the healing art, for the general welfare
of the race, will compare favorably with similar
efforts made by any other section of the world's
workers. Often these efforts have been made in
the face of the wildest and most fanatical opposi-
tion, and practically always have the}- been con-
fronted with appalling obstacles. It needs no
mental acumen to perceive that in order to over-
come successfully anj- evil we must know the
nature of that evil, and according to our present
experience we must know it in all its details. A
disease which in some haphazard way disappears
from our midst today will reappear at a place and
time when we least anticipate it. But if we un-
derstand its peculiarities definitel}' we are not
only in a position to try iutelligentlj- to suppress
it, but also to try and abolish it entirely, or to
successfully meet its future approaches. I am
satisfied that if it were possible to get a complete

4IO

CAUSES OF BLINDNESS.

[September 21,

tabulation of the blind of the various countries
of the globe a well-informed and well-balanced
mind could draw verj' important deductions rela-
tive to man}' peculiarities of the various peoples.
By a complete tabulation I mean a tabulation
which should indicate not only the number of the
blind, but also the various agents which have
■caused the blindness. One verj- peculiar and
interesting fact has been strikingly illustrated by
Dr. Hugo Magnus, of Breslau. Among the many
interesting items in his excellent work, "Die
Blindheit ihre Entstehung und ihre Verhutung,"
in appears that in Bavaria the census of 1840,
1858, and 1871, have shown that the Jews furnish |
a relativeh' greater number of blind than the
Catholics, and that the Catholics furnish rela-
tivelj" a greater number of blind than the Protes-
tants. He has further shown that the censuses
of Prussia for 1871 and 1880 give corresponding
results ; namely, that in Prussia a given number
of Jews furnish more blind persons than a corre-
sponding number of Catholics, and a given num-
ber of Catholics furnish a greater number of
blind than the same number of Protestants. I
do not quote the actual figures presented bj'
Magnus because mj' object is onlj' to call atten-
tion to the item as one of interest in a census of
the blind.

England and Scotland, in the census of 1871,
furnish about the same relative number of blind,
but a little in favor of Scotland. There can be
little doubt that the relative number of Protes-
tants is greater in Scotland than in England.
Ireland, greatly in excess of England and Scot-
land, corresponds absolutely with the channel
islands.

Comparing Ireland with itself, it is stated with-
out further definiteness that the South of Ireland
gives 17 blind in 10,000 inhabitants, whilst the
North of Ireland furnishes only 9 in 10,000 ; not
much more than one-half as many. The North
of Ireland may in general be called Protestant.

If such figures as these are shown to exist
throughout the various parts of the civilized
world they certainly are of intense interest, what-
ever deduction we may draw from them.

Another item of interest which Magnus sets
forth in detail in the book before referred to, is
the number of blind from ophthalmia neonatorum.
In a carefully prepared table giving the various
causes of blindness in 2,528 cases examined by
himself and other competent ob.servers it appears
that ophthalmia neonatorum contributed a larger
percentage of blind than any other affection,
namely, 10.87 per cent., and trachoma and blen-
norrhoea adultorum come next, with 9.49 per

[NoTK. — Were I trj'ing to give an adequate conception
of the disasters that arise from ophthalmia neonatorum
it would be necessary to say that in twenty-two institu-
tions for the education of the blind in different parts of
the continent of Europe 40 per cent, of the inmates were
blind from ophthalmia neonatorum.]

cent. Without inquiring further these two
affections thus contribute 20 per cent., at least, of
the blind, and both of them must be practically-
considered as preventable diseases.

It is not improbable that these figures repre-
sent somewhat accurateh- the percentage which
these affections contribute to the number of blind
here in America. And when we remember that
a case of blindness from ophthalmia neonatorum
is a whole life-long affection, the seriousness of
the affliction becomes apparent. According to
the statistics of the lying-in establishments at
Eeipzig, which may be taken as a sample, in 1874
out of 100 infants 13.6 suffered from ophthalmia
neonatorum, whilst in 1S79 the proportion was
9.2 per cent. I remember, without being able
now to cite the source, that a few 3'ears ago a
report from one of the h-ing-in establishments in
New York the proportion was about 10.7.

I have not at hand any definite and reliable
figures showing the number of blind from this
affection in the institutions for the blind in
America. The principal reason whj- I have
chosen to refer especially to this particular affec-
tion is because it affords an instance of the affec-
tion which of all others has been demonstrated to
be the most favorably influenced b\^ a system of
prophj'laxis. These prophylactic measures are
well known to you and do not now concern me.
What I desire to do is to induce you to make
some effort to render the coming census of 1890
more complete relative to the general question of
blindness. The importance of the question lies
in the fact that it is only bj^ an accurate estima-
tion of the question that we can hope intelli-
genth- to modify its dire results. It ought to
interest the moralist, it certainly must interest the
political economist, the htimanitarian and the
physician. It certainly is not to the credit of
any nation to have a relatively large number of
blind among its citizens, and America ought to
furnish a smaller number relative to her popula-
tion than any other nation on the face of the
earth. But it is useless to claim what ought to
be, the only efficient means of estimation is to
know what is, and the only means of intelligentlj-
profiting by the bare statement of the numerical
fact is to know how it occurs.

I am aware that the tabulation of the blind
with the various causes of blindness is a compli-
cated and difficult question and that it cannot be
accomplished by the general arm)- which consti-
tutes the census recorders. But that it is not
impossible is shown by the efforts of some of the
quiet workers of Germany— Katz, Magnus and
Lackmann. That it is a work which cannot be
accomplished by private individuals, and that it
certainly would form a most valuable basis for a
system of prophylaxis against blindness ; that it
would be a contribution to a kind of international
hygienic and prophylactic exhibition ; that it

1889.]

CAUSES OF BLINDNESS.

411

would furnish the physician, philanthropist, mor-
alist and political economist facts relative to one
of the world's greatest woes, should be stimulus
enough to make the Government undertake the
efiFort. Perhaps it is not to be expected that it
could be satisfactorily carried out all over the
United States at the first effort, but even if the
effort was made in only a few populous and repre-
sentative States, the interest and value of the
work would be great. As has been previously
stated, it is not for one moment supposed that
the de-sired investigation could be accomplished
by the ordinarj' census officers, all that could be j
expected from such officers would be a list of the
names, ages, residences, nationalit)-, religion, etc., !
of the persons afflicted, and the further work of
technical classification of affections must neces-
sarily be accomplished by men intimately ac-
quainted with the nature of the diseases of the
eye and ophthalmological phraseology. It would,
moreover, be desirable that one recognized form
should be used by all such tabulators. Magnus,
of Breslau, has advocated just this work in his
work referred to above, in reference to Germany ;
and to facilitate the matter he has drawn up a
series of questions which leave ver\- little, if any-
thing, to be desired relative to simplicity, com-
pleteness and efficiency. I have translated this
table without alteration, and will take the liberty
to read it.

Name?

Age?

Religion?

Calling, before blindness ; after blindness?

If a child, calling of father?

Parents related?

Parents' eyes affected?

Brothers or sisters affected with blindness?

Married?

Married before or after blindness occurred?

Husband or wife anj' affection of the eyes?

How many children with normal ej-es?

Color of hair?

Color of the iris, when visible?

At what age did blindness occur in right

I.
2.
3-
4-
5-
6.

7-
8.

9-

10.

II.
12.
13-
14-
15-
eve?
' 16.

17-
18.

19-
20.

21.

22.

23-

affection?

At what age did blindness occur in left eye?

Condition of right eye?

Condition of left eye?

Cause of blindness in right eye?

Cause of blindness in left eye?

Grade of blindness in right eye?

(a) Total amaurosis?

(d) Quantative perception of light?

U) Count fingers at 12 to 15 in. (yi m.)?
Grade of blindness in left eye?

(a) Total amaurosis?

(b) Quantative perception of light?

(/) Count fingers at 12 to 15 in. ('.- m.)?
Was the blindness the result of a general

24. Still affected?

25. Do any other conditions, important rela-
tive to the blindness, exist?

26. Did the blindness occur in the countr}' or
city?

27. How long a resident of the place before
blindness occurred?

Such is the proposed list of questions which
Dr. Magnus has formulated as a desirable list in
order to give the investigation of the nature of
blindness a uniform character. It would be diffi-
cult to modify- the form in anj- scientific question
without impairing its efficiency in some way.

It is not for us to suggest how such an investi-
gation should be made. In order to be of value
it should of course be accomplished within a
short time of the general census returns ; and if
it could not be accomplished in all the States and
Territories, it would be decidedly advantageous
if it was done even but in a few States.

Dr. J. L. Thompson, of Indianapolis, said :
We should not be in too great haste in such a
matter as this. Better by far teach the people,
through the medical journals and newspapers,
as to cleanliness and preventive treatment, than
to resort to methods which, owing to the lack of
time, gives to those whose duties concern the
census taking have alread}- been determined.
Our countr)- is vastly different from the older
ones, being much more sparsely settled. Religion
certainly has but little to do with the case. In
the older countries in some quarters the Jews may
have been more crowded, or possibl}- in the Cath-
olic districts of Ireland and other countries the
conditions of the people may not be as favorable
as in other nations where the Protestants are often
in affluent circumstances. Here eye diseases
have been vasth^ increased since our internecine
war, owing to the carelessness of returning sol-
diers communicating brachomatous inflammations
to their families and friends by the use of the
same towel, sleeping in the same bed, handling
the same farming implements, etc. Educate the
people, but let the Census Bureau alone. At
least, as a Society, let us go slow about this
matter.

Considerable di.scussion followed, in which Drs.
Connor, Scott and Jackson took part. Finally it
was moved and carried that a committee be ap-
pointed, by the Chair, to request the General
Assembly to authorize the Section of Ophthal-
mology, together with the American Ophthalmo-
logical Association, to confer with the Census
Committee. Drs. X. C. Scott, Robert Tilley and
J. Chisholm were appointed on this Committee.

Georgi.\ physicians are agitating for an ad-
justment of fees. A meeting was held at King-
ston to-day to advocate a universal fee bill.

412

TREATMENT FOR PNEUMONIA.

[September 21,

A NEW PLAN OF TREATMENT FOR
PNEUMONIA.

Read in the Sectiott of the Practice of Medicine, Materia Medica and

Physiology, at the Fortieth Annual Meeting of the American

Medical Association, June, iSSg.

BY G. R. MARTINE, M.D.,

GLEN'S FALLS, N. Y.

Every new theory is at first more or less ridi-
culed b}' the incredulous class, and the number of
those incredulously inclined is unfortunately as
large to-day as when Harvey discovered the cir-
culation of the blood, or Jenner promulgated the
boon of vaccination. Hence no surprise will be
created should this new plan of treatment for
pneumonia be derided, or even denounced in
terms more vigorous than elegant. But still
among you all there maj- be one patient investi-
gator searching for truth, who will give this new
theorj- a practical test ; and if so, he will be in-
duced to make a second trial ; and when he
ascertains that substantially it never fails, it will
then become his fixed, permanent and unaltera-
ble practice in the treatment of pneumonia.

No attempt will be made in this paper to enter
into an extended research or exhaustive anal3'sis
relative to the cause, pathology- or results of
pneumonia, or to discuss at length its different
forms and phases. It is simph' to a new plan of
treatment toward which your attention is called,
and to this point all efforts will be directed.
Almost everj- known plan has been adopted in
the treatment of pneumonia, and the new reme-
dies have been eagerl}- sought after ; first one and
then another has played its role on pneumonia's
stage with but indifferent success. Bleeding,
vomiting, sweating, blistering, poulticing, deplet-
ing, stimulating, all local and all general plans
■of treatment have been faithfully and persistenth-
carried out with marked thoroughness and per-
severance ; and yet to-daj-, after all the advance-
ment made in the science of medicine, pneumonia,
though a curable disease, stands second only on
the roll-call of death. Shall tt-e continue longer
in these old ruts, with this appalling death-rate
staring us in the face at everj- step, or shall we
seek out a new and more rational plan of treat-
ment ?

The first abnormal symptom observed after the
premonitorj- chill has warned us of pneumonia's
approach, is the quickening of the pulse and the
consequent increased flow of arterial blood. Now,
if we could take a microscopic view of the minute
arterial ramifications in the lung structure, we
would discern in response to the law of causation,
a distention of caliber in the arterial vessels in
order to accommodate the augmented flow of
arterial blood ; and if we could then cast a glance
at the veins, we would observe the plasma-layer
rapidly filling with multitudinous white cor-
puscles, and the walls of the veins irritated by
the friction of increased circulation would exhibit

here and there white corpuscles adhering to their
tenacious sides, and finally penetrating their
walls. A glance at the capillaries would show
not only the white but also the red blood-corpus-
cles forcing their way through the overstrained
capillar}- walls, until the surroundings became
engorged by their extravasation, and the initiatorj^
work of hepatization had commenced, for the
comparatively large size of pulmonary capillaries,
together with the fact of their not being supplied
with vaso-motor nerves, render them easily
dilatable under increased arterial pressure. Now
what are we to do at this stage of the disease in
order to hold in check this increased flow of blood
to the lungs, which, if unrestrained, is sure to
end in consolidation and death. Reducing the
temperature will not accomplish the work. Re-
I duction of temperature does not save in pneu-
monia as in idiopathic fevers. To what plan,
then, shall we resort in this exciting emergency
I to save the patient from being suffocated by his
own blood ? Before an answer is given, allow me
I to use a simile : Should some mischievous hand
hoist the gate of an immense reservoir, located at
an elevation a thousand feet above this city, and
the maddened waters, fiendish with the power of
innundation, should sweep through your streets,
undermining block after block, and strangling all
life within reach of its destructive course, would
you not intuitively cry out, shut down the head-
gate and save the city ?

When the maddened blood, fired by the lash of
inflammation, rushes wildly through the channels
of life, extruding with demoniacial force through
the very walls of the blood vessels the blood-
corpuscles and threatening to strangle out the
life of the unfortunate victim, intuitively I cr\-
out, shut down not the head-gate but the heart-
gate and thus save the suffocating patient who
helplessly looks to you for rescue. Say to the
wildl}- pulsating heart, so far or so fast shalt thou
go, and no faster, and continue to hold the heart's
action under absolute subjection until the crisis
is past and the life of the patient is saved.
(This crisis is usually reached about the seventh
day after the chill.) This is not only what should
be done, but what mitsf be done, in order to ward
off death. Here is where the new plan saves
life. You will naturally ask if this new plan is
intricate or difticult of adoption, or if it be so ex-
tended or complicated as to render it practically
inoperative in the hands of the busy practitioner.
The answer is, no. The whole method can be
given in five words, viz : Hold the pulse below
eighty. Keep your fever thermometer in your
pocket ; it is of little or no use in pneumonia.
Death does not result from high temperature in
pneumonia, but from high arterial action, result-
ing extravasation and consolidation and conse-
quent heart failure. The physician who, dallying
with his fever thermometer, endeavors to cure

1889.]

TREATMENT FOR PNEUMONIA.

413

pneumonia by reduction of temperature, will
make about as much headwaj- and will be about
as successful as he would in trying to eat soup
-with a peg-awl. You maj- ask with what reme-
dies do you hold the pulse at this point. While
veratrum viride seems to have served me best,
possibly there are other arterial sedatives which
in the hands of others may act as well. It has
Tieretofore been the practice of medical writers to
name the medicines to be used in the treatment
•of such and such disea.ses, but in the light of the
present day it would be well to drop this anti-
quated custom and adopt a new method by stating
the indications to be fulfilled, the dangers to be
avoided, the vantage ground to be gained, the
favorable signs to be sought for, and the unfavor-
able symptoms to be controlled, the main points
to be attained, and the results to be expected in
the successful management and treatment of any
■disease, and then allow the attending physician
to select such remedial agents as he maj' choose
from among those possessing his confidence after
long experience in their use.

In pursuance of this course no radical line is
■drawn or arbitrary rule laid down as to the reme-
dial agents used, provided they are successful in
accomplishing the work of holding the pulse
"below eighty if in adults, or if children, from
■one hundred to one hundred and twenty. This
point attained and with persistent vigilance main-
tained, no further trouble need be apprehended,
for with the pulse at or below eighty, there will
be no extravasation, if no extravasation there
■will be no consolidation, if no consolidation there
■will be no hepatization, and if no hepatization
there can be no suppuration, mortification or
■death. Hence pneumonia, by this plan, can be
robbed of all its terrors.

But the inquiry may be made : What is there
in this plan to provide against heart failure, a
-condition so greatly to be dreaded, and the reply
is : It is far better to avert a calamity than to
j)rovide for one. No censure is due the captain
■of a man-of-war who thickly covers his deck with
sawdust to prevent slipping when blood shall
flow freely ; but a higher meed of praise is ac-
corded that captain who so carefullj' erects
defenses, so skillfully plans the attack, so closely
•watches the progress of the battle, and so adroitly
conducts the fight that but little blood need flow.

So in this new plan of treatment for pneumonia,
but little blood will flow if the pulse be kept
below eighty. If no blood be extravasated no
consolidation takes place, and if no obstruction
from consolidation exist, and the heart's muscular
labor be not consequent!}- increased by its con-
tinued efforts to force the blood through pul-
monary channels already- clogged and blocked,
and provided further that the heart is restrained
and thus relieved from the fatiguing additional
labor of 2,000 to 4,000 contractions per hour

during the seven days preceding pneumonia's
crisis, heart failure in uncomplicated pneumonia
would be a thing impossible.

Dr. H. a. Hare said that the use of veratrum
viride was old and ver}' useful, but that a great
mistake is made in saj-ing " use cardiac sedatives
in pneumonia" without recognizing the fact that
they are to be used in the first stage before con-
gestion has gone on to consolidation. The man
who gives such drugs at the middle or end of an
attack of pneumonia might as well stab his
patient. Digitalis is to be used at such times.
As to the lethal results of veratrum viride let me
say that very few cases of death are on record,
owing to the vomiting which is brought on verj'
early by the alkaloid veratroidia and an emetic
resin. It is certainly the safest cardiac sedative.

Dr. I. E. Atkinson, of Baltimore, objected to
the claim that the use of veratrum viride in the
treatment was new ; it had been many j^ears
under trial and had not received general accep-
tance. He called attention to the fact that Dr.
Marline's graphic description of "drowning in
their own blood ' ' as the mode of death in raanj'
cases of croupous pneumonia could not be justi-
fied ; that frequentlj- the cause of death was in
the failing heart action, a condition to which
we could not look for benefits from heart de-
pressants. He would not be much impressed by
the successful results of giving veratrum viride
in the croupous pneumonia of children, since this
disorder usually will recover under anj- ordinary
treatment.

Dr. Cronyn said : Dr. Martine's new mode of
curing pneumonia is not at all new. Bleeding
and rasher emetics were the methods of our fore-
fathers to attain the results pointed out b}- the
doctor. We know x^xy well that about forty
j^ears ago a complete revolution in the treatment
of diseases generally, and pneumonia, was made
the basis of argument particular! 5'. I hold, sir,
that every case of inflammation of the lungs
must be treated upon its own merits, taking into
consideration the constitutional condition. The
peculiarities of such cases and the remedies are
easily determined.

Dr. C. O. Probst, secretary^ of the Ohio State
Board of Health, is .sending out circulars to the
maj-ors and councils of all the cities of that State
that have not formed boards of health, urging
them to do so. The law requires all towns hav-
ing a population of five hundred or more to es-
tablish these boards. The circular saj's : "One
of our smaller villages, which neglected its duty
in this matter, is now paying the penalty in a
severe epidemic which a board of health might
have prevented." — Sanitary Ncil's^ Sept. 7, 1889.

414

MEDICAL PROGRESS.

[September 21,

MEDICAL PROGRESS.

Acquired Leprosy, as Observed in Eng-
land.— Mr. Jon.\than Hutchinson believes
that while the possibility of contagion in leprosy
is universallj' admitted in what may be called
the abstract, it is verj' doubtful whether it takes
an important share in the spread of the disease ;
thus, lupus and cancer might be transferred from
one person to another, but neither is contagious
in a practical sense. In Xorwaj-, India and the
West Indies nurses and surgeons do not fear to
come into contact with lepers for j-ears together.
So far as contagion is concerned, hundreds of sur-
geons daily encounter the same risks that Father
Damien did, but the latter exposed himself to
other dangers as well — to those of food, for ex-
ample. In En'gland the most intimate possible
contact with lepers has not been sufficient in
itself to communicate the disease. The varieties
of leprosj' are the same the world over, in hot
and cold countries alike, facts pointing to the in-
ference that the cause must always be the same.
In countries where lepros}^ has died out it has
died out absolutelj- — not a single sporadic case
ever originates in England. The cause for the
spread of the disease must be sought in food :
there is little room for doubt that it depends upon
some ver3' special kind of poison taken in connec-
tion with- food. Such an h5-pothesis would cover
all the facts, and none other would.

In connection with his opinions Mr. Hutchin-
son cites twelve cases which have come under
his observation. These were all in patients of
British birth. There was no inherited predispo-
sition. In no instance had the patient been ex-
posed to anj' degree of hardship or deviated from
the ordinarj' conditions of well regulated life.
In ever}- case the acquisition of the disease had
occurred in some country' where it was prevalent.
The patients must have received the specific con-
tagion on some part of the skin or mucous mem-
brane, or must have swallowed it in connection
with food. All had, however, partaken of food
common in leprosy districts, and if we incline to
suspect that fish, and especially potted fish, is an
ordinarj' vehicle of contagion, all had undoubt-
edly been exposed to this risk. — Brit. Aled. Jour-
nal, Nos. 1,487 and 1,488, 1889.

Therapeutic Value of Hypnotism. — (From
a paper read by M. Bernheijm before the Interna-
tional Congress for Hypnotism, Paris, August,
1889.) The hypnotic state is that particular psy-
chical state which may be produced and which
increases, in varying degree, suggestibility — that
is to say, the aptitude of being influenced by an
idea that the brain receives and realizes. This is
a definition more comprehensible than that gen-
erally employed, for to define hypnotism as an

induced sleep is to eliminate from hypnotism a
class of cases with great tendencies toward sug-
gestion and even hallucination, for there may be
hypnotism without sleep.

I obtain some remarkable effects without sleep,
I request the patient to close his eyes ; I seek to
make an impression on him — to make his mind
captive, and I affirm the disappearance of certain
functional troubles. This is suggestion by word
without hypnotism. Sometimes the suppression
of a functional trouble or an acute pain may be
accomplished instantaneouslj- either permanently
or temporarily ; at other times it is onlj' gradually
brought about about at the end of a number of
seances depending upon the nature of the trouble
and the degree or character of the suggestibility.
Hypnotism does not enjoy a monopoly in sugges-
tion; the latter may be produced by other means,
it has been practiced in all times by physicians
with better or worse intent. Purgation by pills
of bread-crumbs, the cure of fits by fear of the
police, sleep induced b}' the peroxide of hj-drogen,
the miraculous water of Lourdes, the practices of
the touchers and the masseurs, those of hydro-
therapJ^ metallotherapy, electrotherap3% the secret
ointments, the granules of Mathei, homoeopathy
and the suspension treatment of patients with
tabes, all act in part or whole through suggestion.
Doubtless hydrotherapy and electrotherapy have
of themselves an incontestable action upon the
functions of the organism, but this action is not
well understood ; the assertions of the authors
regarding the therapeutical value of the various
methods are vague and contradictory for the rea-
son that no one has taken pains to first disengage
the element of suggestion.

I often have success with the use of electricity
in the treatment of neuralgias, rheumatism, lum-
bago, ner\-ous aphonia, etc., when I fix m}- pa-
tient's attention closeh' upon the effects obtained
under' electrization and tell him that his symp-
toms will disappear. Electrization with sugge-
tion sometimes succeeds where suggestion alone
fails. One of mj' patients had suffered for months
from extremely severe lumbar and sciatic pains.
Electrization with suggestion (the vigil state)
caused disappearance of the pain at each seance,
but only for a few hours. I then tried hypnotic
suggestion, but with less effect. The patient ex-
pressed more confidence in electrization and said
that hypnotism alone had no effect upon him. I
returned to my former treatment with the result
of obtaining a complete cure in two or three weeks.

In metallotherapy I have been able to discover
nothing of value aside from the element of sug-
gestion ; I do not deny that it possesses other
powers, but I have been unable to discover them.
I have often applied various metals and magnets
to the anaesthetic skin of hysterical patients with-
out informing them of what I was doing, and
without producing any effect. By applying the

1889.]

MEDICAL PROGRESS.

415

metal, however, and saying to the patient or the
assistants, "here is the metal or magnet which I
wish to apply : in three minutes sensibility will
return in the hand and in half of the forearm," I
often obtain the desired result. The English
seem to me to be right (at least in part) when
they ascribe the therapeutical action to expecta-
tion. The treatment of tabes b)- suspension has
made a great deal of noise lately. The surpris-
ing benefits obtained have been attributed to the
changes produced in the blood-supph' of the spi-
nal marrow, as well as to the stretching of the
ner\'es. From the ver\- first I have thought that
suspension is a method of suggestion. Numerous
experiments of this sort, by myself and as well as
others, upon patients suffering from ataxia and
other varieties of myelitis, nocturnal incontinence
of urine, and especially the various forms of neu-
rosis, have led them to the same conclusion. The
science of medicine endeavors to explain all the
mj-steries of life by mechanics, phj-sics, and ani-
mal chemistrj-, but the mind is also a factor in
the human organism ; there is a ps}-cho-biologj-
and a psycho-therapj-.

My final conclusion is that suggestive thera-
peutics rests upon the incontestible influence ex-
erted bj- the mind upon the bod}-. Its influence
upon digestion, nutrition, respiration, circulation,
and upon the secretory or excretory functions, is
v,-ell known, for all the organs, all the functions
are in anatomical and physiological relation with
the cerebro-spinal nerve centres. Even,- cerebral
cell influenced by an idea tends to realize this
idea through the agency of the ner%-e fibres. The
idea becomes an act. Upon this physiological
fact is based the psycho-therapeutics of sugges-
tion.

The hypnotic state itself produced bj- sugges-
tion increases suggestibility b^- suppressing intel-
lection and augmenting cerebral automatism. It
is faith that saves, aud the most incredulous peo-
ple have a faith (I do not say a religious faith) ;
they are no more able to escape from it than thej'
are able to escape from the hallucinations of their
dreams. Credence (I do not saj^ credulit}-) is in-
herent in the human mind, and thus it is that the
human mind becomes a master workman in mir-
acles.— Lc Bulletin Medical.

The Prophylaxis of Tuberculosis. — Last
year a congress for the study of tuberculosis was
held in Paris. At this meeting a permanent
committee was appointed to formulate simple
and practical instructions regarding the prophy-
laxis of tuberculosis. On behalf of this commit-
tee M. ViLLEMiN has recently submitted a report
which had already been approved by four profes-
sors of the medical faculty of Paris. The follow-
ing is a brief summary- of this report :

I. Tuberculosis is, of all diseases, the one
which has the largest number of victims in the

cities, and even in certain countrj- districts. In
1884, for instance, of 57,970 deaths in Paris,
15,000 were due to tuberculosis.

2. Tuberculosis is a vinilent contagious trans-
missible parasitic disease produced by a microbe,
the bacillus of Koch. This microbe, apart from
direct hereditary transmission, finds its way into
the organism through the digestive and respira-
tor}- tracts, and through wounds of the skin and
mucous membranes. The propagation of tuber-
culosis may be prevented by well directed pre-
cautions.

3. The parasite of tuberculosis ma}- be found
in the milk, muscles and blood of the food ani-
mals. The use of raw and underdone meat and
blood that maj- possibly contain the living germ
of tuberculosis should be prohibited. Milk, for
the same reasons, should be boiled before being
used.

4. On account of the dangers concealed in
milk the protection of infants, who are so easity
attacked by tuberculosis, should attract the
special attention of mothers and nurses. The
tuberculous mother should not nurse her child.
Cow's milk, when given, should always be boiled.
There is less danger in giving ass's and goat's
milk unboiled.

5. It is greatly to the interest of the public to
assure the proper inspection of meat, as provided
for by law. The onlj- sure waj' to a-\^oid the
dangers of tubercular meat is to see that it is
thoroughly cooked.

6. Inasmuch as the germ of tuberculosis maj'
be conveyed from a tubercular to a healthj- man
by the sputum pus, inspissated mucus, and any
object containing tubercular dust, it is necessary
to bear in mind that :

1. The sputum of phthisical persons being the
most dangerous agent of transmission, there is a
public danger from its presence upon the ground,
carpet, hangings, curtains, napkins, handker-
chiefs, cloths and bedding.

2. The use of cuspidors by everj-one should be
insisted upon in all places. Cuspidors should
always be emptied into the fire and cleansed by
boiling water. They should never be emptied
into rubbish piles, upon gardens, or where there
is a possibility of infecting poultry-, or even into
water closets.

3. It is unsafe to sleep in the bed of a tubercu-
lous patient, or to spend a great amount of time
in the room of such a patient ; least of all should
young children be allowed to sleep in such a
room.

4. Individuals considered as predisposed to
contract tuberculosis should be kept away from
localities frequented by phthisical patients.

5. One should not use objects contaminated b}^
phthisis (linen, bedding, clothing, toilet articles,
jewelrj', hangings, furniture, playthings, etc.),
except after suitable disinfection.

4i6

MEDICAL PROGRESS.

[September 21,

6. Rooms and houses occupied at watering
places and resorts should be furnished in such
manner that disinfection maj' be easily carried
out after the departure of each invalid. It is the
best plan of all to furnish rooms without curtains,
carpets or hangings, to whitewash the walls, and
cover the floor with linoleum. — Bulletin de V Aca-
•deniie de Medecine, July 30, 1889.

Immediate Treatment With Cure of Lac-

TER.\TIONS OF THE CERVIX UTERI. By MaRY E.

Bates, M. D. — The -^Titer believes that there
are insurmountable objections to suturing a lacer-
ated cer\-ix within a few hours of the termination
of labor ; first, because of the condition of the
patient and of the wound ; second, because of the
difficulty of introducing the sutures ; third, be-
cause of the dangers incident to the necessary
exposure, and' finally because of the impossibility
of accurately determining the extent of the lacer-
ation. Operations made three or four months
post parhim present certain advantages which are
not possessed by the late operations.

A few lacerations may heal by first intention
without any special interference, though in the
majoritj- of cases involution and repair will not
take place satisfactorily. In lacerated cervix the
indications are to promote involution and repair :

1. B3' stimulating the pelvic circulation.

2. By cleansing the parts.

3. By keeping the edges of the wound in ap-
position.

4. By relieving the relaxed ligaments by sup-
porting the uterus.

These desiderata may be secured by tamponing
the vagina with antiseptic wool. This is to be
introduced in such a manner as to keep the edges
of the wound in close contact and give support
to the uterus. The tampon may be left i)i situ
for two or three days at a time, and should be
reapplied two or three times. After the patient
gets up the uterus should still be supported by
tampons for at least two weeks longer. By these
measures excellent union can be obtained and
the processes of involutions be materially has-
tened.— Southern California Practitioner, July,
1889.

Fractured Sternum with Double Pleuro-
pneumonia.— A man, 64 years of age, was ad-
mitted to the General Hospital, Birmingham, in
the service of Sir Walter Foster, on May 20th.
Respirations were 58, temperature 103" ; there
was urgent dyspnoea and pains in both sides of
the chest. An examination revealed a double-
sided pleuropneumonia. There was dulness at
the lower part of the chest and at the sides, to-
gether with bronchial breathing, crepitation, vio-
lent cough and thick tenacious expectoration.
The lower part of the sternum from the upper
border of the fourth costal cartilage moved with

each respiration, giving distinct crepitation. The
patient had sustained a severe fall four days pre-
viously. Treatment consisted in strapping and
the administration of stimulants and a mixture
containing acetate and carbonate of ammonia and
squill. Bj' the eighth day the respirations had
dropped to 44. On the i6th there was a fresh
extension of the pneumonia at the left base, This
attack passed off, and on the 21st he was free
from pain. From this date he made a good re-
covery, and was discharged on July nth, at
which time the chest-walls moved fairly, the res-
piratory sounds at the bases were good, though
accompanied occasionally by dry, creaking sounds.
Union of the sternum had taken place. — British
Medical Journal, Aug. 3, 1889.

TuBERCUL.^R Meningitis in the Adult. — A
man of 52 years, while apparently in the midst
of health, had a profuse pulmonary hsemorrhage,
followed by consolidation of apex of left lung, in
1887. Milk diet and creosote medicinally for
eighteen months enabled him to gain markedl}-.
Temperature during this time, about 99'-°; ex-
pectoration scanty ; increase in weight, 40 pounds.
There was a recurrence of the hsemorrhage in
July, followed by rapid formation of cavity at
apex of left lung and profuse expectoration of
pus. He rallied and resvimed work after an in-
terval. In March he sufiered greatl3' from head-
ache, with exacerbations on alternate da3-s.
Temperature, 105.3°. Nothing served to relieve
pain or reduce temperature. After six days de-
lirium set in at inter\-als. The respiration took
on the character of the Cheyne-Stokes type,
which continued until death, except as modified
by the administration of atropia and str^-chnia.
Convulsions and death eighteen days after the
appearance of cerebral symptoms. — N. O. Med.
and Surg. Journal.

The Pathogeny of Nephritis by Self-In-
toxication,— E. G.\UCHER reports, in the Revue
de Med., No. 11, 1888, experiments made on
guinea-pigs with leucin, tyrosin, kreatin, krea-
tinin, xanthin, and hypoxanthin. Subcutaneous
injection of these substances produced (like min-
eral substances : mercur}-, phosphorus, arsenic,
etc. : and vegetable substances : oxalic acid and
fuchsin, as proven before by the same author) in
ever}' case a nephritis of the epithelium which
led to granular fatty degeneration especially of
the epithelium in the tubuli contorti. The au-
thor warns against giving food rich in extractives
(bouillon, meat-extracts, meat-powders, etc.) in
all cases where with a disturbed digestion the
transformation of azotic nutriment occurs imper-
fectly, as a nephritis threatens from overburden-
ing the organism with such extractives. — Centr.
fitr Klinische Medicin, No. 23, 1889.

1889.]

EDITORIAL.

417

Journal of the American Medical Association

PUBLISHED WEEKLY.

Subscription Price. Including Postage.

Per Annum, in Advance $5.00

Single Copies 10 cents.

Subscription may begin at any time. The safest mode of remit-
tance is by bank check or postal money order, drawn to the order
-of The Journal, when neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
letters.
Address

Journal of the American Medicai, Association,

No. 68 Wab.^sh Ave.,

Chicago, Illinois.
All members of the Association should send their Annual Dues
to the Treasurer, Richard J. Dunglison, M.D., Lock Bos 1274, Phila
delphia. Pa.

London Office, 57 and 59 Ludgate Hill.

SATURDAY, SEPTEMBER 21, iS

EXTRACTION OF CATARACT WITHOUT
IRIDECTOMY.

A careful perusal of the comparatively short
but eventful history of cataract extraction, will
not only repaj^ the reader for his trouble, on ac-
count of the interest inherent to the .subject, but
will also put him in po.ssession of certain facts
regarding this operation which will prove of
special interest at the present moment, when the
question of modifying the usual method of oper-
ating is agitating the minds of ophthalmologists.

The history of an operation is the record of
men's e.xperience therewith. Therefore when the
surgeon is invited to set aside an operative pro-
cedure by which he obtains good results, and to
adopt a modification of a once discarded opera-
tion, it behooves him to turn to the pages of its
liistory, so that he may profit by the accumulated
experience of others. The record should be care-
fulh' reviewed and the reasons for its having been
discarded thoroughly studied. The causes of fail-
ure in the past should be examined in the light
of our present knowledge, and whether any dis-
covery has been made by which the obstacles to
success can be surmounted, is not onlj' a most per-
tinent question, but one which demands a satis-
factory answer.

If the annals of ophthalmic surger3' are con-
sulted it will be found that up to the middle of
this century the operation for cataract most gen-
erally performed was the classical " flap extrac-
tion," without iridectomy. It is undeniable that
when this operation was entirely successful the
result was in every respect all that could be de-

sired. The corneal scar was hardly perceptible,
the iris retained its normal form, and the patient-
once being rid of his opaque lens, looked through
a round and movable pupil. Nothing more
could possibly be demanded of ophthalmic sur-
gerj'. Unfortunatel}' the number of perfect results
fell far short of what was desirable. The large
corneal flap was apt to suppurate, leading to the
total destruction of the eye. The iris, which was
oftentimes badlj- brui.sed during the expulsion of
the lens, frequently reacted, giving rise to haras-
sing iritis, and entailing the contraction of the
pupil, with loss of motility and of its regular
form. But the great disadvantage of the pro-
cedure was the danger of prolapse of the iris.
In many instances the result of a perfectly smooth
operation, giving promise of a brilliant outlook,
was marred by a prolap.se of the iris supervening,
perhaps, two or three days after the operation,
from a fit of coughing, or some other efi"ort, and
sometimes without an\' apparent cause. In some
instances the performance of an iridectomy suc-
ceeded in setting free the entangled iris, but in
the majoritj' of cases the patient was sent out
carrj-ing in his eye a source of irritation which
constantly menaced the integrity of the organ.

To obviate these difficulties Gibson and Travers,
in the earl}' part of this century, tried to extract
certain forms of cataract through a small linear .
incision ; Bowman and von Graefe, simultane-
ously, although independentl}-, revised this method
toward the middle of this century, adding one
more step to the operation^ the removal of a
small portion of the iris. Finally, the master-
mind of Graefe, perceiving that each operation
offered certain advantages, and that neither was
adapted to all cases, devi.sed, and then gave to
the world, the "modified linear extraction,"
which did away with the disadvantages of the
old flap and the linear extraction, and combined
the advantages of both.

The result was most satisfactorj^ along the
whole line of operators. Even those who had
performed for many years the old flap extraction,
securing its occasional brilliant results, reluct-
antly gave waj' before the obvious advantages
of the new operation, and went over to the ranks
of its advocates. The reason for this uncondi-
tional surrender is not to be sought, however, in
any alleged perfection of the method, for its sub-
sequent historj- revealed that the operator had to

4i8

EXTRACTION OF CATARACT.

[September 21,

encounter other dangers, such as the escape of
vitreus when the incision was made too far into
the sclerotic ; but the reason for its general adop-
tion is to be found in the fact that it eliminated
almost entirely the two prevailing sources of fail-
ure in the old operation, viz. : suppuration of the
cornea and prolapse of the iris.

The operation was not destined to live long in
its original form. Notwithstanding the acknowl-
edged advantages ensured by the iridectomy, the
eyes of some ophthalmologists turned back with
longing toward those round, movable pupils ob-
tained in the good old days of flap extraction.
Soon the incision began to travel more into the
cornea, and ever>' effort was made to do away
with the defacing iridectomy. Modification fol-
lowed modification in rapid succession, so that
after a few years all that remained of Graefe's
original operation was the knife. Finally a calm
ensued, during which the merits of all these mod-
ifications were thoroughly tested. The majority
of ophthalmologists, perceiving that Graefe's
claims were satisfactorily sustained by experience,
gradually settled down to perform extraction with
iridectomy, limiting their modifications to slight
deviations from the original form and seat of the
incision. A few operators, however, have from
time to time made desultory efforts to banish
iridectomy, but within the last two or three years
there has been a well-defined movement in this
direction. The proposed operation is known as
"simple extraction."

As this movement is led by some of the most
distinguished ophthalmologists in Europe and
America it is bound to command attention, and
to exert great influence. Furthermore, some of
its advocates are most enthusiastic, and their
claims are in some instances supported by care-
fully prepared reports. To gainsay the state-
ments made by such men is, in a sense, to stand
condemned in one's own words. Yet it is un-
questionably true that a calm, dispa.ssionate ex-
amination of the merits of simple extraction,
which, after all, is but a modification of the old
flap operation, does not reverse the verdict of the
past. It is quite true, that the advances made in
antiseptic measures have greatly diminished the
dangers of suppuration of the wound, but the
proposed improvement over the " combined oper-
ation," does not depend so much on the form of
the incision, as it does upon the banishment of

the iridectomy. And in this particular no ad-
vance has been made which will help us out of
the old difiiculty. The surgeon's control over an
eye ceases when the bandage is applied, and the
worst cases of prolapse occur after this time. It
has been suggested to leave the bandage undis-
turbed for six days, and to restrain the patients
more to their beds, but notwithstanding all these
precautions the dreaded "de/c noire," as Critchett
used to name prolapse, will occur, and an anterior
synechia is universally recognized as a most un-
desirable complication.

That removal of lens without performing iri-
dectomy (thus securing a round, movable pupil)
is the goal to which every experienced oculist
should direct his steps, is undeniable. But the
road to this goal is full of pitfalls and difliculties.
Hence a note of warning should be sounded for
those who have not acquired sufiicient experience
in ophthalmic surgery to realize the dangers
which lie ahead. It requires a most experienced
ej'e to discover when a lens can be extracted
without iridectomj', and further, it necessitates a
nicety of manipulation acquired only by j-ears of
practice to thus accomplish its removal. Let
simple extraction then take its place as the ideal
operation, but let us bear in mind that like many
other ideals it is not always practicable. The
modified linear operation, as performed to-day,
offers inducements, both in safety of procedure and
in brilliancy of results, which cannot be denied,
and which should not be underestimated.

Many distinguished ophthalmologists who had
discarded iridectomy have returned to it, experi-
ence having taught them that it is safer in the long
run. It therefore behooves the expert operator to
weigh the evidence most carefully — the beginner
should unquestionably adopt the method which
on the whole offers the best assurance of suc-
cess.

Leprosy in Nova Scotia and New Bruns-
wick.— Dr. Smith, the medical attendant of the
Tracadie Leper Hospital, New Brunswick, having
been commissioned by the Canadian Agricultural
Department to make inquiry concerning suspected
cases of leprosy reported in Nova Scotia, fully
confirms the diagnosis. It is also reported that
there are a considerable number of other cases be-
lieved to exist in the northern part of the prov-
ince.— Brit. Med. Journal.

1889.]

AUTO-INFECTION.

419

AUTO -INFECTION FROM
GASTRO-INTESTINAL

THE PRODUCTS

FERMENTATION.

OF

There is a large and important class of cases,
examples of which are constantly coming under
the observation of the general practitioner, some-
times under one guise, sometimes under another ;
at times bearing clinical aspects of familiar ap-
pearance, again presenting an array of symptoms
without apparent interdependence and exhibiting
manifold functional disorders which seem to
affect ever}' organ of the human economy, and
to spring from sources so well hidden as to baffle
the quest of even the astute physician. These
are the ca.ses of that hydra-headed enemj^ of
modern civilization. Indigestion. To compass
etiology' we are obliged to summon to our aid all
the wisdom of physiology, chemistry and bacteri-
ology. In our efforts at treatment we have al-
ready well-nigh exhausted the resources of ma-
teria medica and dietetics, and have little to fall
back upon save hygiene — id est, common sense.

We can scarcelj^ doubt — indeed, we have al-
ready admitted — that it is the Americans who
have received the worst drubbing from this mon-
ster ; and yet, at first blush, it would seem as
though the United States, the granary and pas- !
ture of the world, with a population supplied
with a greater variety and better quality of food
than anj- other nation, would hardly be this mon-
ster's favorite victim. It might be said, indeed,
that we have too great an abundance, and that
we are suffering from the results of too much
luxury and refinement in eating and drinking.
But if sophistication in the preparation of food is
a danger, it would seem that the French, with
their culinary subtleties ; the Germans, with their
insipid steamed meat and stomach-destroying
" mehlspciscn," and the Italians, with their garlic
and oil, ought all to come in for their full share
of punishment. The truth of the matter is,
doubtless, this : The Americans are no more in-
discreet in what they eat and drink than are the
other nations. The difference is rather to be
found in the -u'ay they eat and drink, and in the
manner of their life ; in other words, the hygiene
of European life is, in manj^ respects, more ra-
tional than ours. In European life there is less
hurrj% less anxiety, less precipitation, and more
of out-door life and physical exercise. Even
their habits of drinking are less injurious than
ours, for they rarely drink beer or wine or liquor

except at meal times. In fact, were it not for
the abhorrence that the continentals exhibit for
fresh air within doors, one might say that nearly
all their hygienics are superior to our own.

Fortunately enough for the great army of
' ' dyspeptics, ' ' the work that has been done in
the study of the causes and treatment of the dis-
orders under consideration (and certainly in no
department of medicine has more been done than
in this) has borne rich fruits ; and especially
may we congratulate ourselves in the develop-
ment of the facts elicited by the aid of bacteri-
ology. From the chaos of dyspeptic symptoms
we have learned to differentiate, more or less
accurately, certain complex uses of disordered
function which supply us at once with the key-
note of etiology and the guide-post to rational
treatment. The modest general practitioner, who
has hitherto feared lest he might tread upon the
toes of the redoubtable neurologist, is beginning
to learn that it is really the latter who has all
along been trenching upon the general practition-
er's own favorite field. Auto-infection has now
come to explain to the general physician much
that has hitherto been a perplexing puzzle to
him. Brunton has drawn attention to this mat-
ter in the following striking expressions : ' ' Per-
haps we are not yet sufficiently alive to the im-
portant results produced by the absorption from
the intestinal canal of substances generated in it
by fermentation, or imperfect digestion. We
recognize the danger of breathing gas from a
sewer, but probably we do not sufficiently realize
that noxious gases may be produced in the intes-
tines, and, being absorbed into the circulation,
may produce symptoms of poisoning."

An excellent illustration of this thought is
found in a recent contribution to the New York
Medical Journal on " Ner\'ous Symptoms Caused
by Functional Gastro-intestinal Disorders," by
Drs. W. W. Van Valzah and Chas. R. Cran-
DALL. To a verj^ interesting report of such a
case these writers have added an able analysis of
the underlying causes, together with the rational
indications for treatment in this and similar cases.
The patient in question was a typical one of a
class, a middle-aged American gentleman, a law-
yer by profession, and a member of Congress.
Of neurotic ancestry and of nervous temperament,
the excitement and strain of such a career as he
chose, and a moderate disregard of the ordinary

420

THE PHYSICIAN AND HIS JOURNALS.

[September 21,

laws of hj'giene, was all he needed to become
what he was — a constant sufferer, tormented by a
great variety of aches and pains. Even in boy-
hood and early manhood he was a martyr to in-
digestion, as well as the victim of numerous acute
diseases. In the full tide of his activity his busi-
ness affairs were interrupted by frequent break-
downs, requiring him to discontinue work and
resort to watering places and take extended jour-
neys in the interest of his health. He suffered
greatly from insomnia, nervous irritability, in-
ability to concentrate his thoughts, pain and
burning sensations in his limbs, distress after tak-
ing food, acidity, flatulence, grinding sensations
in the stomach and bowels, constipation, etc. A
physical exa,mination also revealed a gaseous dis-
tension of the stomach and intestines, the pres-
ence of yeast ferments in the blood, and of phos-
phates and bile in the urine, which showed a
specific gravity of 1,030, The treatment insti-
tuted and faithfully carried out consisted almost
entirely in altering the hygienic conditions of
this man's life. He was placed in the midst of
healthful mental and moral surroundings. To
these were added rest, freedom from all sources
of irritation, baths, massage, moderate exercise,
and a suitable diet, which consisted in the with-
drawal of fermentable food, including all sweet,
starchy and greasy articles, all fruits and vege-
tables, and everything containing acids. His
diet was almost entirely one of animal food, com-
posed mostly of beefsteak and the muscle pulp of
beef prepared by a machine made for the purpose.
Meanwhile frequent examinations were made of
the patient's blood, urine and faeces. L,ater on,
when a less restricted diet was enjoined, he was
allowed to gradually add stale bread, a small
quantity of milk, then a little game, and finally
some vegetables. Tea, coffee and stimulants
were all prohibited, and he was required to drink
a pint of hot water one hour before each meal.
As regarded the use of purely medicinal agents,
spch were administered as tended to give tone to
the nervous system, stimulate the digestive or-
gans to better action, aid the digestion of food,
and induce rest to the nervous system. The par-
ticular ones chosen were cinchona, nux vomica,
damiana, salicin, cascara, pepsin, bromides, and
sulphonal. Under this treatment, in a single
month, the patient passed from constant wretch-
edness to a state of entire comfort. After three

months of such treatment he returned home, not
cured, indeed, but on the high road to health.

It is by such thorough examinations of our
patient's condition, and by such rational applica-
tion of the simple remedies which, when judi-
ciously employed, possess so great a potentiality
for good, that we ma)' hope to obtain success in
the treatment of digestive disorders when once
they become fairly established. But in this, as
in most other diseases, the best of all treatment
is the prophylaxis, and here it is the wives and
daughters who are the real physicians ; and it is-
our firm belief that until the domestic arts of the
kitchen and dining-room attain a rank of dignity
among the other accomplishments, until they are
taught verj' much as music and painting are
taught, it is going to fare pretty badly with all
of us.

THE PHYSICIAN .•VXD HIS JOURNALS.

There is an ever present tendency among men,,
in a sort of vague and misty way, to venerate the
past ; in a way quite egotistical to magnify the
present, and also to compass the future with,
grandiloquent interrogations.

To the first and third counts we plead not guilty
— but to the second we enter our confession, since
a simple statement of facts can hardly seem to-
those in other lands other than most notable ex-
hibitions of egotism. When we come to enumer-
ate the medical practitioners in the United States,
the number of our medical schools and their im-
proved facilities for teaching, the rapid develop-
ment of medical societies and the numbers of
medical journals that are in demand, we submit
that the parallel is not to be found in the past or
present history of any nation. If any one has
doubts upon this subject we commend to him the
simple study of statistics. Again, there never
was a time when in this and in other lauds there
was such an array of talent applied with utmost
tension, to medical investigation. There was
never a time when there was .so much of original
discovery, and never before such facilities for rapid
advances in medical education. There never was
a time when medical journalism was so enterpris-
ing as now, nor its pages so tilled with valuable
instruction, and there never was a time when a
physician could so soon fall behind and be lost
sight of as now. A single year's neglect will

1889.]

EDITORIAL NOTES.

421

render his needs conspicuous. Only the most in-
dustrious and critical readers are fully abreast of
the times, and in the hour of need and of their
opportunity how quickly these come to com-
manding prominence.

If all these facts be true, how can we do other-
wise than by their simple statement magnify the
present? If they be true it is obvious that to the
well informed physician his journals are as essen-
tial as is his daily bread. And while making his
selections, will he pardon if we make one or two
suggestions.

We believe that a first duty of the medical man
is to help develop, foster and sustain the medical
societies and medical interest of his own locality.
He has power personally to stimulate his associ-
ates and to aid them in organization and in med-
ical progress. In the development of such local
interests nothing can be so helpful as the ably
conducted and well supported local medical jour-
nal. To this he owes a primary obligation, both
literary and pecuniary. Its pages should be re-
plete with the recorded experiences of local con-
tributors while, in turn, it should gamer for them
the best of medical productions from all lands.

To the physician in quest of his second journal
we respectfully commend the value and the claims
of The Journai^ of the American Medicai,
Associ.'i.TiON. While it is National in its rela-
tions and circulation, it will seek to further his lo-
cal interests. It will give a continued series of val-
uable original papers, prepared and submitted by
the leading men of the profession, at the annual
meetings of the American Medical Association.
It will give prominence to translations of the best
literature published in foreign languages, and co-
pious selections from the best writings at home
and abroad. It will devote itself to the dissem-
ination of clinical instruction, and to the pre-
sentation of condensed reports of the proceedings
of prominent medical societies. These, with the
work of a corps of editorial writers widely repre-
sentative of the American States, constitute our
claim to the second place on the physician's list
of medical journals, to which he should add as
many others, home and foreign, as he can thor-
oughly utilize.

Butcher-Shop Regulation. — The Municipal
Council of Paris has ordered that the debris of
butcher-shops shall be removed before daybreak.

THE MISSISSIPPI VALLEY MEDICAL
ASSOCI.\TION.

The fifteenth annual meeting of this Associa-
tion was held in the city of Evansville, Ind.,
September 10, 11 and 12. The Committee of
Arrangements had made ample provisions for
every need and their work seemed perfect in
every detail.

The meeting was one well representing the lead-
ing men of the Mississippi Valley and was con-
spicuous, /f;.?/', for the absence of any excessive
convivial spirit ; and secondly, for the earnest pur-
pose with which, from first to last, the members
applied themselves to solid scientific work. Of
the eighty- three papers which had been prepared
for this meeting seventy-one of the writers were
at hand to present them in person. Owing to the
admirable tact of the presiding officer not a mo-
ment was lost. The papers followed in quick
succession. The discussions which they elicited
were as conspicuous for their aptness and force as
were the papers themselves.

It may seem to the members of our Association
in other portions of this broad land that The
Journal is according undue prominence to this
particular organization ; in answer to which we
wish simply to say, that wherever, or whenever
an association shall so manifest its interest in,
and its loyalty to, the American Medical Asso-
ciation as does this, and command within itself
such elements of strength and culture. The Jour-
nal will be only too glad to recognize its claims
and, as in this instance, to further its interests in
every possible way.

Our regret is, that in connection with the pub-
lication of Association papers the pressure upon
our columns will not permit the solicitation of a
number of those there presented, for a like pur-
pose. Our cotemporary journals, it is hoped, will
afford ample and adequate facilities for their dis-
semination. In the present issue we give, as fully
as our space will permit, an outline Report of the
Proceedings.

editorial notes,
home.
The Delaware Hospital. — The corner stone
of this hospital was laid by the Masonic Grand
Lodge on the 17th ult. Dr. L. P. Bush, Presi-
dent of the Hospital Board, in his address said
that "had the desire of the physicians of Wil-

422 EDITORIAL NOTES. [September 21,

.mington been carried out there would have been a
place long ago to which the sick and wounded of

he instituted a Pasteur laboratory' for the treat-
ment of hydrophobia, and was elected visiting

our city who were in need of assistance could be surgeon to the Charity Hospital. At the time of
taken. But it is a happy event which has brought his call to Philadelphia he was Professor of Phy-
us here to-day to attempt to supply the deficien- ' siology and Hygiene in the High School Depart-
cies of the past and to help to wipe away what- ^ ment of the Tulane University, and Demonstrator

€ver of odium may have rested upon the reputa-
tion of our city by this neglect."

The building will be ready for occupation before

of Microscopical Anatomy and Bacteriology in
the Medical Department of the same school.

Hospital Bequest. — By reason of a bequest

the close of the year. The present structure will ^^^^ ^^. ^^^ ^^.^ ^^^^^ ^^^ ^^ ^^^ ^,^^j^^^. ^.^._

be added to from time to time. A copy of The ^^^^ of' Pittsburg, the sum of one hundred thou-

JoURNAL, together with a copy of each of the ^^^^ ^^^^^^^ .^ appropriated for the benefit of the

local papers, the New York Herald and Philadel- ^ -^^^^ „f ^^^^ ^i^y.
nhia P?-ess, were placed in the foundation stone.

*^ FOREIGN.

New York Medico-Legal Society.— At a ! ^^^ Intern.ational Congress of Hydrologj^
meeting of this Society held at the Hotel Buck- ^^^ Climatology will open at Paris October 3,
ingham last Wednesday the following papers were ^gg^ Numerous excursions to points of interest
read: "The Hygiene of Interments," by Dr. C. ^^g among the features ofi'ered for this occasion.
A. F, Lindorme, of Florida; "Classification of the ^ .,,. ,^ „ ^

,^ . . ^ -. -i ,, u -r. T u't^ ^ ^r A Scientific Mission. — Dr. \ lault. Professor
Varieties of Insanity," by Dr. Joseph Jones, of r -a a u u

^ , ^ ,,„, ' c -n t n^^ * of the Medical Faculty of Bordeaux, has been

New Orleans, La. ; "Resume of Recent Tnp to , .,, • ■ ^ .1 1 • 1, w r

^ ,, , ^, , T> II T^ I charged with a mission to the high plateaus of

Europe," by Clark Bell, Esq. j -o ,• • t u • . .• ^

^ ! Peni and Bolivia, where he is to continue the ex-

The Southern Surgical and Gynecologi-
cal Association will hold its next session at
Nashville, Tenn., November 12, 13 and 14, 1889.
The preliminary programme contains a list of

periments of Paul Bert relative to rarefied air. —
Le Bulletin Medical.

Antiseptic Properties of Tobacco Smoke.
Hajek, of Vienna, and Tassinari, of Pisa, have

thirty-five papers by eminent physicians from the ^^^^^3^;^^^^ by experiment that tobacco smoke

destroys germs, and the former has found, by
consulting statistics, that men who smoked were

North and South

Dr. Samuel Wolfe, of Skippack, Pa., will

fill the Chair of Physiology at the Medico-Chirur- ' far less susceptible to infection than the remainder

gical College of Philadelphia during the coming I of the population during an epidemic of diphthe-

yg^j. 1 ria. The British Medical Journal now endeavors

■r. ^ -D.-^TT^T^^,. A f to explain the latter fact, pointing out that the

Appointed Professor of Pathology. — At ^ , , . , ^ c

r ^1 T> 1^ f tt ^ AT^^;^^ robust men who can tolerate large amounts of

the last meeting of the Faculty of the Medico- • . • r ■

^, . • 1 ^ ,r -nui J 1 1,- T-i T? „<.of T ., ; tobacco are the very ones who resist infection any

Chirurgical College, Philadelphia, Dr. Ernest La- ; . -^ ^ ^, •

*' . r , ^ c rnn,! r>' way ; it also advises non-smokers not to put their

place was appointed Professor of Pathology. Pro- ■>' . . ^

r T 1 • ^- f Ts.T..„. n.-i..o„e o«^ trust lu thc autiscptic pyridine of tobacco, aud uot

fessor Laplace is a native of New Orleans and ^ ,, j ■ ■, ■ ■, •,

^,-., „ . , r .,„; to make themselves unwell during epidemics while

a graduate of the Literarj' Department of the .,,•..., 1 . ^i, c

^ ,, . . ^ ry \ c 1 attempting to habituate themselves to the use of

Georgetown University, D. C. After several '* ^ '^

years' study in Tulane University and the Char-
ity Hospital he went abroad and graduated in the Pharmacy Rkgi.str.\tion in France.— The
Faculte de Medicine de Paris, where he studied Minister of Commerce has given notice that no
under Pasteur and Cornil. He afterward spent ■ pharmacist will be permitted to take his oath be-
several months in Vienna under Billroth and ; fore reaching the age of 25 years, and in order to
Strieker, and a vear in Berlin with Koch and von ! secure the rigid enforcement of this measure the
Bergmann. While with Koch he discovered the university authorities have received orders to
superior efficiency as a germicide of acid subli- confer no diploma (without which young students
mate of mercury and the sulpho-carbolic acid as are unable to establish themselves) until the pro-
a disinfectant. After his return to New Orleans | per age has been attained.— Zf Bulletin Medital.

1889.]

TOPICS OF THE WEEK.

423

TOPICS OF THE WEEK.

THE INTERNATIONAL MEDICAL CONGRESS OF 1890.

As organizing committee of the International Medical
Congress to be held in Berlin next year. Professors Vir-
chow, von Bergmaun and Waldeyer have issued the fol-
lowing resolutions: The Congress is to be opened on
August 4 and closed on the loth. It is to consist of di-
plomated physicians and surgeons who have registered
themselves as members and have taken tickets of mem-
bership. The registration fee is twenty marks, and each
member will receive a copy of the Transactions. The
purpose of the Congress is purely scientific, and its busi-
ness will be transacted in Sections. The Committee of
Organization will cause the definitive officials to be elect-
ed in the first sitting of the Congress — namely: a Presi-
dent, three Vice-Presidents, and an indefinite number of
honorary' Presidents and of Secretaries. In the first sit-
tings of the various Sections a President and a sufficient
number of honorary Presidents will be elected, the latter
to preside alternately with the former. Owing to the
difference of language, a sufficient number of Secretaries
will be appointed from among the foreign members.
After the Congress the Transactions will be edited and
published by an Editing Committee appointed by the
presiding officials. The general sittings are intended for
debates regarding the work and general relations of the
Congress, and for addresses and communications of gen-
eral interest. Such addresses are to be delivered only by
members requested to do so by the Committee of Organ-
ization. Proposals relating to the work of the Congress
must be made to the said Committee before July i, iSgo.
The Committee will decide whether they shall be adopted
or not. All discourses and communications in the gen-
eral and in the Sectional meetings must be delivered to
the Secretaries in writing before the close of the sitting.
The Editing Committee will decide whether and in what
compass these writings are to be printed in the Transac-
tions. The official languages used at all meetings will
be German, English and French. The by-laws and pro-
grammes will be printed in all three languages. It is
permitted, however, to use another language at the meet-
ings for brief remarks, provided that one of the members
present undertakes to communicate the meaning of such
remarks in one of the official languages. Introductory
discourses in the Sections are to be limited, as a rule, to
twenty minutes; in discussion only ten minutes are al-
lowed to each speaker. Students of medicine and other
persons of both sexes who are not physicians, but feel
interested in the debates, may be invited by the Presi-
dent, or may receive permission to attend the sittings.

THE FOURTH INTERNATIONAL PRISON CONGRESS.

Over and above its great interest to the student.of State
Medicine, this Congress, which is next year to meet at
St. Petersburg, will have special attractions for the Eng-
lishman. Coinciding as it does with the centenan,- of
John Howard's death, it will be utilized for the bestowal
of international honors on that noble philanthropist.

The Government of the Czar, bearing in mind the fact
that it was on Russian soil — at Kherson in fact — that
Howard met his death in 1790, desires to show its appre-
ciation of his philanthropic work by offering a prize for
the best monograph on " The part filled by John Howard
in the History of Penitentiary Reform." Competitors
must write in the Russian or French language, and their
work must include a biography of John Howard and a
review of his publications ; a characterization of peni-
tentiaries at Howard's time, and a full list of all the in-
novations completed or proposed by him in these institu-
tions ; an estimate of Howard's influence on the subse-
quent course of penitentiary reform ; and a bibliography
of all his writings. Competing monographs must bj^
Mav ist [i. e., according to the Russian almanac, the
15th), 1S90, at latest, be in the hands of " The President
of the Organizing Committee of the Fourth International
Prison Congress at St. Petersburg." They must be fur-
nished with a motto, and accompanied with a sealed letter-
containing the writer's name and address. The jury
which will examine the monographs will be selected by
the Congress itself, and it will award two medals of gold,
a larger and a smaller, as well as silver medals and cer-
tificates of honorable mention. The competitor to whom
shall be adjudged the larger gold medal will also receive
2000 fr. l^"8o\ and his monograph will be inserted in the
Proceedings of the Fourth Congress, while he will also
have the right of reprinting it. All competing mono-
graphs, whether printed or in writing, which have not
been withdrawn within two years by their authors are to
be destroyed ; and, lasth-, the result of the Competition
will be published in the Bulletin of the International
Penitentiarv Committee, and also in the Proceedings of
the Fourth Congress. Besides the above-mentioned com-
petition, there will be another at the instance of the con-
ductors of the Prison Discipline Rei'iezi'. Its subject is
the following : " What in the most civilized nations has
been the historical development of the institutions re-
lating to the correctional education of minors who have
been convicted of crimes at common law, or who have-
been put in custody for idleness and vagabondage, or with
a view to paternal discipline?" The conditions of the
competition are identical with those of the preceding,
except the following modifications. The competing
monographs, in writing or in print, may be written in
any language, but there must be a French translation of
the same appended. The successful competitor will re-
ceive as prize the sum of 2000 francs (^80) from the con-
ductors of the Prison Discipline Review. The Organiz-
ing Committee of the St. Petersburg Congress will be
entitled to publish the successful monograph in the Pro-
ceedings of the Fourth Congress, while the author,
will, at the same time have the right of reprinting it. —
The Lancet.

THE INHALATION OF DUST.

Dr. Kunze, in his inaugural thesis for the M.D. degree
in the University of Kiel, publishes as a contribution to
the diseases caused by the inhalation of dust a series of
examinations of lungs so affected. In all these dust was-

424

TOPICS OF THE WEEK.

[September 21,

found microscopically, and after chemical tests in the
various anatomical and histiological parts of the lungs
and in the interior of the lymphatic vessels numerous
leucoc}'tes were found covered with the dust. Being ar-
rested in its progress, it causes inflammation producing
hyperplasia of connective tissue, especially where a dense
network of lymphatic vessels exists. Dr. Kuuze also
proved that the degree of alteration in so-called " dust
lungs " depends not merely on the quantity of the dust
inhaled, but also on its greater or less morphological
power of injuring the tissue. He concludes from his ex-
periments that even the greatest alterations in these
lungs — such as nodes, indurations, and vomicae — are
mainly produced by the inhaled dust, and that tuber-
culosis is onU' an occasional coincidence. The least
serious alterations in the lungs resulted from the inhala-
tion of lamp-black, the particles of which are ver\- line
and little injurious ; the most serious, from dust inhaled
"by earthenware manufacturers and stonemasons. The
lungs of a locksmith showed only a moderate hyperplasia
■of connective tissue, the dust consisting partly of the finest
particles of iron. In a worker in oxides of iron the lungs
were found full of small granules, and the morbid changes
in the tissues were very considerable. The lungs of gold
miners were generally indurated and atrophied ; the dust
in these cases is exceedingly fine. Sand produced numer-
ous circumscribed hard nodules and thick indurations.
In cloth manufacturers, the lungs, in spite of their con-
tact with an enormous quantity of organic dust, present-
ed but few indurations. In the lungs of two stonemasons
induration and tuberculous disintegration were observed ;
all the other lungs were entirely free from tuberculosis of
any kind, an observation which was verified by the ab-
sence of tubercle bacilli in the muco-pus in the vomicae.
— Lancet.

DISINFECTION.

The following practical remarks upon the important
subject of disinfection are abstracted from an address
delivered by Franklin Parsons, M.D., at the annual
meeting of the British Medical Association at Leeds, in
August, 1S89 :

For the disinfection of the discharges of the sick
chemical agents must, as a rule, be used, though the dis-
charges from the throat and nostrils in diphtheria and
scarlatina are best received upon pieces of rag and burnt.
It is of prime importance that infectious discharges
should be disinfected immediately on being passed from
the body, both because delay will give them more oppor-
tunity of causing mischief, and also because if the in-
fected matter be mixed with a large quantity of other
organic matters, as in a drain or privy, before the disin-
fectant is applied, the action of the latter will have to be
exerted on a greater mass of material, and its effect will
be pro tanto weakened ; and the chances will also be
great that portions of the infected material will escape
its action. It is thought by .some that germs of enteric
fever, for instance, may long lurk unsuspected in defec-
tive drains and privies until some accidental circum-
stance, such as disturbance of the contents, brings them

into activit}', and that many of the " sporadic " cases of
this disease thus arise.

Of chemical disinfectants for the disinfection of ex-
creta, corrosive sublimate is probably the most trust-
worthy and suitable for ordinary use. In its use, how-
ever, three precautions have to be borne in mind : i.
It is very poisonous, and hence, in order to avoid acci-
dents (such as frequently occur with carbolic acid), the
solution should be colored, as with permanganate of pot-
ash, sulphate of copper, or aniline blue. 2. It corrodes
iron and other common metals, and is instantly decom-
posed by contact with them ; hence it must be used in
non-metallic vessels. 3. It forms with albumen an inert
insoluble compound, but this may be prevented by acid-
ulating the solution. A solution suitable for disinfection
of excreta, clothing, etc., is made by dissolving half an
ounce of corrosive sublimate with one ounce of hydro-
chloric acid and five grains of aniline bhie in three gal-
lons of water.

Chloride of lime is a useful disinfectant for excreta,
but too strong a solution injures clothing. Carbolic acid
is especially an antiseptic, retarding putrefaction, for
example, in sewage, but a 5 per cent, solution is recom-
mended by Koch by preference for disinfecting excreta
and soiled linen of cholera patients. Creolin, a sub-
stance allied to carbolic acid, is said by recent experi-
menters to exceed it in destructive action upon spores of
bacilli, at the same time that it is not poisonous to hu-
man beings. Permanganate of potash is an excellent
deodorant, and has the advantage of not being poison-
ous. It is also, to some extent, a true disinfectant, but
its action upon infective matter is much weakened when
this is mixed with a quantity of other organic matter.
Green copperas (ferrous sulphate) is a cheap deodorant,
but, according to Koch, is not a disinfectant proper. Its
habitual use for flushing sewers in time of cholera was
strongl}- recommended by Dr. Budd, and was said at
Bristol to have produced excellent results.

With regard to the disinfection of clothing, bedding,
etc., used b}' the sick, it may in the first place be pointed
out that for such articles as will stand it, boiling in water
for say five minutes is an eff'ectual means of disinfection.
And since the infectious matters are not actually incor-
porated with the fibres of the fabric, but merely attached
as dirt to their outside, there is reason to think that even
a thorough ordinary washing will be a sufficient disinfec-
tion, so far as the articles themselves are concerned ; but
the infectious properties are transferred to the water in
which they have been washed. The dangerous proper-
ties of such water are shown by the frequency with
which cholera is contracted by those who wash the linen
of cholera patients, and by cases like that at Moseley,
recorded by Dr. Ballard, where an outbreak of enteric
fever occurred among the persons drinking the water of
a well into which had percolated the soapsuds in which
the soil.ed linen of an enteric fever patient had been
washed. To avoid such risks it is necessary that infected
articles which are washable should be disinfected before
being washed ; this should, for obvious reasons, be done
innnediately on tlieir being left off. Boiling might be
used for this purpose, but boiling water in sufficient

1889.]

SOCIETY PROCEEDINGS.

425

quantity is not always at hand ; and again, if soiled
clothes are boiled, the coagulation of albuminous matters
fixes stains in them and spoils their color. Hence it is
more convenient to put the clothes to steep in some
chemical disinfecting solution, of which a panful should
lae kept in readiness. A solution of corrosive sublimate
is the best for this purpose, as, besides being the most
•effective, it has the advantage that it does not stain or
rot the linen. When the grosser dirt has been removed
"by rinsing in water, the articles may be boiled.

Articles which cannot be boiled in water without in-
jurs-, such as cloth clothes, blankets, and beds, are best
disinfected bv exposure to heat, and the experiments
which I have quoted show that for this purpose a steam
lieat is preferable to a dry heat for several reasons,
■especiallv because a lower temperature and a shorter ex-
posure suffice to kill infective organisms, and because a
steam heat penetrates much more rapidh' than a dry
teat into bulky and badly conducting articles. Further
advantages are that in a steam apparatus the tempera-
ture is approximately equal in all parts, that it can be
accurately ascertained and kept constant at any required
■degree for any length of time — conditions which are
essential to a good apparatus, but which are very difficult

to obtain where dry heat is employed

As regards disinfection of food, no one would, I pre-
sume, willingly eat or drink articles that he knew to be
infected. As, however, one cannot always guarantee
the absence of infection in the viands we eat or the water
or milk that we drink, it is satisfactory to know that
boiling or thorough cooking may be trusted to secure
■complete disinfection. In the experiments I have quoted
it was found that even the very refractory spore-bearing
"bacilli of anthrax were destro\-ed by one minute's boiling
in water at 212° F., though certain non -pathogenic ba-
•cilli found in vegetables and milk require for steriliza-
tion a higher temperature or more prolonged boiling, a
fact familiar to the housekeeper who makes jam. It is,
doubtless, owing to the efficiency of cooking as a disin-
fectant that sanitarians in France and Germany, where
milk is, I believe, always boiled before use, are sceptical
as to the possibility of the propagation of infectious dis-
ease by that medium ; whereas with us in England, j
where milk is drunk raw, epidemics of milk origin are a
matter of almost everyday experience. On the other
hand, trichinosis, so common among the Germans, who
eat their ham raw, that it has to be guarded against by
an elaborate system of microscopic examination of all
slaughtered swine, is practicall}- unknown as a human
disease in England and France, where meat is always
cooked

For house disinfection, fumigation with sulphurous
acid or chlorine gas, the latter preferred, followed by
thorough cleansing and scrubbing, removal of wall-paper
and lime-washing, are to be recommended ; but these
processes, to be effectual, need to be carried out with
more thoroughness than is frequently done. A difficulty
often met with is to know where the inmates are to go
while the house is being disinfected ; and it would be
useful for this and other purposes if sanitary authorities
had power to provide refuges for people whom, although
not themselves sick, it might be desirable to remove
from their homes. — British Medical Journal.

SOCIETY PROCEEDINGS.

Mississippi "^^alley Medical Association.

Fifteenth Annual Meeting, held at Ei'ansville, In-
diana, September 10, 11 and 12, 1889.

First Day — Morning Session.

The President, Dr. Geo. J. Cook, of Indi-
anapolis, Ind., in the chair.

After the usual address of welcome the Presi-
dent made a few remarks, saying that on account
of the large number of papers on the programme
he would not present the usual Presidential Ad-
dress.

The first paper presented was by Dr. G. V.
Woolen, of Indianapolis, on

NASAL DIFFERENTI.^TION.

The author arrived at the following conclusions:

1. The nares should not be regarded as a whole
in relation to etiological factors.

2. Their correct interpretation must be with re-
gard to their anatomical and pathological char-
acters.

3. The regions of the inferior turbinates are the
seats of hypertrophies which are the essential pa-
thological factors of haj- fever.

4. The posterior tips of the inferior, and fre-
quently middle turbinate are likewise the seat of
hj-pertrophies which are the essential pathological
factors of asthma and its congener.

5. That this is true primarily because the sen-
sorj- apparatus of these parts isessentiallj' distinct.

6. These products do not become factors in hay
fever and asthma except there be a special dj's-
crasia.

7. Other reputed causes of asthma are associ-
ated products of hypertrophic disease of the nares
and may have led to confusion as to cause, and
may possiblj' have been reported prematurelj% if
hj'pertrophj' were not removed.

8. The anterior tips of the middle turbinate are
the seat of hypertrophic disease which produces
much nerve disturbance which is attributed to va-
rious other causes.

9. By pressure of these hypertrophies on the
nasal ner\'es we get the chief results in neuralgias
in the region of distribution of the first division
of the fifth pair of cranial nerves, and b}' obstruc-
tion of the orifices of ducts of anterior ethmoidal
cells and frontal sinu.ses this is greatly intensified.

10. Thorough removal of these hypertrophic
products is the only radical cure for these various
affections.

In the discussion that followed Dr. Wm. Por-
ter thought that clinically there were exceptions
to the conclusions arrived at in the paper.

Dr. Dudley S. Reynolds said that many per-
sons had hypertrophy of the turbinated bones

426

SOCIETY PROCEEDINGS.

[September 21,

without asthma, and in many cases of asthma the
excision of the hypertrophied tissue did not re-
lieve the asthma. To say that any case of asthma
or hay fever is caused by hypertrophy of the tur-
binated bones he considered an error.

Dr. Woolen in closing the discussion said that
in every case Tiis theory had been found correct.
It is not the magnitude of the hypertrophy but the
fact that hypertrophy exists, that causes the dis-
orders, and the thorough removal of everj' portion
of the hypertrophic tissue was in every instance
followed by complete recovery.

Dr. J. M. Mathews, of Louisville, read a pa-
per on

A simpler method of treating fistula

IN ANO,

and showed a fistulatome, a new instrument of!
his own invention, for use in certain cases where
patients would not submit to operation by the
knife. The instrument is used to dilate and
straighten fistulous tracts, and carries a concealed
knife which can be used if necessary.

Dr. Murdock thought that but for a small and
very select class of cases the instrument and meth-
od of treatment would be of little avail. The
fact that the sphincter could not be put to rest
was the chief objection to all non-cutting meth-
ods. If the sphincter can be divided and thor-
ough drainage secured fistulous tracts heal as I
readily as any other.

Dr. Grant, of Louisville, thought that the !
use of ligatures was to be condemned, and in
but few cases would the method of treatment of
Dr. Mathews be of practical benefit on account of
the lack of perfect drainage.

Dr. Wathen, of Louisville, difiered in opinion
as to the cause of non-union of fistulous tracts,
viz. : the contraction of the sphincters. This is
probably the cause of irritation, but certainly does
not prevent union. The important point of secur-
ing primary union can almost always be secured
by using the deep buried animal sutures, the same
as the deep perineal suture. If the sphincter is
thoroughly divulsed no division of the sphincter
will be necessary in many cases. The pj'ogenic
membrane must be dissected out and the parts
thoroughly brought together, and primary union
will occur.

Dr. Arch. Dixon, of Henderson, Ky., believed
that the method of Dr. Mathews could not be
compared with the advantages to be gained by the
thorough use of the knife. The knife is the only
radical cure.

Dr. J. M. Mathews in closing the discussion
agreed with the expressed opinion that the use of
the knife constituted the best method of treatment,
but there are many cases where the patient will
not submit to the knife, and for these cases the
method of dilatation and drainage had proved
beneficial in many cases.

On motion the Society adjourned to 2 p.m.

Afternoon Session.
Dr. a. S. Barnes, of St. Louis, read a paper on

THE accoucheur and HIS FORCEPS.

The author advocated the more frequent use of
the forceps in difficult or delayed labor, believing
that by their use the comfort of the mother and
safety of the child are promoted. He never uses
ergot after delivery and disapproved of the use of
anaesthetics in labor.

In the discu.ssion Dr. W. H, Wathen, of Lou-
isville, asked as to the percentage of stillborn
children in forceps cases. He had tried in vain
to secure statistics on the subject. He believed
that the statistics of Caesarean section (93 per
cent, of living children) were as good as those of
forceps delivery- .

Dr. Bell said that there were two indications
for interference with forceps, the danger to the
mother and the danger to the child. The danger
to the child can always be determined by the lo-
cation of the fcEtal heart sounds. Real danger to
the child should be the rule in every case for the
use of forceps.

Dr. Murdock, of Pittsburg, Pa., believed that
forceps had contributed very much to the lessen-
ing of the pains of labor. Every physician should
use them more frequently ; even for his own com-
fort their use was justifiable.

Dr. Dixon, of Henderson, Ky., thought that
the number of cases reported, 128 per year for
thirty-five years, was remarkable, and that the
conclusions should be of value as to the statistics
of stillborn children.

Dr. Barnes in closing the discussion said that
the use of chloroform complicated labor, that both
the long and short forceps should be a part of the
obstetrical annamentarium of everj' obstetrician,
as by the use of the short forceps in many cases
the woman could be delivered without change of
position.

Dr. B. Merrill Ricketts, of Cincinnati, read
a paper on

PLASTO-COSMETICS IN SURGERY OF THE FACE,

in which he made three classifications : i . Re-
moval of malignant growths. 2. Correction of
deformity due to the loss of parts from either con-
genital or traumatic causes, or from previous oper-
ations, or diseases of any kind, including pug
nose and ptosis. 3. The removal of nsevi, warts,
moles, hairs, pigmentary deposits, cicatrices, al-
veola fistula;, enlarged glands, or anything abnor-
mal, other than malignant growths, that may
appear on the face or neck. He spoke of the dif-
ferent operations now resorted to to correct the
various kinds of deformity such as are indicated
in this classification, such as thick lips, ears, lids,
and aloe, the grafting of cartilage, skin and bone,
electrolysis, the natural chlorides, and the substi-
tution of various kinds of tissue.

1889.]

SOCIETY PROCEEDINGS.

427

' The paper was discussed by Drs. I. N. Bloom,
of lyouisville, Ky., and G. H. Rohe, of Baltimore.
Dr. S. E. Mumford, of Princeton, Ind., read
a paper on

PERINEORRHAPHY — ITS IMMEDIATE OPERATION,

in which the advantages of the early operation,
-not later than twenty-four to thirty-six hours after
■delivery, were clearly set forth.

Dr. L. Worsham, of Evansville, believed that
the immediate operation was of decided advantage
in the majority of cases.

Dr. Joseph Eastman, of Indianapolis, said
there were at times conditions present which are
impossible to operate immediatelj' with success.

Dr. Bell thought that in conditions of uraemia,
cedema and the like, immediate operation for
restoration of the peripeum was not advisable.
In his opinion the most frequent cause of lacera-
tion of the perineum was not the head, but the
■ shoulder.

Dr. W. H. Wathen, of Louisville, believed
that it was impossible for anyone to do a large
obstetric practice without occasional ruptures of
the perineum. He believed that the efforts to
prevent rupture had been the cause of more rup-
tures than it had prevented. He advised in cases
of complete rupture the use of the kangaroo ten-
don sutures.

Dr. I. N. Love, of St. Louis, read a paper on

antipyretics, analgesics, and sedatives,

referring especially to antipyrin, antifebrin, and
exalgin, as the most recent additions to the list.
He prefers acetanilid (antifebrin) to antipyrin, and
had most happy results from the use of exalgin.

Dr. Mumford warned phj-sicians against the
use of antipyrin in the continued fevers, believing
that its continuous administration was detri-
mental.

Dr. Smythe, of Greencastle, Ind., insisted on
the necessitj' of the high temperature being con-
trolled by antipyrin, or some similar agent, to
prevent fatty and parenchymatous degeneration
taking place as a result of high temperature.
He believed that the continued use of acetanilid
and similar agents in continued fevers was detri-
mental to the patient.

Dr. E. Linthicum, of Evansville, had had an
unfavorable experience with exalgin, believing
it inferior to the other agents of its class.

Dr. J. H. Hollister, of Chicago, had had
occasion to regret the use of antipyrin in decided
pyrexia. He had used acetanilid and quinine
with decided benefit.

Dr. J. L- Gray, of Chicago, had used acetanilid
in epilepsy with decided benefit, and believes it
superior to the bromides in the majority of cases.

Dr. Dudley Reynolds, of Louisville, believed
that the use of agents which merely reduce tem-
perature was not a scientific treatment of disease.

and their influence on mortality was not marked.
On motion, the Association adjourned to 9 a.m.
Wednesday.

Second Day — Morning Session.

The first paper was by Dr. W. C. Chapman,
of Toledo, Ohio, on Prognosis in Pidmonarv Dis-
eases ; Dr. C. F. McGahan, of Chattanooga,
Tenn., followed with a paper on Treatment of
Pidmo7iary Phthisis ; Dr. F. C. Wilson, of Louis-
ville, read a paper on Differe^itial Respiration^
exhibiting a new apparatus for systematic lung
exercise ; Dr. Edwin Ricketts, of Cincinnati,
reported a case of Tubercular Peritonitis ivith
Tubercular Fallopian Tubes ; and Dr. Wm. Por-
ter, of St. Louis, read a paper on Cotitagiousfiess
of Tuberadosis.

The first paper, that of Dr. Chapman, was a
plea for more energetic treatment of the disease
as a local disease, believing that thereby a more
favorable prognosis was possible. Dr. McGahan
believes that the climatic treatment of phthisis
offers the best results, that every case of phthisis
should, upon the discovery of the disease be re-
moved from the locality in which it developed.
The climate of South Carolina is best adapted to
such cases. Dr. Porter believes that the latest
opinions uphold the theory of the contagiousness
of tuberculosis.

Dr. Ricketts cited 100 cases of tubercular peri-
tonitis that had been treated by abdominal in-
cision where 25 cures, from nine months to twenty-
five years, had taken place, claiming that enough
operative evidence has been given to positively
as.sert that lives have been prolonged, and suffer-
ing greatly relieved, and that bolder and prompter
surgical measures are justifiable. The Doctor's
case presented for consideration : i. Failure to
diagnose the trouble previous to abdominal in-
cision. 2. The lowering of pulse and tempera-
ture as a result of the operation. 3. The non-
recurrence of dropsical fluid. 4. Fragile condi-
tion of tubal tissue and proneness to bleeding
upon the slightest abrasion. 5. Good results ob-
tained (haemostatic) in the application of per-
chloride of iron.

Discussion was had upon all the papers bearing
on the subject.

Dr. Theodore Potter, of Indianapolis, said
that the disease is not commonly hereditary ; it
is a local disease and only accidentally becomes a
general disease. He believed that a child never
emerged from its mother's womb with tuberculo-
sis. Statistics are verj^ unreliable as to heredity
and are easily misinterpreted.

Dr. Woolen, of Indianapolis, said that until
the question of heredity was settled no conclusion
could be arrived at. Can disease be hereditary ?
Most emphatically, no. But there is a type of
constitution which maj- be transmitted. This

428

SOCIETY PROCEEDINGS.

[September 21,

vulnerabilitj- of constitution may be hereditary,
but to presuppose that a germ of disease can be
transmitted through the spermatozoa or o\Tim
through fcetal life is entirely unreasonable.

Dr. Dudley Reynolds, of Louisville, believes
that the choicest food for the development of the
bacillus is the lymph corpuscle. The inhalation
of the bacillus through the imperfect air passages
carries the disease to the lungs.

Dr. Joseph Eastman, of Indianapolis, thinks
the most important treatment is the improvement
of the vital forces. Latent syphilis is the cause
of many cases of tubercular peritonitis.

Dr. J. A. Larrabee, of Louisville, said that
the predisposing and the exciting cause must be
present in ever}' case. As to the theory of micro-
organisms, they are present ever>'where. They
are not essentially the disease. He does not be-
lieve it is a case of tuberculosis unless the bacilli
are present. The matter of lung exercise is of
the greatest importance, giving, as it does, apex
expansion.

Dr. Chapman said that the question of hered-
ity was not one of transmission of disease, but of
constitution. This is proved by the fact that the
disorder skips one generation frequently.

Dr. McGahan said that he did not believe in
heredity in consumption.

Dr. Porter said that he did not believe that
the direct inheritance of tuberculosis was proven.
Chest exercise is of the greatest importance.
Good tissue is the best antidote to the bacillus.

Dr. L. Bauer, of St. Louis, read a paper on
Recto- Vesical Lithotomy, after which the Associa-
tion adjourned to 2 p.m.

Afternoon Session.

Dr. a. B. Shaw, of St. Louis, read a paper
on

suspension in affections of the spinal
cord,

and exhibited a Suspension Apparatus which he
has devised. The apparatus is a modification of
the Sayre and Varity apparatus.

Dr. Lewis, of Kansas City, had seen many
suspensions at Hot Springs, Ark., and had him-
self undergone the treatment with beneficial re-
sults.

Dr. Ryan, of Cincinnati, did not believe that
any stretching of the cord took place.

Dr. Vance, of Louisville, thought that any
stretching which might occur would be liga-
mentous, that the cord could hardly be affected.

Dr. Shaw, in closing the discussion, said that
in cases of locomotor ataxia, certain cases of
cerebro-spinal sclerosis, and old cases of myelitis
were benefited by the treatment. Paralysis agi-
tans was not benefited.

Dr. H. C. Dalton, of St. Louis, read a paper
on the subject

IS senn's hydrogen gas test infallible? •

He reported several cases in which the gas test
failed, and one in particular, of a Chinaman with
bullet wounds of the stomach, in which the
stomach was partially filled with rice and the in-
flation by gas simply plugged the bullet holes in
the stomach and prevented the efiectiveness of
the test.

Dr. Eastm.\n said that he had used the sul-
phuretted hydrogen gas in preference to the ordi-
nary hydrogen, as its odor was more persistent
and seemed to better answer the demands. He
had had a number of failures of the gas to ignite.

Dr. H. O. Pantzer, of Indianapolis, read a
paper on

rupture of ovarian cyst,

with report of a case in which death occurred be-
fore operative interference was had. A pedicle
was found, post-mortem, which was twisted to
the left. A diagnosis of twisted pedicle was made .
ante-mortem.

Dr. a. M. Cartlege, of Louisville, presented
a paper on A Case of Ovarian Tumor.

In the discussion that followed the two papers
Dr. Eastman said that he had seen the twisted
pedicle case before death, in consultation, and
considered the diagnosis one of extreme diffi-
culty.

Dr. Ricketts said that the matter of twisted
pedicle was to be explained by the fact that before
the tumor became adherent there was pressure
upon the colon, and in the passage of feces the
tumor was gradually turned to the left, and thus
the pedicle became adherent. This can occur
only where the pedicle is long. Senn's test he
found faulty frequently. Then the distension of
the intestines by the gas and their replacement
was a matter of great difficultj\

Dr. Vance, of Louisville, endorsed the views
of Dr. Dalton as to the unreliability of the gas
test.

i Dr. Steele said that he had a case in which
the gas test was applied. It would not ignite.
The patient asked to have laparotomy performed.
It was done, and eleven holes were found in the
small intestines.

Dr. Bransford Lewis, of St. Louis, read a
paper on the Rational Treatment of Gonorrha-a,
which was followed by a paper on Excision of the
Knee for Convenience, by Dr. Ap, Morgan
Vance, of Louisville. Dr. G. W. Ry.\n, of
Cincinnati, presented a paper on Orthopccdics in
Infantile Paralysis, after which the Association
adjourned to 9 .\.m. Thursday.
Third Day.

The Committee on Nominations reported the
following officers for the ensuing year : President,
Dr. J. M. Mathews, Louisville, Ky. ; ist \'ice-
President, Dr. C, R. liarly, Ridgway, Penna. ; 2nd
Vice-President, Dr. T. B. Har\'ey, Indianapolis,

1889.]

FOREIGN CORRESPONDENCE.

429

Ind.; Secretarj', Dr. E. S. McKee, Cincinnati, O.;
Treasurer, Dr. F. McGahan, Chattanooga, Tenn.

The next meeting will be held in Louisville,
Ky., the second Tuesdaj' in September, 1890.

Papers were read by Dr. A. J. Thomas, of In-
dianapolis, on The Insane of Indiatia — their Care
and Treatment ; by Dr. D. A. Thompson, of Indi-
anapolis, Ind., on Some Forms of Eye Trouble ;
by Dr. S. S. Bishop, of Chicago, on The Abortive
Treatment of Aeute A'aso-Pharyngeal Catarrh : by
Dr. O. Everts, of Cincinnati, on The Treatment 0/
the bisane as Related to Other Conditions of Society :
by Dr. G. F. Eydston, of Chicago, on Apparent
Concretiotis, Tra7tsfortnatio7is of Syphiloma of the
Tongue.

FOREIGN CORRESPONDENCE.

LETTER FROM PARIS.

tFROM OUR REGULAR CORRESPONDENT.)

Professor Peter on the jVeeessity of Antiphlogistie
Treatment at the Onset of Acute Pneumonia and
Aaite Pleurisy — Professor Lcpine repoi'ts a Curious
Case of Cerebral Accidents determined by a HcEma-
toma atid Cured by Trephining — Dr. Constantin
Paul' s Researches on the Action of Saccharin — Dr.
Maurice Per r in.

Professor Peter lately delivered a very interest-
ing clinical lecture at the Necker Hospital, on the
necessity of the antiphlogistic treatment at the
onset of acute pneumonia and acute pleurisy.
The lecturer said that he was induced to take up
this subject owing to the neglect, now-a-daj's, of
this precious measure in properly selected cases.
If, he said, our predecessors bled to much, we
have gone to the opposite extreme, much to the j
prejudice of the patients. He based his present'
lecture on a case in his ward in which the patient 1
was affected with pleurisy accompanied with effu-
sion, for which he was, for the fourth time, being
tapped. This might have been obviated if the
antiphlogistic treatment had been adopted at the
commencement. Professor Peter is one of the
few physicians of the Paris Facultj' who employ
the antiphlogistic treatment in these and other
cases in which it was formerl)' adopted, but it is
owing to the divers theories where bacteriology
plays a preponderating role, it has been wrong-
fully abandoned. By antiphlogistic medication
the lecturer not only referred to drugs, but in-
cluded bleeding, cupping after scarifications,
leeches and blisters, the latter being applied in a
later stage of the acute inflammatory affections.
He cited the teachings and practice of such men
as Andral, Bouillaud and Grisolle in support of
his own practice, although he must admit that
Bouillaud, by his exaggeration of this treatment,
did much harm both to the cause that he advo-
cated and to the patients, a reaction in the pro-

fession was produced, and the antiphlogistic-
method fell into disuse. The introduction of
bacteriology' has struck the last blow to this mode
of treatment. At the present moment, pneumo-
nia is considered a microbian malady. The con-
sequence is, one sees only this microbe, which it
is necessarj' to kill, whence the idea of practicing
injections into the lungs ; but it was scarcelj- pos-
sible, in all the cases, to reach in this waj' the
microbes. It is suiEcient, in leaving only a few,
for a rapid multiplying of the microbes to take
place. This system was soon abandoned ; but
the misfortune is that these theories do not lead
to any useful medication. Professor Peter con-
cluded his lecture by repeating his injunction of
slight depletion in all cases of acute pleuris}-. If
phlebotomj' is objected to, scarifications followed
hy cupping glasses may be employed, or a few
leeches to the number of from six to ten may be
applied, and thus prevent effusions, or the mala-
dy becoming chronic. In the same wa}-, he finds
that when pneumonia is treated in a proper man-
ner, cures rapidly. He believes that cases of
chronic pneumonia have become more frequent
since the abandonment of the antiphlogistic
method.

Professor Lepine, of Lyons, lately reported
to the Academy of Medicine a curious case of
cerebral accidents determined by a haematoma
and cured by trephining. The patient was a man
of 29 years of age, alcoholic, and for five years
he was subject to epileptiform fits which were at-
tributed to a fall. He soon got into a comatose
state which was followed by complete aphasia
and slight hemiplegia of the right side. Tre-
phining was decided upon, as the state of the pa-
tient was not improving. The operation was per-
formed ten days after the accident, about the level
of the ridge of Rolando. At the moment when
the dura mater was incised, about 25 grams of
liquid of a chocolate color spouted out with some
force. On the next day, the patient was able to
write his name, and in a few days later the apha-
sia and the hemiplegia disappeared. But not-
withstanding the success of the operation in this
case, Dr. Lepine is of opinion that it should be
practiced with great prudence and reser\-e.

Dr. Constantin Paul has lately made some new
researches on the action of saccharin. It results
from his new experiments that the antiseptic
power of saccharin diminishes by the addition of
alkalies. The maximum antiseptic effects are
obtained when the saccharin is directly incorpor-
ated in a state of powder in the nutritive medium,
the latter being in general sufficiently alkaline to
dissolve the saccharin. The therapeutic conse-
quences of these facts are as follows: When it is
wished to employ saccharin as a sweetening sub-
stance, an equal proportion of the bicarbonate of
soda should be added to it, and then there would
be no fear of the gastric troubles sometimes com-

430

DOMESTIC CORRESPONDENCE.

[September 21,

plained of by certain diabetic subjects. The
saccharinate of soda may be administered to the
extent of 5 grams. Should, on the contrary, a
strong antiseptic action be required, pure saccha-
rin in powder should be employed. If, however,
it is intended for the microbe of putrefaction or of
suppuration, the proportion of 2 parts of the bi-
carbonate of soda with 3 of saccharin, renders the
saccharin very soluble and permits it to arrest the
development not only of these two microbes, but
of all the numerous microbes which live in the
mouth and possess the property of fluidifying
gelatin. Saccharin rendered soluble in these pro-
. portions constitutes a valuable mouth-wash.

Military Surgery has just sustained a great
loss in the person of one of its most illustrious
representatives. Dr. Maurice Perrin, who died at
Vezelise, his native town, on the 31st of August,
last, after a very short illness. He was Inspector-
General of Military Hospitals, President of the
Academy of Medicine, and Commander of the
l,egion of Honor. Born on the 13th of April,
1826, after having prosecuted his studies at Nancy,
he came to Paris in 185 1, and took his degree of
Doctor of Medicine. In 1858 he was appointed,
after competition, Agrege of Val-de-Grace ; and
ten years after he was elected Professor of Opera-
tive Surgerj'. His most remarkable works con-
sist in his studies of the psycho-chemical action
of anaesthetic substances, on the role of alcohol
and of anaesthetics in the organism. Treatise of
Surgical Anaesthesia, Treatise of Ophthalmoscopy
and Optometry. He was elected Member of the
Academy of Medicine in 1875, and raised to the
Presidency' in 1889. A. b.

DOMESTIC CORRESPONDENCE.

A Tribute to Dr. Samuel Jackson.

To the Editor: — The writer, who in the winter
of 1862-3 attended the last course of lectures that
Dr. Samuel Jackson delivered at the medical de-
partment of the University of Pennsylvania, re-
members that distinguished lecturer well, and
recalls with what feeling he delivered his farewell
address to the medical students of the class in the
spring of 1863, when he forever bade farewell as
a lecturer and retired from the chair of physi-
ology. The tears ran down over his cheeks
while he was speaking, and there were few dry
eyes in the building. The decrepitude of age
had crept upon him in the many years he had
lectured in the university. He had lost the use
of his lower extremities, so that he had to be car-
ried to and from the chair from which he lec-
tured. His hair was gray and his face wrinkled,
but he was still lucid and fluent in his delivery.
He had been Heiirj' Clay's physician, and in his

discourse upon death, in the the lecture-room,
told the story of how timid that great man ex-
pressed himself as being as to the pains of phj-si-
cal death. Dr. Jackson endeavored to soothe the
mind of the great orator by saying that death
takes place by such easy and gradual processes
that it was entirely void of pain. He compared
death with the going out of the flame of a candle
that was burning in the room at the time, and
which was flickering out for want of combustible
material. He said: " ]\Ir. Cla}', you see how
easily and slowly that flame is being extin-
guished ; so it will be with you when dying —
easy, gradual, painless."

In a visit I made to Dr. Jackson in the sum-
mer of 1865 he said to me: "I have always,
during life, been a hard student, and one of the
problems I have been unable to solve j-et is how
much inflammable matter in a given time the
sun used in warming that space included in the
solar system." But he stated further that, if un-
able to solve the problem in this life, in the next
life, to which he was fast hastening, he hoped
to be enabled to solve the problem, then and
there.

At a speech that Dr. Samuel Jackson delivered
at a reception given to Edwin Forrest at Philadel-
phia, Pa., in 1838, oijp who was present and
heard the great speeches of the evening said :
" The speech of Dr. Samuel Jackson was by all
odds the gem of the evening. His diction was of
the best, and a constant stream of eloquence bub-
bled from his lips. He appeared to be of imagi-
nation all compact, and his fancy seemed to be
as free and boundless as the chainless wind.
Striking figures and beautiful metaphors came at
his call as readily as though he wielded the wand
of the magician. His words, expressing the most
beautiful thoughts, fell from his lips with the
grace and readiness of water sparkling from a
fountain. He spoke with great ease and rapidity,
and to the then immature and inexperienced
mind of the writer it was the most brilliant and
eloquent speech. He has since heard the death-
less three of America, Clay, Calhoun and Web-
ster. He has listened with delight to George
McDuffee, William C. Preston, John J. Critten-
don, George Poindexter, Jeflferson Davis and Ed-
ward Everett. He has hung enraptured many
times over his utterances while that marvelous
child of genius. Sergeant S. Prentiss, poured forth
a stream of impassioned eloquence as resistless as
the rush of the mighty river he loved so well,
and on the margin of which he had his home.
That imperial river, not inaptly termed " a great
inland sea" by Mr. Calhoun, now flows by his
grave ; and its turbid billows, as they roll in sol-
emn grandeur to the ocean, murmur an eternal
requiem to the memory of the most eloquent ora-
tor of modern times, or, in my judgment, of any
known period of the world's history. And 3-et,

1889.]

MISCELLANY.

431

iaving often listened to the great masters of elo-
quence whom I have named, the speech of Dr.
Samuel Jackson, heard more than half a century
since, still lingers in my memory, not only as a
" thing of beauty," but "a joy forever."

John M. Batten.
309 Fifth ave., Pittsburgh, Pa., August 9, 1S89.

Audi Alteram Partem.

To the Editor : — The making of punctures,
exploratory and otherwise, through terebrated,
instead of trephine openings, as described by Dr.
Edmond Souchon, and referred to in your edi-
torial of September 7 th, is not new in any sense.
It was carried out by me and its results described
several years ago.' I have never claimed origi-
nality for it, as Gibier, if I remember rightly,
employed terebration ten years ago, in the course
of some inoculation experiments involving the
brain. The apparatus used by me was an ordin-
ary watchmaker's drill.

Respectfully yours,

E. C. Spitzka, M.D.
712 Lexington Ave., New York, Sept. 7, 1SS9.

BOOK REVIEWS.

Transactions of the New York State Med-
ical Association for 1888. Vol. v. Edited
for the Association by Alfred Ludlow Car-
roll, M.D., of Richmond County. New York :
J. H. Vail & Co., 1889. Pp. viii-610.
This is a volume of far more than ordinary in-
terest, and we feel like congratulating the Asso-
ciation on the superior character of the work done
and on the excellence with which the editor has
performed his part. More than forty papers were
presented at the meeting in question, and it is
not too much to say that all are of a highly mer-
itorious character. Of especial interest are the
discussions of various important subjects in which
the leading topics are considered seriatim, as for
example the " Discussion on Puerperal Septicae-
mia." In this the " Introductory Remarks" were
made by Dr. C. C. Frederick ; then followed a
series of six leading questions, some of them par-
ticularly comprehensive in character. Each of
these questions formed the text of one or more
short papers, in which the writers confined them-
selves closely to the immediate question under
consideration ; in this discussion the papers were
read bv Drs. H. M. Biggs, E. D. Ferguson, S. B.
W. McLeod, A. L. Carroll, F. W. Ross, John
Shrady, W. H. Robb, Frank Grauer, William T.
Lusk and R. L. Banta.

1 " On Some Points Regarding Therapeutical and Other Injuries
of the Brain." Proceedings American Neurological Association.
1SS7. Journal of Nervous and Mental Diseases ; also, Journal of
Comparative Medicine, July, 1886.

The New York State Medical Association was
founded in 1884, and has thus far been presided
over by such distinguished men as Henry D. Di-
dama, John P. Gray, E. M. Moore, Isaac E. Tay-
lor, John Cronyn and William T. Lusk. The
membership has already reached the large figure
of 681. It comprises five branch associations in
the various sections of the State, between which
the membership is prettj' evenly divided.

NECROLOGY.

Alexander T. Darrah, M.D.

Dr. Alexander T. Darrah, of Bloomington,
111., died at his home on September 4, 1889, after
a short illness caused by congestion of the bow-
els. Dr. Darrah was born in Delaware, Ohio, in
1837, was graduated from Rush Medical College,
Chicago and practiced medicine in Tolono, 111.,
until 1883, when he removed to Bloomington.
He enjoyed a deservedly high reputation as a
physician and public spirited citizen. He was
also very prominent in the Masonic fraternity,
having been elected Grand Master of Illinois in
1886 and 1887. A wife and three children sur-
vive him.

IVllSCELLANY.

Edison's Impressions of Paris. — A correspondent
of the Scientific American asked Edison: "How are
}'OU impressed with Paris?" "Oh, I am dazed. My
head's all in a muddle, and I reckon it will take me at
least a )'ear to recover my senses. I wish now that I had
come over in my laboratory blouse, and could have gone
about unknown and have seen something. The exhibi-
tion is immense, larger than our Philadelphia exhibition.
So far, however, I have seen but very little of it. This
morning, however, I saw a tool which will save me jt6,ooo,
clear, a year. It is a chisel worked by hydraulic pres-
sure. I'just saw it, passing by — just a glance. I shall
order some, and send them out. They will enable us to
reduce our labor by eighteen hands. What has struck
me so far chiefly is the absolute laziness of everybody over
here. When do these people work? What do they work
at? I have not seen a cartload of goods since I came to
Paris. People here seem to have established an elaborate
system of loafing. Some of these engineers who come
to see me, fashionably dressed, walking-stick in hand —
when do thev work? I don't understand it at all."

The McLean County (Ti.l.') Medical Society met at
the office of Drs. Darrah & Corley on the 2d inst. There
were present Drs. H. Parkhurst', F. J. Parkhurst, J. B.
Tavlor, F. W. Keyes, C. C. Safer, L. E. Spear, John Lit-
tle^ J. L. White, C. J. Corley, Rhoda Galloway, E. Mam-
men, S. T. Anderson, D. A. White, W. R. Shinn, N. F.
Jordan, F. C. Vandervort. Drs. H. F. Ballard and W. L.
Hallam were elected to membership. The application of
Dr. C. E. Ballard, of Saybrook, for membership, was re-
ceived and referred to the Board of Censors. Dr. E.
Mammen exhibited with the microscope a piece of epi-
thelioma; Dr. J. B. Taylor read a very able and interest-

432

MISCELLANY.

[September 21, 1889.

ing essay on "The Faults of the Medical Profession." i
Dr. C. J. Corle)-'s essay on " Urinalysis " was attentively
listened to by all present. A vote of thanks was tendered
by the Society to Drs. Tajdor and Corlej' for the excel-
lence of their papers. The President appointed Drs. D.
A. White and F. J. Parkhurst as essayists for the October
meeting, and Drs. W. R. Shinn and E. Mammen for the
November meeting. The Society adjourned to meet on
the first Monday in October.

The Profess ionai. Canvasser No. 3 is a thirty-two
pages pamphlet combining a price list of the scientific
medical periodicals of the United States and a concise
consideration of the subject, " What can be done with
old books ?" Applicants for copies are solicited to remit
six cents to cover costs of postage, etc. Address all com-
munications to Fred. D. Van Horen, 23 Clinton Place,
New York.

Senile Microbio-mania. — -The Revue de Therapeutic
says : A savant of Naples, Dr. Malinconico, has made a
greater discover}- than the famous elixir of youth of
Brown -S^quard. The journals announce very seriously
that Dr. Malinconico is about to discover the microbe of
old age.

This microbe is transmitted, according to the Italian
savant, by inheritance, invades with age the entire human
organism, ravages and destroys it, producing old age, and
finally death.

Dr. Malinconico hopes that he will be able to discover
the means to combat, and finally to destroy, this terrible
microbe, which will prevent men growing old. The
savants are invaluable ! — Times and Register.

Progress of Sanitation. — There are now thirty-nine
crematories in various parts of the world. Italy leads
easily with twenty-three, then comes America with ten,
while England, Germany, France, Switzerland, Denmark
and Sweden are satisfied so far with one apiece. In Italy
there were two cremations in 1S77 ; the number rose to
fifteen in 1877, and in 1878 the number was 226. Since
1876, 1,177 cremations have taken place i" Italy, whilst
the combined numbers from other countries bring the
total only to 1,269.

Queries Wanted. — At the San Francisco meeting of
the American Pharmaceutical Association a resolution
was passed requesting the members to propose such que-
ries as they would like to see answered next year. Such
queries should be forwarded at once to the chairman of
the Section on scientific papers, H. M. Whelpley, St.
Louis, Mo. Members who have decided to write papers
should send the titles to the same address.

New York State Medical Association. — The sixth
annual meeting of this Association will be held at the
Hotel Brunswick, New York, commencing next Wednes-
day and continuing three days. The programme con-
tains a list of sixty-six papers, the writers of which are
eminent and well-known members of the profession.
The membership now numbers over 680 physicians and
we have no doubt there will be a full attendance and a
large accession of new members. Dr. J. G. Truax, 17
East 127th St., New York City, is the Secretary.

Health in Michigan. — For the month of August,
i88g, compared with the preceding month, the reports
indicate that cholera morbus, dysentery, cholera infan-
tum, diarrhoea, and typho malarial fever increased, and
that rheumatism, neuralgia and inflammation of kidney
decreased in prevalence.

Compared with the preceding month, the temperature
in the month of August, 1889, was higher, the .ibsolute
and relative humidity were less, and the day and night
ozone were more.

Compared with the average for the month of .\ugust in

the three years, i885-88, bronchitis, cholera morbus and
tonsillitis increased, and neuralgia and rheumatism were
less prevalent in August, 1889.

For the month of August, 1889, compared with the
average of corresponding months in the three years 1S86-
'88, the temperature was slightly higher, the absolute and
relative humidity were less, and the day and night ozone
were more.

Including reports by regular obser\'ers and others, diph-
theria was reported present in Michigan in the month of
August, 1889, at 21 places, scarlet fever at iS places, ty-
phoid fever at 40 places, and measles at 7 places.

Reports from all sources show diphtheria to have been
reported in 5 places less, scarlet fever at 12 places less,
typhoid fever at 22 places more, and measles at 6 places
less than in the preceding month.

LETTERS RECEIVED.

Dr. W. H. Atkinson, New York ; Dr. W. K. Sutheriin,
Mansfield, la.; Prof. Schnitzler, losefstadt, Vienna, .Aus-
tria; Dr. Thos. Eliot, Worth, Tex.; Dr. E. E. Montgom-
ery, Philadelphia; Dr. C. H. Cook, Natick, Mass.; Dr.
Frank H. Ingram, Chicago ; Dr. Henry O. Marcy,Boston;
Dr. John B. Hamilton, Washington ; Dr. W. A. Scott,
Swanton, O. ; Dr. William H. Morrison, Philadelphia;
Dr. H. Judd, Galesburg, 111.; Dr. J. G. Truax,New York ;
Merchants' Exchange National Bank, New York; Dr.
Henrv H. Smith, Philadelphia ; Dr. James Grundv, Mac-
leod,'Pa.; Dr. R.J. Dungli.son, Philadelphia ; 'Dr. G.
Eiskamp, Richmond, la.; Dr. C. W. Richardson, Wash-
ington ; Dr. B. Chapman, Copley, O.; Dr. D. D. Bramble,
Cincinnati, O.; E. Steiger & Co', New York ; Dr. J. M.
Dunham, Columbus, O.; Dr. Walter Channing, Brookline,
Mass.; Dr. Richard J. Forster, Charlestown, Mass.; E.
Merck, New York ; Dr. Wm. L. Worcester, Little Rock.
Ark.; Dr. E. S. Everett, Wichita, Kan.; Dr. Bransford
Lewis, St. Louis, Mo. ; Dr. Landon B. Edwards, Rich-
mond, Va. ; Dr. M. E. Connell, Wauwatosa, Wis.; Dr. A.
B. Judson, New York ; Dr. Geo. Mackie, Drydeu, Texas;
Dr. O. M. Bourland, Van Buren, Ark.; Dr. C. Armstrong,
Carrollton, 111.; Dr. W. E. H. Morse, Dallas Centre, la.;
Dr. Frank D. Green, Louisville, Ky.. E. White, Chester-
ton, Ind.; Oneida Springs Co., Utica,N. Y.; Dr. Jonathan
Wright, Brooklyn, N. Y.; Dr. C. Kennedy, Macleod,
Northwest Territory, Canada ; Dr. C. O. Cooley, Madelia,
Minn.; Dr. E. P. Brewer, Nomich, Conn.; Dr. Wm. B.
Atkinson, Philadelphia ; Plvmpton Mfg. Co., Hartford,
Conn.; Dr. J. Soli£-Cohen,' Philadelphia ; Dr. J. D. S.
Davis, Birmingham, Ala.; J. Walter Thompson, New
York ; Dr. Allison Maxwell, Indianapolis, Ind. ; Henni-
Bernd & Co., St. Louis, Mo.; Dr. J. M. Bessey, Manitou
Springs, Col. ; Dr. .\lex. Boggs, Paris, France ; Lloyd
Bros., Cincinnati, O.

Official List of Changes in the Stations and Duties of
Officers Serving in the Medical Department, U. S.
Army, from September 7, iSSg, to September /j, 188$.

With the approval of the Secretary of War, the leave of
absence granted Major John H. Janeway, Surgeon, in
S. O. 52, Div. of the Pacific, July 29, 1889. is extended
two months. Par. i, S. O. 206, A. G. O., September 5,
1889.

First Lieut. Freeman V. Walker, Asst. Surgeon, leave of
absence on surgeon's certificate of disability granted
in S. O. 92, April 20, iSSg, is extended one mouth on
surgeon's certificate of disability, by direction of the
acting Secretarv of War. S. O. '211. '.\. G. O., Septem-
ber II, l88q.

CORRIGENDU.M.

In The Jocrnal of September 7. 1889. pace 34S. eighth line from
top of second column, for "Dr. E. P. Kurd" read Dr. Henrj- M.

Hiird.

THE

Journal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.
PUBLISHED WEEKLY.

Vol. XIII.

CHICAGO, SEPTEMBER 28, 1889.

No. 13.

ORIGINAL ARTICLES.

SOME OF THE GRAVER AND RARER
FORMS OF CINCHONISM.

Read in the Section of Medicine at the Fortieth Annual Meeting of
the American Medical Association, June 2S. /SSg.

BY I. E. ATKINSON, M.D.,

PROFESSOR OF MATERIA MEDICA AND THERAPEUTICS, AND OF
CLINICAL MEDICINE IN THE UNIVERSITY OF MARYLAND.

Although everyone knows that the preparations
and alkaloids of cinchona bark occasionally pro-
duce verj^ undesirable effects upon the human or-
ganism, there seems to be a widespread impression
that results of a more serious character are not to
be apprehended, and one is accustomed to see
these preparations administered with utter reck-
lessness. It is true, the unpleasant results ob-
ser\'ed are usually the outcome of idiosyncrasy,
and are not part of the regular physiological
action of cinchona. As ordinarily observ'ed this
action cannot be said to be toxic in the sense in
which we speak of the toxic action of strj-chnine,
of opium, of arsenic, and the other well-recog-
nized poisons. We regard as exceptional the
various cutaneous disorders, the disturbances of
the digestive, the respiratory, the circulatory and
nerv'ous systems not infrequently observed, and
usually hold them to be accidental expressions of
the resentment of the economy at the presence of
the drug, expressions of idiosyncrasy. Although j
graver forms of quinine intoxication may very
often be considered as due to the peculiar suscep-
tibility of the individual, it is certain that in ex-
cessively large doses definite, dangerous, and
even fatal poisoning may follow. Beyond the
limits of physiological action there is an indefi-
nite area in which idiosyncrasy appears to deter-
mine the toxicity, in which there can be no a \
prion determination of the danger line. While !
there is but slight danger to life from any but in-
ordinate doses, quantities but little beyond the
limits of everyday administration are capable of
entailing grave consequences. These graver effects
of cinchonism present but few terrors to the gen-
eral medical mind, and when considered in relation
to the universal employment of cinchona pre-
parations in medicine are indeed numerically in-
significant, yet research shows that our literature

abounds in indubitable evidence that their abso-
lute frequency is by no means small. That the
general medical public has failed to properly ap-
preciate these dangers is largely attributable to
the fact that manj^ of the most important and
intelligently reported observations have appeared
in special journals.

Recent observation of disastrous results of cin-
chonism has prompted the writer to attempt to
lay before this Association a brief resume of a
portion of the subject ; and in bringing it before
a body of gereral practitioners, he hopes to be
pardoned for having presented in abstract and
quite inadequately, a number of reports prepared
with distinguished ability and with such minute-
ness of detail, that their exhaustive consideration
can only be appropriately attempted by the spe-
cialist.

QUININE BLINDNESS.

Case I. — On August 31, 1888, I was called to
the country to see, in consultation, a young lady,
1 3 years of age, who had spent two weeks during
the early part of the month at Atlantic City.
She returned home on August 13th, not feeling
well. She continued ill and on the igth had a
slight chill and took to her bed. She was visited
by her physician who, finding her temperature to
be 104° F,, gave her sulphate of quinine in large
doses, but without controlling the fever. The
dose was gradually increased until she was taking
45 grains daily. She did not appear to be pro-
foundly cinchonized; tinnitus was not verj' marked
and deafness was slight. Her sight, however,
began to fail and by the 27th she had become
totally blind. The administration of quinine
was not abandoned, and on the 30th she took
three 10- grain doses. During this period the
temperature ranged from 102° to 105° F., and the
symptoms of typhoid fever became established.
At the date of my visit she complained of slight
pain in the occipital region. Her eyes were star-
ing and her pupils widely dilated and quite irre-
sponsive to light. There was a constant snapping
of the lids, which the patient declared she could
not control. There was complete blindness. She
was not sensitive to the strongest light. No more
quinine was given and the typhoid fever pursued
a favorable course. On September 24th the blind-

434

CINCHONISM.

[September 28,

ness was still complete, but b3' October gth she
was able to distinguish objects about the room,
but with a field of vision still extremelj' limited.
Dr. Russell Murdoch saw her on September 14th,
and has kindlj' informed me, from his note book,
that he found that "the arteries and veins were
extremely reduced. There was entire loss of
sight, both eyes being equally affected." On
October 30th, after general tonic treatment and
the use of strj'chnine, Dr. Murdoch found that
the vessels had been restored to their usual size
and the vision to =~, the field of vision alone re-
maining ver}' slightly contracted.

Although the power of quinine to produce
blindness in certain susceptible individuals, when
given in excessive doses, has long been known,
the fact has attracted suprisingly little attention
until quite recently. As early as 1841 Giacomini'
had observed quinine amaurosis. His case was
as follows :

Case 2. — A man took from 12 to 15 grams
(180 to 225 grains) of sulphate of quinine at a
single dose. Within an hour he was seized with
cardialgia, nausea, vertigo, incapacity of move-
ment, and unconsciousness. Eight hours after-
ward there was subnormal temperature, cold ex-
tremities, livid lips and fingers, fetid breath, slow
respiration, regular but very feeble pulse, inaudi-
ble voice, verj' dilated pupils, with sight and
hearing almost gone. Recovery' from this condi-
took place very slowly.

Case J. — (Lewis, 1845.)' This was a case of
total blindness occurring during the administra-
tion of large doses of sulphate of quinine.

Cases 4, 5 and 6. — (McLean, 1846.)* In one
case about 16 grains of sulphate of quinine were
given hourh- until nearly an ounce had been
taken. Another patient took 3 grains hourly for
three days, and the third had 3 drachms in 6-grain
doses within thirty-six hours. In all perfect
blindness was the result. Amendment was slow,
and recoverj' was perfect in none. One patient
for nearly a year could look steadily toward the
sun without seeing it. When he began to see
sufficiently to read he would perceive a small
luminous spot upon the paper about one inch
in diameter, outside of which all was cloudiness
and confusion.

Case 7. — (Baldwin.)' A negro girl, 6 years old,
was given 28 grains of sulphate of quinine in
forty-eight hours, for a tertian remittent fever.
Shortl}- after the last dose the skin became dry
and restlessness became verj' pronounced. Con-
vulsions followed. The pupils became dilated
and total blindness ensued. She was able to
answer questions. Two hours later, with blind-

ness and dilated pupils, and restlessness, she
died.

Case S. — (Baldwin, ibid.) An adult male, with
pneumonia, took 68 grains of sulphate of quinine
in twenty- and a half hours. One and a half hours
after the last dose had been taken Baldwin saw
him. A little while previously' he had been
seized with a jerking motion of the whole body.
This lasted several minutes, and immediately
afterward his vision was so imperfect that he
could scarcely distinguish anything. There was
great restlessness, anxiety and alarm. The pupils
were dilated. Convulsive movements of the body
came on every ten or twelve minutes, sometimes
apparently of the whole body, sometime confined
to the arms. During these convulsions he was
not insensible — occasionally the eyes presented a
vacant, staring look, with upward rolling. Three
hours after the ingestion of the last dose of qui-
nine he was completely blind. Vision began to
improve in twentj'-four hours afterward, but was
never perfectly recovered.

Case p. — Trousseau.)" A patient in whom a
dose of 48 grains of sulphate of quinine had
caused temporary blindness and deafness.

Cases 10 and II. — (Guersant.)' Mme. Bazire,
being seized with malarial fever, was given by
her husband, a physician, in a verj- short space
of time 240 grains of sulphate of quinine. Soon
afterward, her symptoms becoming more grave,
she was given, at one dose, 375 grains. Dr. B.
now fell sick himself, and no more of the drug
was administered to her, but within a short space
of time he administered to himself, b\' mouth and
rectum, 900 grains, and took in eight or nine
da}-s 5 ounces. Reveillon found him covered with
cold-sweat, completely deaf and blind, with slow
and difficult respiration, and in a profound stupor,
with the physiognomy of a drunken man. In
this condition he died. Mme. B. recovered im-
perfectly, having been for a long time blind and
deaf. The senses of sight and hearing always
remained feeble.

Cases 12, ij, 14. and 75. — (Briquet.)' These
were four patients who had taken from 45 to 75
grains of sulphate of quinine daily for several
days. Twice the blindness was transitorj-, lasting
only a daj% and then completelj' disappeared.
In the third case the blindness lasted longer, and
in the fourth case it only disappeared after a
month. (Briquet also quotes Monneret as having
seen four cases of temporarj- weakening of the
sight, in two lasting onlj- a few hours, in one a
day, and in one four days. He also quotes Hatin
as having seen a case of quinine amaurosis which
lasted several months).

Case 16. — (von Graefe.)' A patient took 6

' Dictioiiaire de M6decine, 2in. Edition. Art. Quinine, p. 567.

-Western Jour. Med. and Surg,, Louisville, 1S45. 3d sertes, Vol.
iv, p. 396.

iRnnkin^'s Abstract, Illinois and Indiana Med. and Surg. Jour-
nal, December, 1S46.

4 American Journal of the Medical Sciences, April, 1S47, p. 292.

5 Dictionaire de M6d. Loc. cit.

C'Dictionairc de M6d., 2me Edition, •■Vrt. Quinine, p. 567.
rTrait^ Thcrapentiqne du Quinquina, Paris, 1S53.
"Arch, fiir Ophthalnioloiiie, Berlin, 1S57, Vol. iii, pp. 6S3-6S5.
Archives of Ophthalmology, Vol. x, p. 220. Knapp.

1889.]

CINCHONISM.

435

drachms of quinine within two weeks. There
resulted, violent tinnitus, deafness, moderate am-
bl5'opia in the left eye, and almost total blindness
in the right eye Four months later amblyopia of
the right eye still existed. The visual fields and
ophthalmoscopic condition in both eyes was
normal.

Case ij. — (von Graefe. ) A man took 15 grains
of sulphate of quinine daily until almost one
ounce was taken. When he increased the dose
to 22 grains he had tinnitus aurium, hardness of
hearing and weakness of sight, which increased
in a few days to total blindness. Three months
later blindness of the right eye was still complete.
The sight of left eye was restored. Ophthalmo-
scopic condition aud visual fields in both of these
cases was normal.

Case iS. — (\"oorhies.)' A young lady had
taken within a few hours one ounce of sulphate
of quinine, and one ounce additionally each day
for the two succeeding days. On the morning of
the second daj' she was extremely prostrate,
hardly able to move her fingers. She had feeble
pulse and hardly comprehended the simplest
question. Audition was but slightly impaired,
but she was perfectly blind. There was marked
pallor of her face and of the palpebral conjunc-
tivce. The pupils were normal, responding
promptly to light. There was anaesthesia of the
cornea. The ophthalmoscopic examination re-
vealed perfectly white discs. There was not a
trace of the optic nerve vessels, veins or arteries.
The choroidal vessels were empty. There was a
pale, yellowish tinge of the retina. The treat-
ment with amyl nitrite and quinine was not fol-
lowed by improvement until the middle of the
tenth week. The return of sight proceeded slowly
until she was able to read Jaeger No. i. More
than a year afterward the optic discs remained
perfectly white, with no trace of the central ar-
tery, except a small twig of that of the left e}'e,
which was bareh- perceptible. The field of vision
was greatly contracted, the greatest diameter
(vertical) being less than 4" when taken at a dis-
tance of 2 feet.

Case ig. — (DeWecker. )■' A man took a large
but indeterminate dose of quinine. He awoke
perfectly deaf and blind. Eventually he recov-
ered his sight and hearing, the former imperfectly.
The accident occurred in the tropics and some
time must have elapsed before De Wecker saw
him.

Case 2o.- — (Solomon.)" A seafaring man, 30
years old, took a teaspoonfuj of quinine at one
dose. There soon followed vertigo, chilliness, a
sense of sickness and failure of sight. After
some interval Solomon found that he could read
brilliant type (Jaeger's No. i), a single letter

9Transact. Amer. Med. Assn., 187^, p. 411.

1^ Ocular Therapeutics. Translation. London, 1S79.

" Ranking's Abstract, Vol. Iv, 1872.

only at a time, so contracted was his field oi
vision, so complete was the anaesthesia of the
retina, except at the point occupied by the yellow
spot. The pupils were of normal diameter but
moved sluggishly. The symptoms gradually
subsided, and nine months afterwards the patient
declared himself to be in perfect health.

Case 21. — (Roosa.)'- The patient was a man
who began to take compound tincture of cin-
chona to remove the cravings of the alcohol habit.
He was 50 years old. On June 24th, 25th, 26th,
27th and 28th he continued to take this prepara-
tion in doses of from one to two ounces at short
intervals. During these days he drank a quantity
representing 125 grains of an alkaloid of cin-
chona. Two days later (July i) he was stupid,
with flushed face and conjunctivae, and was ap-
parently unable to see or hear. On July 3d hear-
ing had become almost normal, but his sight
remained much impaired. Vision : R. E. =
quantitative perception of light. L. E. Could
count fingers at a distance of one foot. The
ophthalmoscope revealed lessened size of the
arterial vessels, there was no abnormality in the
veins, there was a lessened number of vessels on
the papillae, but no marked paleness. There
were no changes in the membrana tympani.
Strjchnine was ordered. On Julj' 6th he was
able to walk about. Vision : = | {J- in each eye,
but the visual field was very much contracted.
Julj- 1 6th. Both visual fields were concentrically
limited. Measurements drawn on a blackboard
14" distant were : Rt. field, vertical 9", horizon-
tal 7jj" ; limitation most marked on the temporal
side. Left field, vertical 7", horizontal 8", limi-
tation more regular. Optic papulae yexy pale and
arteries narrow. July 20th. Vision : = If in
each eye. Can see perfectly well in a straight
line, but when walking about a room has some
difficulty in seeing small articles of furniture.
On April 23, 1879, his condition was substantiallj^
the same. The visual field was increased some-
what in the left eye, = 9" vertically and 16" hori-
zontally. The optic discs remained pale and the
arteries small. There were no other opthalmo-
scopic changes.

Case 22. — (Roosa and Ely.)" Mrs. B., 34 years
old, was seen Nov. 7, 1879. She had pernicious
malarial fever in Cuba in Nov., 1877. During
one day she took 50 grs, of sulphate of quinine,
during the next day 90 grs., and during the three
or four succeeding days 30 or 40 grs. At 11 p.m.
of the day upon which she took 90 grs. she be-
came blind and remained so for three or four daj-s.
After that a gradual restoration of sight occurred.
There were no aural symptoms. Her intellect re-
mained clear most of the time. The blindness was
so complete that she had no perception of light.

'2 Archives of Ophthalmology- and Otolog>-, 1879, Vol. viii, p.
■3 Archives of Ophthal., Vol. ix. 18S0, p. 41.

436

CINCHONISM.

[September 28,

Vision was perfect before her illness, but had
never been so good since. She felt as if there
were a veil over her eyes and was unable to tell
whether her linen was clean when it came from
the wash. She could not see certain shades of
dark blue well, but distinguished all other colors
imperfectlj' ; she had most difficulty with red.
When her vision first began to return she had no
color perception whatever. R. E. Vision = |^ ;
reads i Jaeger fluently. L. E. Vision = |g; reads
I Jaeger fluently. V. = ^ with both eyes open.
The fundus of each eye was somewhat indistinct;
the discs were too white ; the capillaries seemed
deficient. The visual fields as tested at 12" by
Carmalt's perimeter were concentrically limited.
Case 2j. — (Gruening.)" A woman, 35 years
old, had a miscarriage at the sixth week. Septic
symptoms succeeded. She was given 80 grs. of
sulphate of quinine in thirty hours. Shortly after
the last dose she had convulsions characterized by
twitchings of the facial muscles and jerking of the
upper and lower extremities. She did not lose
consciousness during this attack. When this had
passed she was totally deaf and blind. Her hear-
ing returned in twenty-four hours. Gruening
found the pupils dilated ad maximum, without
either direct or consensual contraction. Accom-
modative contraction was clearly demonstrable
when the patient made a strong convergent effort.
Both refractive media were clear. The optic discs
were pale and transparent, with well defined out-
lines. The retinal arteries and veins were so at-
tenuated that in the inverted image they could
hardly be perceived. In the upright image the
vessels appeared as continuous, exceedingly nar-
row bands tapering to fine points somewhat ab-
ruptly. The slightest pressure upon the eyeballs
made all the vessels bloodless. At the macula of
each eye there was a cherry-colored spot surround-
ed by a zone of bluish-gray opacity. Blindness
was absolute — the light of an Argand lamp con-
centrated upon the eye by means of a convex lens
was not perceived. There was no phosphene by
pressure. The galvanic current elicited no reac-
tion of the optic nerve. There was no pain.
Hearing was blunted. The tympanic membrane
was not injected; there was no albuminuria. Eight
days after the occurrence of blindness Knapp saw
the case and agreed in the diagnosis of quinine
amaurosis. At that time the circumvascular ret-
inal opacity and the cherry- colored spot at the
macula had disappeared ; the optic discs and the
retinal vessels remained unchanged. The pupils
were moderately dilated and fixed except with ef-
forts of convergence, when slight contraction was
noticeable. July 19 (twenty-second day) she could
discern the position of the window. She had quan-
titative perception of light in both eyes. After
losing and regaining perception of light more than
once -she was finally (August 16, about seven

'J Archives of Oplithal., Vol. x, i8Si, p. 91.

weeks after the attack), able to count fingers with
either eye at a distance of 4 feet. August 30 she
read ordinary' type with -h 3 D., her hypermetro-
pia being 3 D. The letters, however, appeared
white upon a black ground. She was totally
color blind. On September 23 the pupils were
moderately dilated without any direct or consen-
sual action, but contracted with accommodating
efforts. Refractive media clear. The optic discs
were still very pale but transparent. The retinal
veins and arteries were filiform, with + 3 D. ; her
sight was \% and she read Snellen i 'i with either
eye. Field of vision concentrically limited ; that
of the right eye measured 30° on the temporal
side but did not extend to 20° in any other direc-
tion ; the left eye vision was still more contracted,
extending to about 18° on the temporal side, less
than that in all other directions. On Snellen's
color chart she recognized no color. All the let-
ters appeared gray to her, but the yellow ones
were much lighter than the others, In the spec-
troscope she saw only a number of gray stripes of
different shades. Novembers. The field of vis-
ion slightly enlarged and color sense improved.
December 28, 1880, she was able to distinguish
the four fundamental colors, yellow, blue, red and
green ; the two latter, however, only when pre-
sented in large surfaces. The fields of vision
were increased.

Case 24. — (Buller.)'* A woman, 34 years old,
had recently been confined. Septicsemic symp-
toms appearing, she was given two doses of sul-
phate of quinine, of 20 grs. each, during the first
twenty-four hours, the same doses on the second,
and on the third day she took three doses of 20
grs. each. On the following day fever and deli-
rium were gone, but she was absolutely blind.
Buller saw her during this day (August 27, 1879).
Externally, the eyes appeared normal. The ten-
sion and movements were natural, the pupils were
widely dilated and not responsive to the strongest
illumination, nor to the effort of accommodation.
The refractive media were normal. Left eye.
There was a diffuse, bluish-gray haziness or tur-
bidity of the retina for a considerable distance in
every direction, most markedly in the region of
the macula, the centre of which, by the direct
method, had the appearance of a cherry red patch
about I line in diameter. There were no retinal
haemorrhages and no choroidal changes. The
retinal veins as compared with the retinal arteries
were unusually large, but decidedly paler than in
healthy eyes. The arteries were normal except
actually or relativeh- diminished in size. Arte-
rial pulsation was readily evoked by pressure
upon the sclerotics. The opacity of the retina
nowhere obscured the ves.sels, and the small
branches converging toward the macula were un-
duly conspicuous. The retinal cloudiness gradu-
ally faded toward the peripherj'. Right eye. The

'5 Trans. Ainer. Ophth.il. Sec. iSSi, p. 262.

1889.]

CINCHONISM.

437

same changes were present, though to a less de-
gree. By 5 P.M. of August 29 (second day) she
was able to distinguish bars of light through the
Venetian shutters. September i (fifth day), at a
distance of 15 feet vision was clear over a surface
I foot in diameter and indistinct over an area of
2)2 feet. She could tell blue and red letters in a
motto across the room. On the seventh day she
could distinguish all colors in a subdued. light,
but for the first time there was noted a marked
diminution in the calibre of the retinal vessels.
The condition looked like one of moderately ad-
vanced atroph}-. September 4. The retinal ves-
sels were not half their normal size. The cornea
was not anaesthetic. September 6. Read Jaeger
8 easih' without glasses. November i . At a dis-
tance of 14" the vision of the left eye was: up-
ward 8", downward 9^2 ", inward 8" outward 12".
Vision = ff. She could distinguish all colors,
at the centre only. After an interval of twenty-
two months, there was a total abolition of all
sense of color except central color perception,
which was perfect. Central vision was perfect.
The nerves were both pale but not white. The
arteries and veins were not more than oue-third
as large as normal. The arteries could not be
traced as far as the ophthalmoscopic border and
some of them had white bands for a short dis-
tance. Some of the veins, however, were not
lost. Subjective sensations of light and after-
images that were formerly quite troublesome were
now only occasionally noticed. Buller assumed
that the final changes had now been reached. I

Case 2j. — (Webster.)'' A man, 23 years old, j
had taken, seven years previously, during the
course of a night, half a dozen large doses of sul-
phate of quinine. The next morning he was to-
tallj' blind. He remained thus only a few hours,
but he had never seen so well since. Vision, right
eye, = 1^, with + ^V C, axis 90°. Vision, left
eye, = TB ; not improved by glasses. Ophthal-
moscopic examination. Except that there were
whitish bands running along the borders of the
nasal branches of the left central retinal vein and
that the optic disc of the same ej-e was slightly
paler than it should be, both eyes were normal.

Case 26. — (Webster )'■ A ladj', 40 years old,
after frequent attacks of cholera morbus, had a very
severe seizure of the same maladj- on July 25. Qui-
nine was given per rectum until she had received
105 grs. (in doses at inter\^als of three hours).
Next daj- its use was resumed, she w'as given 5 gr. ]
doses every third hour up to 25 grs. whenever
there seemed to be signs of the return of a chill.
(She had also taken, as a tonic. 5 grs. of quinine
daily ever since until Januarj' 13.) On the third
day of her attack she became aware that she was '
blind and very deaf Her hearing returned in a !
few daj-s. The return of vision was gradual, but {

•'■ Archives of Medicine, Vol. x, 18S3, p. 338.

'7 Archives of Medicine, Vol. x, 1883. I

it remained extremely imperfect. January 13,
she could see a circle of light about a j'ard in di-
ameter when she looked at a lighted lamp, or saw
as if the light were shining through a thick fog.
At first she only saw through the extreme outer
corners of the eyes and not at all in front. Now,
objects seen on either side were dark, while those
in front were still outlines of golden light. Pres-
ent condition. Right eye = jiVtt ; left eye = -yhi.
The discs were perfect!}' white and the arteries
were entirely obliterated and replaced by white
lines. The very few minute retinal arteries had
white lines along their sides. There were a few
white, fleecy looking connective tissue changes in
the retina near the disc and a mottled condition
of the choroid. The pupils dilated downward
and outward nearly symmetrically and there were
deposits on the anterior capsules of the lens. She
derived no benefit from treatment

Case 2j. — (Michel.)'' A man, 38 years old,
took in twenty-four hours 40 grs. of sulphate of
quinine. During the next twenty- four hours he
took 50 grs. Then during the following night
he took 220 grs. in powder. Part of this was
not retained. Suddenly, at midnight, without
pain, his vision became totally extinct, "just
as if you had blown out a lamp. ' ' Deafness was
not absolute. It lasted ten days, but he never
regained his previous acuitj' of hearing. Four
weeks later both pupils were widely dilated.
Neither the strongest light nor sulphate of atro-
pine affected them in the smallest degree. The
optic discs were white with a slight tinge ; the
inner third (inverted image) somewhat darker
in hue. Scleral rings were very marked. The
artericT centrales were barely visible as minute
threads, not traceable far from the origin of the
disc. The veins were less than one-half their
normal size. The choroids were pale. March 9
(five weeks), the arteries and veins were slightly
increased in size and color. The patient thought
he could perceive a slight glimpse of light. March
21, the retinal vessels were even more threadlike
than at any time since first seen. 'S,y the follow-
ing August (six months), he noticed that in cer-
tain positions he could perceive varying degrees
of light. By the middle of October he was able
to roughly locate an object held up before him.
By November i he could read words in a news-
paper. Since then the patient thought there had
been no improvement. Februarv 14, vision R.
E. = H ; L. E. = \\. Both eyes together = f|
imperfectly. Field of vision, tested at i metre :
Right, in vertical diameter, = 23 cm.; right, in
horizontal diameter, ^ 29 cm. Left, in vertical
diameter, = 18 cm.; left, in horizontal diameter,
= 24 cm. Pupils in the strongest light = 4 mm.;
pupils in ordinary light = 5 mm. They respond-
ed slowly. Ophthalmoscopic examination : All
of the retinal vessels had increased in calibre; the

i^ Archives of Ophthalmol., Vol. x, p. 214.

438

CINCHONISM.

[September 28,

arteries were about one-third their normal size ;
the veins about one-half. The arteries could be
followed two- thirds of their normal course. March
9, the field of vision was improved in both eyes.
May 5, the field of vision unchanged in right eye,
apparently a little less in left eye. Tested with
Galezowski's echelle chroma liq lie, he saw no color
in grade No. i (No. i consists of very light
shades of red, yellow, green and blue). In grade
No 5, red and yellow were easily distinguished,
blue with some diificulty, green not at all ; violet
looked like "dirty white." In grade No. 10,
red, yellow and blue were promptly distinguished;
violet was called purple; green looked like a mix-
ture of green and yellow. In grade No. 15, red,
yellow and blue were quickly recognized ; green
was not seen. (He acknowledged that before his
blindness he did not know colors well.) June i
(sixteen motaths). The field of vision was un-
changed, likewise the size of the pupils, but they
responded promptly to light. No changes were
observed in the fundus of the eyes.

Case 28. — (Baumgarten. Reported at the same
meeting at which Michel's case was related.)" A
boy, after taking what was estimated to be about
5 drachms of quinine, lost sight and hearing. He
recovered in about six weeks.

Case2 g. — (Knapp.)'"" A girl, 7 years old, had
been treated for malaria three months previous-
ly and had taken a great deal of quinine. On
the sixth daj' she became hard of hearing, and
for four days could see nothing and the pupils
were immovable. On the tenth day she saw fire in
the grate. Improvement had been slow, and she
continued to have weak sight, and she felt uncer-
tain in walking. When Knapp saw her she could
easily read Snellen xx at 20', and 0.25 at 8" with
each eye, with moderate concentric limitation of
visual fields. Color perception was normal. Both
optic discs were white, the retinal vessels scant
and very small, especially the arteries (February
16, 1878). May II, 1879. Four months previ-
ously she again took quinine for malaria ; no
more, however, than 10 grs. in one da^'. From
that time her sight was impaired. Knapp found
S. -jVtt in the right and -rV.r in the left eye. She
read 0.50 with difficulty, no improvement with
glasses. She was green-blind. Field of vision
was very much contracted ; in the right eye al-
most to the point of fixation, in the left having a
diameter of 15°, of which 5° were on the nasal,
10° were on the temporal side, from the point of
fixation. The optic discs were white ; the blood-
vessels, especially the arteries, few and small.
Now referred the disturbance to the influence of
quinine. In May, 188 1, her sight was ^" in each
eve. Emmetropia. She experienced no incon-
venience from her eyes in any way. Her percep-
tion of color, carefully tested, was perfect. Her

19 St. Lo»is Courier Med.. November. 1880.
aoArchives of Ophthalmol., Vol. x, 1881, p. 223.

light sense was normal ; her field of vision, how-
ever, was contracted. The optic discs were white,
with a faint pinkish tinge. Both arteries and veins
were few and small, but none were white. The
choroidal vessels, clearly visible, were normal in
color, size and distribution. Otherwise the ap-
pearance of the fundus oculi was normal.

Case JO. — (Knapp.)"' A boj', 17 years old, had
had ".a terrible malarial fever from sewer- gas,"
four years previously. He was ill two weeks.
After the first daj' he took large doses of quinine
every third hour for a whole week. In the sec-
ond week he took one large dose every day before
the attack. The pupils dilated. On the tenth
day he did not see anything ; later, he gradually'
and very slowly recovered his sight, but he has
been awkward and stumbling ever since. For
two and one-half years nystagmus had been not-
ed. Condition on examination: " \'ertical vi-
bratory nystagmus. Periodic divergence of the
right ej'e ; pupils move well. Optic discs white ;
vessels very small, some converted into white
cords. Y. R. fVir ; L. t^- Recognizes colors cor-
rectly. Field of vision in both ej-es concentri-
cally contracted ; in the right eye to a diameter
of 20°; in the left eye, of 30°.

Case J. — (Knapp.)-- A boy, 8j4 years old, had
cerebro-spinal meningitis when in his third year
(mother's statement). He was brother to the pre-
ceding case. He took a great deal of quinine.
When he came out of his stupor at the end of
two weeks, he could not see anything, not even
a bright light held before his eyes. After some
weeks he began to see a bright light and ver}-
slowly recovered his sight, his eyes remaining
weak for some years. When Knapp saw him,
December 18, 1880, his optic nen-es were pale,
the left more so than the right ; atrophic-looking.
The retinal blood-vessels were abnormall)' small.
He was myopic and read with — yV Sn. Ixx at
20', and 0.50 near by, with each ej-e. Visual
fields were moderately contracted and had the
shape of a horizontal ellipse. June 8, 1881.
Light sense normal ; color sense carefully tested
proved normal too, but he had some difficulty in
recognizing contrast shadows and called the yel-
low shadow from a blue glass, brown.

Case J2. — (Saunders.)-^ A boy, 8 3'ears old,
who had been healthy previously, was taken ill
September 15, with fever and vomiting. On the
1 6th he was ordered to take a 6 gr. capsule of
quinine every second hour. The third capsule
was rejected. No more was given until the next
day, when he took doses of 12 grs. every second
hour until three doses had been given ; then, the
stomach becoming irritable, 20 grs. were given
by enema. The quinine was now withheld until
midnight of the 17th, when 10 grs. were given
by the mouth, but were rejected. This dose was

'• Ibid. '■ Ibid.

-•3 Mississippi Valley Med. Monthly, No. ii. 1SS2. p. 43.?.

1889.]

CINCHONISM.

439

repeated and, after its partial rejection, 20 grs.
were given by enema. This was partially thrown
off and 20 grs. more were administered by enema
at 4 A.M. (The patient had been quite deaf for
the past twenty-four hours. He had taken more
than 100 grs. in three days.) Shortlj^ after this
hour he became more deaf and stupid and difficult
to arouse. His respiration was labored and quite
slow, only 4 or 5 per minute. His attendants be-
coming alarmed, active efforts at resuscitation
were practiced, and he rallied in about one hour,
but he was totally blind, not able to distinguish
light from darkness. Deafness lasted thirty-six
hours ; blindness four days. Saunders also refers
to three other cases of quinine amaurosis as hav-
ing occurred in the neighborhood of Memphis dur-
ing the past few years.

Case jj. — (O'Bryen.)^' A man, aet. ^t, years,
had high fever. A ship's surgeon attempted to
reduce it bj' giving quinine ; this was taken in
doses of 25 or 30 grs. every second hour (January
6). On January 7, the patient noticed buzzing,
deafness, dimness of vision and finally total blind-
ness. On March 20, he remained totally blind.
His pupils were widely dilated. There was no
albuminuria. About twenty days later he was
able to perceive a blue and white handkerchief at
a distance of about 3 feet. At a later report, sight
appeared to be slowly but steadily improving.

Case ,v. — (Dewe3\)"' A man, 22 3'ears old,
was seized with pneumonia. There was a pro-
longed cold stage, lasting some hours, during
which his physician gave him yi oz. of sulphate
of quinine in divided doses, A good deal of this
was rejected by vomiting. In less than twelve
hours he was totally blind and deaf The deaf-
ness entirely disappeared in seven or eight days,
but the blindness remained. After three months
he could hardly distinguish night from daj-. His
sight gradually improved, and at the end of eight-
een months he was able to go about his farm and
to attend to business a little.

Case jj. — (Bruns.)^° A young man, 24 years ;
old, suffering from malarial coma, was given 480 ''
grs. of sulphate of quinine within twenty-four
hours. There was a .sudden reduction of vision
to light perception. The further course was not
■reported.

Case 36. — (Roosa,)" Mrs. L- took for malarial
coma, 30 gr. doses of sulphate of quinine, per rec-
tum two or three times. Consciousness was re-
stored upon the third daj', when she was found to
be unable to distinguish light from darkness. The
pupils were dilated and the ocular conjunctiva
greatly congested. For some time there was no
improvement, and when recovery began, it was
slow. After si.K weeks she could not see to walk
alone but could distinguish, with difficulty, col-

=4 British Med. Journal, i, 1886, p, S23.
25 Trans. Med. Assoc, of Missouri. 1S82, p. i6r.
i^New Orleans Med. and Surg. Jour.. June, 1888.
=" Trans. Amer. Ophthalmol. Soc. 1S.S7. p. 431.

ored objects in the room. She could count fin-
gers 4 feet distant, but could not make out a
letter. The ophthalmoscopic appearance were
those usuallj' seen in similar cases. Under the
hypodermic use of strj'chnine there was much
improvement. This patient had marked nystag-
mus and eccentric vision.

Case JJ. — (Gruening.)-* A lady, 50 years old,
took 30 grains of quinine on account of malarial
intoxication. On the following morning she
awoke blind and deaf The deafness lasted until
the evening and the blindness began to disappear
the succeeding morning. Five days afterward
she had a perfectly healthy fundus in each ej'e.
Central vision was normal, but the fields were
much contracted, not more than 30° in any di-
ameter.

Case j8. — (Diez.)" A boy, 6 years old, suffer-
ing from chronic malarial poisoning, took heavy
doses of quinine. As the fever disappeared there
developed divergent strabismus, more pronounced
in the right ej'e. There was also exaggerated
dilatation of the pupils. Vision in each eye di-
minished more and more until he could hardly
distinguish light from darkness. The ophthal-
moscopic examination showed perfect transpa-
rency of the refracting media. The optic nerve
papillae were pale and the retinal vessels very
much contracted. Under treatment with str\-ch-
nine there was verj- decided improvement during
the thirty days he was under obser\^ation.

Case jg. — (Peschl.)'" A woman, 28 years old,
had taken from 45 to 60 grains of quinine in six
daj^s. There developed suddenly symptoms of
cinchonism, especially blindness and deafness.
The former symptom lasted only several hours,
the latter, two days. Five days afterwards cen-
tral vision for colors had not returned. The field
of vision was much restricted. There was ex-
treme ischaemia of the fundus of the eyes. The
papillfe were pallid, but circumscribed. There
was slow but continuous improvement. Color
perception returned, but fields of vision remained
very limited. Nine months later the visual power
was normal, but the field of vision for colors
notably restricted. The fundus remained very
ancemic, the arteries were accompanied by white
streaks.

Case 40. — (Hobby.)" A young lady, 21 years
old, had taken large doses of quinine for supra-
orbital neuralgia. When seen by Hobby the
right eye was apparently normal. The pupil of
the left eye was widely dilated and not appreci-
ably affected by light. The ophthalmoscope re-
vealed intense ischaemia of both retinae. O.D.S.
. /-> o ci _3_ There was improvement
but the neuralgia becoming

, O.S.S.=

under treatment,

28Transact. Amer. Ophthalmol. Soc.. 1S87.

=9 La Ophthalmalogia Practica, Madrid, 2, 1883, p. 13.

30 Ann. di Ophthalmolugie.Vol. xvi.. 1S87-8S. p. 421.

31 Archives of Ophthamol., 18S2, Vol. xi, p. 34.

440

CINCHONISM.

[September 28,

severe and markedly periodical she was given 20
grains of sulphate of quinine in two doses one
hour apart. Upon the fourth day following this
she returned to Hobby with both pupils dilated to
the utmost. O. D. S.= ^; O. S. S. = -^. The
visual field was reduced to one-tenth of the nor-
mal. Both retinae were profoundl)' ischaemic.
Quinine amaurosis recognized and stiychnine
administered h}'podermicall3\ There was rapid
improvement ; in ten days the acuteness of vision
had returned to -^ in both eyes ; the visual field
in each had doubled. Six weeks later the visual
acuteness remained unchanged. The visual field
had increased but was still less than half the
normal.

Case 41. — (Nettleship.)" A man, 26 years old,
who had been ill with fever in Western Africa
toward the end of Summer. Before leaving the
Coast or during the earlj^ part of the voj^age he
took 7J2 grains of sulphate of quinine, in divided
doses, dail}', for two days, and on the third day
he took the same amount in a single dose. His
sight rapidly became dim during this day, so that
he could neither read nor see distant objects
clearly. He took no more quinine. His sight
improved, but had not entirely recovered when
Nettleship saw him, three weeks later. He in-
formed N. that two years previously he had dim-
ness of vision for a single day while taking qui-
nine.

Case 42. — (Nettleship.)'' A man, 29 years old,
had had Congo fever in June (22d). For this he
took immense doses of quinine. Three days later
he discovered that his sight was very bad. He
quickly recovered from his fever and started for
home. By July 3d he was able to read. Nettle-
ship saw him August 19th. Visual acuteness
was nearly normal. There was very marked
contraction of the field for colors, especially for
red and green, the color, as a rule, being only
recognized when close to the center. Though
vision was almost perfect it was not quite so in
bright light, and early in the morning he saw
everything as through a mist. The optic discs
were rather pale all over and the neighboring
parts of the retina slightly haz)\ The arteries
were decidedly' diminished, the veins normal.

Case 4j. — (Doyne.)" A patient, in whom blind-
ness supervened in the night while he was taking
large doses of quinine. The arteries were con-
tracted to mere threads and scarcely conveyed
blood beyond the disc. Complete blindness lasted
for several days. \'ision was slowly recovered,
but the fields of vision were still ver>' contracted.
Though the accident had occurred several months
previouslj' the arteries remained contracted and
the discs were still whitened.

^Transact. Oplithal. Soc. I'liit. Kingdom Vol, vii, p. 21S.
3iTransact. Opthal. Soc. Unit. Kingdom, Vol. vii, p. 219.
34 Ibid.

Case 44. — (Dickinson.)"" A boy, lo years old,
had ague, August 3d, 5th and 7th. During the
intervals his father gave him about 30 grains of
sulphate of quiniue. On the nth he complained
of feeble vision and darkness. On the 13th
vision was so diminished that he could hardly see
to eat. His vision continued to decline and in a
day or two he lost all perception of objects, and
even of the light of day. Occasionally he per-
ceived flashes of red light and had pain in the
occiput. This extended forward on each side to
the external canthus. There was also pain in the
neck and back. When Dickinson saw him,
August 22d, he was totally blind. The external
appearance of the eyes was normal. The pupils
were dilated and not responsive to light. All
dioptric media were intact and transparent, but
there was marked congestion of the retinal and
choroidal vessels, together with a remarkable
tumefaction of the optic disc, it appearing swollen
and pushed forward prominentlj' with the vitre-
ous. Its condition was very similar to that de-
nominated " stauungs papille, " "choked disc,"
the usual concomitant or resultant of neuro-
retinitis. A stasis of blood had been occasioned,
in which the lamina cribrosa had especiallj' par-
ticipated. Under treatment, quite good vision
had been regained in ten days, and two weeks
later advices were very encouraging. Vision re-
turned first in the right eye, which had also been
the first to be affected. It was stated that the
boy's mother had had a similar experience.

Case 4j. — (Browne.)™ A powerful man, 34
years old, who had had syphilis in 1877, was
seized with pneumonia on January 4th. On Jan-
uary 6th, his temperature being 104° F., he was
ordered to take 10 grains of sulphate of quinine
everj' sixth hour. January 9th, temperature 105
F., the dose of quinine was increased to 30 grains
ever}' second hour. He thought he took about
120 grains. On the afternoon of the 7th he be-
came deaf, and remained so about twenty-four
hours. About 4 p.m. there was a flickering before
his eyes and his sight went, "exactly as if j'ou
had turned out the gas." He could tell the differ-
ence between sunlight and darkness bj- the per-
iphery of the left retina. Centrally he could not
do this. The pupils were widelj- dilated. He
could not see the flame of a candle. Six weeks
after his attack his sight began to return. Re-
covery for central vision was rapid. March 24th
Messrs. Power and Vernon saw him at St. Baf-
tholomew's Hospital. Both optic discs were
white, the vessels small and contracted. The left
pupil was slightly the larger. Both acted slowly
to light and to accommodation. \'ision : Right
eye = I Sn. i'-,. . All colors had a dirty, faded
look. Left eye, YjSn. 1^2. He named and matched
colors pretty correctly. The fields were much con-

35 St. Lotiis Med. and Surg. Jour.. Oct.. iSSi. p. 352.

i^ Transact. Ophthal. Soc. United Kingdom, Vol. v-ii, p. 193.

1889.]

CINCHONISM.

441

tracted. There was a small area of perception of
white on the outer periphery of the left- field.
Field for color limited to the forea centralis.
Browne saw him on April 19th. Pupils 3'jmm ,
equal, acting to light and to accommodation.
Central color vision quite perfect. Vision : R.
-H f§ 2 ; I Jaeger at 12" fluently. L. 1% 5 In 2 ;
I Jaeger at 12" fairly. Slight paresis of left in-
ternal rectus ; optic discs pale ; vessels remark-
ably small and contracted. There were no other
changes in the fundus. Dec. 4th. There was
scarcely any change, except slight failure of vision
in the left eye. V. : R. = H 6. L. IS 4. When
reading i Jaeger with the left eye the letters
danced (slight weakness of internal rectus?). The
fields were unaltered. He could distinguish a light
thrown from a small mirror up to the periphery
of the retina. Very curious telescopic vision.
Health was remarkablj' good.

Case ^6. — Galezowski,'" quoted bj' Browne.)
Blindness occurred in a man who took 105 grains
of quinine. It was complete. The patient could
not see the sun. This lasted some days. Seven
months afterward his vision = f| — 2 J. difiicult.
During convalescence he had central scotomata
for awhile. There was no contraction of the field.
The optic discs were pale and the vessels very
contracted.

Case ^j. — (Championiere — quoted by Browne.)
A woman who took from 45 to 60 grains of qui-
nine became completely deaf and blind, and could
only communicate by touch. She recovered both
sight and hearing.

Case ^S. — (E. Williams — quoted by Browne.)
A man took one ounce of quinine in four days,
and became totally blind and deaf Both sight
and hearing were restored in six weeks. Hearing
was permanently impaired. The optic discs were
white and the vessels small. The vessels were
contracted concentrically.

Case 4g. — (E. Williams — quoted by Browne.)
A boy, 14 years old, who took a large dose of
quinine. He was totally blind for four days.
The optic discs were white. The visual fields
were contracted.

Cases of amblj-opia from the excessive use of qui-
nine have also been reported by Nucl,'" Hixson,"'
H. C. Wood,*" who mentions that he has seen
complete temporary' amaurosis produced in a lady
by 12 grains of quinine. The subject has also
received attention from Lopez,'' Masimiliano,"
and a number of other writers. Blindne.ss has
likewise been noted, as will be shown later, among
the symptoms of dangerous and fatal general
poisoning by quinine.

In the (more than fifty) cases of quinine amau-
rosis of which I have found records, the blind-

37Les Ainblyopies Toxiques, 1S77, p. 148.

a^Nagel's Jahresber, 1S71.

39 Leavenworth Med. Jour., 1869-70, iii, 215.

4'^ Therapeutics, Materia Med. and Toxicol., 1877.

4' Recueil d' Ophthalmologie. Paris, 1888, x, 79.

4= Osservatori, Torino, 1S8S, Vol. xxxix, p. 32.

ness was absolute in nearly all, but, unquestion-
ably, if careful research were instituted it would
be discovered that impaired vi.sion is not at all an
infrequent symptom of cinchonisra. Rogers*' has
already called attention to this phase. He asserts
that after the ingestion of 20 grains of sulphate of
cinchonine the following phenomena may be pretty
constantly observed : In about one hour there
are cardiac weakness and irregularity, and much
debility with tremor. Paresis of visual accom-
modation progresses to such an extent as to be
almost complete in manj' instances at the end of
the second hour ; at this stage even the emmetro-
pic eye will require the aid of a No. 10 convex
glass to properly distinguish objects at the nor-
mal near point. This paresis, he says, lasts eight
or ten hours. Probably the great majority of
cases of incomplete quinine amaurosis escape ob-
servation and record. Briquet, who saw four
such cases thus describes the evolution of the
symptoms. Says this writer, the patient begins
to complain of the light, and the effort to fix the
eye upon objects is painful. There is a sensation
like that produced by using strong glasses. The
eye is brilliant. The pupils are usually normal
and the conjunctiva not injected. There is, then,
a slight degree of excitation of the optic nerve,
analogous to that so often seen in the beginning
of paralysis of the nen,-e. In a more advanced
degree, patients see as through a mist. Objects
seem small, or double, or are not perceived at a
distance of 2 or 3 metres. Finally incomplete amau-
rosis may occur, when the pupils become dilated,
insensible to light. Briquet quotes Monneret
as also having seen four cases of this incomplete
amaurosis. A number of the cases here presented
in synopsis were examples of incomplete blind-
ness. For instance, Bruns' case was one of sud-
den reduction to perception of light, so was that
of Diaz. Nettleship had a case in which, after
doses of 7)-2 grs. of quinine taken in two doses daily
for two da5^s and a similar dose taken on the
third day, the sight rapidly became dim, reading
became impossible and distant objects were seen
indistinctly. This patient had two j^ears previ-
ously had indistinctness of vision after taking
quinine." In most cases the blindness develops
suddenly. More than once it has been described
as occurring "just as if a lamp had been blown
out." In manj' cases, however, vision fails much
more gradually. Blindne.ss generallj' becomes
complete within twenty-four hours, though in
some cases several days may elapse before this
occurs. The duration of total blindness, the ab-
sence of all perception of light, varies within
wide limits, from a few hours (Peschl, Webster, f/(z/)
or a daj' or more (Briquet, Baldwin, BuUer, Grue-
ning, cl al) to several, even many, weeks (three,
Gruening ; fiv^e, Michel ; ten, Voorhies ; nearly

43 Alienist and Neurologist, 1882, Vol, iii, p. 445.
44 1,0c. cit.

442

CINCHONISM.

[September 28,

three months, Dewey). In most cases perception
of light returns within a few daj's. I can find
no case recorded where blindness remained abso-
lute. In all sight is recovered, though often
slowly, and nearly always imperfectly. Six
months after the beginning of blindness one of
Graening's cases was still partially color-blind and
the fields of vision remained contracted. During
the greater part of the first year one of McLean's
patients ' ' could look steadily at the sun without
seeing it or even without any painful sensation
being produced. ' ' In one of Roosa's cases the visual
fields remained contracted, the optic discs pale,
and the arteries small. In another the patient,
whose vision was said to have been perfectly nor-
mal previously, felt, after two years, as if there
had been a veil over her eyes, and she could not
tell if her linen was clean as it came from the
wash. She vC'as also unable to distinguish certain
shades of dark blue. In Voorhies patient the
optic discs remained perfectly white after nearly
a year, and there was no trace of the central ar-
terj% except a small twig. The visual field was
greatly contracted. After an interval of twenty-
two months, Buller found in his patient a total
abolition of all sense of color, except by central
perception. Central vision was perfect. The
nerves were both pale, but not white. The ar-
teries and veins were not one- third as large as
normal. Webster reported a case, where, seven
years after the beginning of blindness, which was
total only a few hours, the sight remained im-
paired. Browne states that in one case the visual
field remained contracted after fifteen years. In
nearly every case where the condition of the sight
was accurately determined some damage to vision
remained when the patient was last observed. As
regards peripheral vision the blindness remains
permanent. Central vision gradually returns to
the normal after some days, weeks or months
(Gruening).

The exact nature of the eye affection has been
carefully studied by Voorhies, Roosa and Ely,
Gruening, Knapp, Buller, Webster, Michel,
Browne and other ophthalmologists, and we are
able to-day to recognize in quinine amaurosis a
pretty well-defined symptom — complex. This is
constituted by i. Transitorj' blindness, complete
or incomplete, usually developing suddenly.
This blindness may be more complete than in any
other recoverable condition, and is comparable to
the V)lindness of atrophy (Browne). 2. Color-
blindness. As sight begins to return most cases
will be found to be color-blind, completely or par-
tially. The color sense gradually returns and
may ultimately become restored. In some
ca.ses the diminution of light .sense is permanent.
3. Wide dilatation of the pupils. The pupils are
irresponsive to light, but are said to respond to
accommodative effort. It is to be inferred that
the dilatation is due to the blindness, and that

there is no implication of the third or sympa-
thetic nerves. 4. There is pallor of the optic
discs and extreme diminution of the retinal ves-
sels, both veins and arteries. In many cases this
is permanent. In cases examined early by the
ophthalmoscope, a whitish haze, with cherry-
colored spots, has been observed at the maculae,
as in cases of embolism (Browne, Buller, Gruening).
5. There is contraction of the visual field. This
is extreme and expands slowly. There is no reli-
able evidence that it ever regains its normal ex-
tent. " The contraction is concentrical or ellip-
tical, with the longest axis in the horizontal di-
rection." (Knapp.) Impairment of hearing (at
times to total deafness) with tinnitus appears to
be present almost invariablj'. It is rarel}' com-
plete more than twenty-four hours and gradually
disappears. Some variations from this type have
been noted. Voorhies' patient had ansesthesia of
cornea. Diez, Knapp and Browne obser\-ed di-
vergent strabismus. One of Roosa's cases had
marked nj'stagmus ; likewise one of Knapp's.
Dickinson noted in his patient " marked conges-
tion of the retinal and choroidal vessels, together
with a remarkable tumefaction of the optic disc,
it appearing swollen and pushed forward promi-
nently with the vitreous. Its condition was very
similar to that denominated 'stauungs-papille,'
■ choked disc,' the usual concomitant or result-
ant of neuro-retinitis." This is a striking varia-
tion from the, otherwise, universal experience,
and it may not be impossible that the symptoms
in this case were expressions of malarial intoxi-
cation, such as are occasionall}- obser^-ed.*' Taken
altogether the symptoms of quinine amaurosis
are strikingly definite and constant. Knapp's
first case appears to show that relapse may be
excited by quite small doses. One of Nettleship's
patients exhibited the predisposing idiosyncrasy
in its extremest degree, his sight being seriously
damaged by 23 grains of quinine administered
during three days two years after he had been
similarl}^ affected by quinine.

The pathogenesis of quinine amaurosis is by no
means understood. Browne remarks that the
subjective symptoms and ophthalmoscopic ap-
pearances resemble those of embolism of the cen-
tral artery or hsemorrhage into the optic nerve,
but that the bilateral occurrence and complete
recover}- of central vision refute this theory. He
considers the anaemia of the retina to be local and
that the occlusion of the arteries is probably not
retro-ocular and is not complete, or atrophy of the
optic discs would have occurred, as it does after
embolism. There is no sign of perineuritis.
There is no pressure. Buller, who thinks that
the seat of the morbid changes is the optic nerve
between the cliiasm and the eyeball, notes that a
galvanic current applied to the optic nerve of a

45 1.edd.i. Temporary Bilateral .•Vrablyopia in Consequence of
Malarial Poisoning. L,o'Spallanzani, 1SS5, Vol. xiv, p. 201, er/ al.

1889.]

CINCHONISM.

443

rabbit will speedily induce a blanching of the
retina and nerve similar to that which occurs in
quinine blindness. He details an example where,
by the same means, he accidentally produced a
similar picture in the human e3'e. The needle,
introduced back of the orbit, he thought, must
have penetrated the optic nerve. After the appli-
cation had lasted one and a half minutes the
pupils became widely dilated and the patient
averred she could not see. A few minutes later
the vision in this eye was reduced to counting
fingers at a distance of one foot. The retina
whitened to the disc and macular region. The
arteries were slightl)^ reduced in calibre and the
ner\-e was decidedly pale. The retina cleared up
in a few daj-s, but the optic nerve remained very
much blanched and the arteries small. The dim-
inution of vision, which finally settled down to
^-^fl■,, appeared to be uniform. There was no con-
centric limitation of the visual field and no color-
blindness. Buller attributes the sudden blindness
in cinchonism to a rapid efi"usion into the lymph
spaces around the nerve, producing an external
strangulation, too transient to produce the phe-
nomena of papillitis, but sufficient to produce
oedema and blanching of the retina, and a perma-
nent impediment to the blood-carrying capacity of
the central arteries.

The dose of quinine sufficient to produce blind-
ness is very indeterminate and largely depends
upon idiosyncrasy. H. C. Wood has seen com-
plete temporary blindness following the ingestion
of 12 grs. Nearly always, however, the doses
must be very large. Briquet thought that trou-
bles of vision did not occur ordinarily mitil, for
several days, doses of 1.5-2 grams (23-30 grs.),
or for a single day doses of 3-4 grams (45-60
grs.), had been given. On the other hand, enor-
mous doses sometimes fail to affect vision, though
blindness always results when the dose has been
lethal. Taussig*'' mentioned a dose of i oz. of
sulphate of quinine given to a soldier suffering
from ague. The only results were complete deaf-
ness and a kind of stupor, followed by recovery.
Brjxe'' saw a child 2 years old, to whom 1 2 grs.
of quinine were given daily for four or five daj'S.
Great prostration resulted, with unilateral para-
plegia, great oppression, pallid, cool and clammy
skin, but no blindness. Barlow tells of a lady
with severe congestive fever who took 40 grs. of
sulphate of quinine every two hours for ten doses,
or 400 grs. within twentj^ hours, without suf-
fering from any injurious effects of the quinine,
and who made a good recovery. Without doubt
immense doses of quinine are frequently taken
without disastrous consequences and, while blind-
ness may be alwaj's expected in case of lethal
poisoning, it is impossible to fix within definite
limits the non-lethal doses that may be expected

■1'' Med. Times. April 23, i!j64.
•r Medical Herald. Vol. iv, p. 441.

to induce it. It unquestionably largely depends
upon idiosyncras3% and although it hardly ever
develops except after the ingestion of large quan-
tities of the drug, and even then with the greatest
absolute rarity, the results are so terrible, that
even the remote possibility of its occurrence
should have influence in placing some check
upon the lavishness with which quinine is but
too often used in the treatment of disease.

QUININE DEAFNESS,

While tinnitus aiaium and temporarj^ diminu-
tion of the sense of hearing are the earliest and
most characteristic S5'mptoms of cinchonism, it
is not a little remarkable that permanent alter-
ation of the organs of hearing is verj^ uncom-
mon. So far as I have been able to ascertain, per-
manent complete deafness from quinine has never
been recorded ; indeed, complete temporary deaf-
ness is exceedingly- rare. Briquet" saw but two
cases. Giacomini and Guersant" relate one case
in which, after a single dose of 12 grams (180 grs.),
there was complete deafness which onh' disap-
peared after several daj-s, and another case, after
taking 41 grams (615 grs.), in which hearing was
restored very slowly. Records of incomplete tem-
porarj^ deafness from quinine are, of course, com-
mon enough, the sj-mptom belongs to the ordinary
pharmacology of quinine, but complete temporary
deafness without concurrent amaurosis has but the
scantiest authentic record. Joseph Williams-"' has
noted such cases, in one of which hearing only
began to return after three weeks and was never
entirely restored. The patient was able to hear
only those who addressed her in a verj- loud tone.
Although there is a widely pre\-alent popular im-
pression that quinine exerts a damaging influence
upon the auditory apparatus, there is a singular
dearth of definite proof that this action may be
permanent. Most of those who prescribe quinine
freely and in full doses are ready to declare that
they have never witnessed such results, although
ever}' one admits that the drug most readily tem-
porarily increases the difficulty of hearing of those
who are already partiallj^ deaf. In a number of
the cases of quinine amaurosis, however, the ac-
companying deafness never entirel}- disappeared,
and popular opinion has received important con-
firmation in the declaration of a number of most
competent authorities that quinine may be the
cause of permanent aural defect ; such writers,
for example, as Roosa, Burnett, J. Orne Greene,
Kirchner and others have so expressed them-
selves. Graefe, Hammond and Roosa earlj- de-
clared that hyperaemia of the auditory apparatus
followed the ingestion of quinine. Roosa found
that there was decided conge.stion of the blood-
vessels which run along the manubrium in the
membrana tympani. These vessels are intimately

J^' Op. cit., p. 140.

4<> Dictionaire de M^d., 2me edition, .-^rt. Quinine, p. 567.

5^' Lancet, i, 1840, p. 639.

444

CINCHONISM.

[September 28,

connected with those of the middle ear. The
blood-vessels of the tympanum are also in direct
communication with the circulation within the
labyrinth. From the close connection between the
vascular systems of the tympanum, the membrana
tympani and the labyrinth, and from the appear-
ance of congestion as the direct result of 10 and 15
gr. doses of quinine, we have evidence that the ef-
fect upon the ear is congestive rather than anaemic;
but as the congestion visible is slight and dis-
proportionate to the intensity of the tinnitus au-
rium, it seems reasonable to conclude that the
congestion of the greater cavities is greater (J.
Orne Greene)."' In a most instructive article up-
on the same subject, Burnett"'" states that if to a
healthy man from 15 to 120 grs. of quinine be
o-iven, a watch will only be heard at contact and
bone conduction is abrogated. The membrana
tympani assumes a hazy look, due to the intense
congestion of the mucous surface of the drum
membrane. The participation of the labyrinth is
shown by inhibition of bone conduction and by
inability to hear high notes by aerial conduction,
or by a ver>- limited power of perceiving them.
This impaired power is due to the congestion in
the lower whorl of the cochlea, where the nerve
fibres for hearing for high tones are supposed to
be. Important confirmation from experiment has
been supplied by Kirchner.". Upon examining
the labyrinth of a cat after large doses of quinine,
Kirchner found hyperccmia and excessive extrava-
sation of red and white blood cells extending from
the vas spirak over parts of the sulcus spiralis, the
auditory pillars, Corte's arches and the membrana
basilaris. In three of ten rabbits he found, un-
der similar conditions, extravasations extending
from the semicircular canals to the vessels in the
surrounding osseous substance in the temporal
bone (Burnett). Greene, Roosa and Burnett are
all convinced that great injury to the hearing is
often produced by the drug, and in occasional
cases the changes are no longer limited to simple
hyperasmia, but otitis has been produced by it
(Roosa," Burnett).

Very singularly, the effects of quinine upon the
sight and hearing appear to be attributable to two
quite opposite conditions. Upon the ear the ac-
tion is decidedly hypersemic, upon the eye it is
even more pronouncedly anaemic. How these
changes are induced is quite unknown. It is gen-
erally a.ssumed that they depend upon influences
exerted through the vaso-motor centre. Regard-
ing the ear, Kirchner concludes that the cause of
the pathological changes after quinine is probably
a vaso-motor disturbance whereby not only tran-
.sitory alterations are excited, but also a paralysis
of the vessels with congestion and exudation in
the different parts of the organs of hearing. With

5" Boston Med. and Surg. Jour., Vol. cviii, p. 220.
52 Polyclinic, Vol. iii, 1SS5-S6. p. 54.
53 Berliner Klin. Wochenschr.. No. 49. 1881. p. 727.
5J Treatise on the Ear, third ed., p. 155.

this condition of the aural blood- ves.sels and the
narrow contraction of the retinal blood-vessels
concurring, it .seems difficult to refer the altera-
tions to a central vaso-motor lesion. It is alto-
gether more probable that the vaso-motor effects
are local. It should be noted that the blindness
is not necessarily associated with deafness. In
some instances (few indeed), amaurosis has been
present with little or no aural disturbance (Roosa,
Voorhies).

GENERAL POISONING FROM CINCHONA PREPARA-
TIONS.

Doses of cinchona alkaloids that are sufficient
to produce complete deafness and blindness are
often the cause of general symptoms of an alarm-
ing, even dangerous character. Bochefontaine.'''
arguing from results obtained in animals, con-
cludes that in order to place the life of a man in
jeopardy, lo grams (150 grs.) of sulphate of qui-
nine must be injected under the skin, or 16 grams
(240 grs.) of sulphate of cinchonine administered
in the same manner. He estimates the lethal dose
by the stomach to be 35 grams (525 grs.) of qui-
nine, or 50 grams (750 grs.) of cinchonine. These
doses, however, exceed the amounts that have
been known to produce death. I have already
detailed a case of Baldwin's, where a negro girl
died after convulsions produced by 20 grs. of sul-
phate of quinine given in fortj'-eight hours. This
do.se appears almost too small to be followed b}'
such results, but the symptoms (described in
1847) tally so closely with those of more recent
observations, that Baldwin's claim would seem to
be well founded. Briquet reports two fatal cases,
in one of which death followed the administration
of 100 grs. in two days. The other patient (from
Recamier) took nearly 120 grs. in doses of 5 grs.
repeated every hour. Nevertheless it is pretty
safe to assert that in order to produce death from
quinine, enormous doses are necessar3\ Voor-
hies' '" patient, it will be remembered, took an
ounce within a few hours, and an equal amount
was given each daj' for two days by stomach and
rectum. She was in a critical condition for some
hours, but recovered. The soldier who took one
ounce at once with but unimportant consequences
has also been referred to. It is certain, however,
that doses that maj- prove dangerous are frequent-
1}' prescribed and taken with reckless freedom.
The practice has elicited protests from a number
of writers. Dr. A. A. Smith" has written a
vigorous paper upon this subject. J. Williston
Wright relates several cases illustrative of the peril
following excessive doses. One of his patients was
a child 10 years old who took within twelve hours
25 grs. of sulphate of quinine bj- the mouth and
25 grs. by the rectum. Within two hours after

-■^5 Comptes rendtis des S<?ances de I'Academie des Sciences, No.
96. l8>^.^. p. .SO,v

5'> New Vork Medical Jonrnal. Vol. xxxix, 1SS4, p. :i5.
57 New Vork Medical Journal, Vol. xxxix, 1S84, p. 116.

1889.]

CINCHONISM.

445

the last dose, the child fell into a state of collapse,
with a temperature of 93.9° F., a pulse of 60,
very weak and intermittent, a respiration of 32,
shallow and gasping. The face and lips were
cyanosed, the skin cool and moist. Recovery
followed. Even small doses may produce in
some predisposed individuals symptoms that ex-
cite alarm ; and no reference is made here to the
distressing and violent seizures following even the
smallest doses in some persons, in whom severe
acute gastric catarrh, extensive cutaneous erup-
tions, active circulatory disturbances are observed.
Lente,°' for example, records a case where two
small doses of calisaya elixir threw the patient,
a woman, into a comatose condition. She had
cold extremities, a hot head and symptoms of !
cerebral congestion. Lente relates other similar j
cases. A number of the cases detailed in the \
foregoing pages also presented alarming general
symptoms. I

In more severe cases the patients may pass into
a condition bordering upon collapse. Tliere will
be extreme prostration, with or without loss of
consciousness, or coma, lowered temperature,
gradual weakening of the pulse and respiration,
and chilling of the entire surface, copious cold |
sweating, deafness, dilatation and immobility of!
pupils, blindness, lividity or cyanosis of the coun- '
tenance. Convulsions have occurred in a goodly
number of reported cases. Both of Baldwin's
cases had them ; one, however, without losing
consciousness. In this man, they began with a ■
jerking of the whole body and great restlessness,
anxiety and alarm. The convulsive movements
came on every ten or twelve minutes, sometimes
of the whole body, at other times of the arms.
Briquet quotes Talbot as having seen convulsions 1
follow verj' large doses, Pereira'^" records among
cases of typhoid fever treated with 4 grams (60 I
grains) of sulphate of quinine daily, four who de-
veloped epileptiform fits. Gruening's patient,
who took 80 grains in 36 hours, had convulsions
shortly after the last dose. These were charac-
terized by twitchings of the facial muscles and
jerking of the upper and lower extremities. Al-
though the patient denied all knowledge of the
fits, Gruening thought that she did not lose con-
sciousness during them. Similar extreme action
has been noted by Gho.se. * The patient was a
Hindu female, 35 years old, who took, for remit-
tent fever, 20 grains of quinine in four pills, one
hourly. After the third pill she became insensi-
ble and convulsive movements of the limbs set in.
After two hours she remained in.sensible, lying
on her face with both hands clinched. Her eye-
balls were turned upward and her pupils dilated.
The muscles of mastication, of the arms, hands,
and lower extremities in a condition of tonic con-

5^ New York Med. Record. Vol. xiv., 1S7S, p. 3.SS.
?9 Emploi du sulphate du quinquina a haute dose. Th^se,
Paris. 1S41.

'^' Indian Medical Gazette, Vol. ii, iSSi. p. 337.

traction. The reflexes of the soles, palms, and
even of the conjunctivae, were abolished. The
woman had never been hysterical.

Fatal cinchonism has ver>' rarely been observed.
Several such have ahead}' been referred to ; with-
in a few years two very interesting accounts have
been published, the one, a case of poisoning by
sulphate of cinchonidine (Winters), the other by
sulphate of quinine (Lamb). Winters'"' patient
was a cachectic boy, 5 years old, who had remit-
tent fever. By mistake he was given 32 grains
of sulphate of cinchonidine every second hour
until 128 grains had been taken within six hours.
None was rejected. Winters saw him one hour
after the last dose. He had then had three gen-
eral convulsions of an irregular character. The
temperature was 94.6° F., the pulse almost im-
perceptible at the wrist. Bj' auscultation the
cardiac pulsations were found to be 74. The skin
and mucous surfaces appeared utterly bloodless.
The pupils were dilated. The child was semi-
conscious. The condition of sight and hearing
was not noted. Despite stimulants, heat and
friction, the bo}' graduallj' sank and died, appar-
ently of exhaustion, eight hours after Winters
first saw him after the poisoning. The necropsy
revealed engorgement of the cerebral sinuses with
dark, slightl)' coagulated blood. The brain was
anaemic throughout. The left heart was con-
tracted, but not firmly, and was empty. The
right heart contained a small quantity of dark
colored blood. Lamb's'" patient was also a little
boy. He was 3 years old. He had found a pack-
age of eighteen 3-grain sulphate of quinine pills
and had swallowed them all. After a few hours
he died, apparently of syncope. At the necropsy
several of the pills were found undissolved, and
Lamb estimated the amount actually absorbed to
be 42 grains. Curiously, the cardiac conditions
post-mortem were exactly unlike those found in
Winters' case. The heart was relaxed ; the right
cavities were empty, the left cavities contained a
little fluid blood. It was also discovered that
the child had a mild but unsuspected t>'phoid
fever.

In the cases in which convulsions occurred it
is not clear that they were dependent upon the
" nervous perturbation" that is .so often seen in
cinchonism. Comparative experiments upon
animals show, however, prettj' definitely that
while quinine cannot be considered a convul-
sivant in the same sense in which strychnine
is held, convulsive movements of an irregular
character are pretty constantly provoked. As
long ago as 1847 Baldwin found, after giving
large doses to dogs, at first great restlessness,
then vomiting, and occasionally purging. Next
followed tremulous movements with a constant
motion of the head, resembling that of paralysis

6' New York Medical Journal, Vol. xxxix.

*« New York Medical Journal, Vol. xxxix. p. 549.

446

TREATMENT OF SCIATICA.

[September 28,

agitans. There was loss of consciousness, fol-
lowed by complete paralj-sis of the hind extremi-
ties. In every case, where the doses were suffi-
cient to produce death, except one, convulsions
were observed. Bochefontaine's researches led
him to the conclusion that both cinchonine and
quinine are convulsivant, the latter less so than \
the former. This author, with See," attributes a
similar physiological action to cinchonidine, and
quotes Chirone and Curci°* as entertaining simi-
lar views. According to Soulier"" the first efiect
of quinine is to produce an acceleration of the
pulse, then, after a variable time, according to
dose, to slow it. In warm blooded animals the
first phenomena observed are lateral movements
of the head, accompanied by general enfeeblement
and incoordination of movements. The enfeeble-
ment becomes pronounced, and vomiting occurs.
The animal sinks down upon its thorax and neck
and then, but only in a certain number of cases,
epileptiform and even tetanic spasms occur.
These, however, maj' be only secondarj-. Brun-
ton," who has seen epileptic convulsions appar-
entlj' caused bj' medicinal doses of quinine, act-
ing through a stimulation of the motor centres,
explains that in fatal poisoning the animal dies
in convulsions consequent on stimulation of the
nerve-centres by the venous condition of the
blood produced bj' failure of the respiration. The
loss of voluntary' and then of reflex movement
indicates that quinine acts upon the nerve-centres
in gradually' abolishing their function. In the
fatal poisonings from quinine, the vagus nerve
becomes paralyzed and death occurs through fail-
ure of respiration, and only occurs through car- '
diac paralysis if the drug be injected into the
blood in large quantities. Douvreleur's experi-
ments with animals with sulphate of cinchonidine
show that after lethal doses the heart slows and
the blood- pressure progressively diminishes and
reflex movements gradually grow feeble and are
finally abolished, at the same time with the res-
piratory movements.

While it may be freely admitted that the dan-
gers of lethal poisoning bj' quinine are very re-
mote, it is certain that not sufficient attention
has been given to some of the graver consequences
that may follow its administration. In addition
to the blindness and deafness which we have al-
ready considered, might probablj- be added abor-
tion as a possible result of cinchonism. As, how-
ever, the oxytonic action of quinine has not as
yet been determined satisfactorilj', this aspect of
the question will not be introduced at the present
time.

Dr. Lyster, of Detroit, remarked regarding

63 Coinples rendus des Stances de rAcademie des Sciences, No.
96, 1883, p. 1081

64 Rev. des Sciences Med., Vol. xviii, p. 47.

65 Th^se de Paris, 1S83, p. 53.

^ Pharmacolug>', Therapeutics and Materia Medica, 3d .Ameri-
can Kdition, p. 947.

the use of quinine in large doses, that he quite
agreed with the doctor preceding him that only
such portion of the dose as was required to neu-
tralize the malarial intoxication was appropriated ;
an}' excess of dose was eliminated from the sys-
tem usually without any markedly injurious ef-
fect. He believed that quinine was strongly an-
tiseptic, and that the combination of alkalies and
mercurials on account of the ptomaines and leu-
comaines existing where the quality of the bile
was so inferior as it generally is in cases of ma-
laria, then we have passive congestion of the
liver and a lessened alkalinity of the bile. The
conditions are quite similar to that observed in
cirrhosis of the liver. The very large doses fre-
quently repeated will not be required if such other
valuable antiseptics be exhibited at the same
time. The hypodermic use of the quinine should
be made in suspected cases of the congestive or
malignant variety in regions where such cases
were met with.

Dr. W. J. Scott said that the doses of quinine
should be in size suitable to the necessity for its
administration. He thought excessive dosing of
quinine may do harm.

Dr. De Schweinitz, of Philadelphia, had a
case under his care in which amaurosis was caused
bj' 12 grains, and lasted several hours. There is
a case recorded bj' a French writer of a soldier
who took over an ounce. Safety depends upon
the precipitation in the intestine bj' alkaline
juices of an acid salt.

SUSPENSION AND EXTENSION IN THE

TREATMENT OF SCIATICA. A NEW

USE FOR AN OLD INSTRUMENT.

Read in the Section of Surgery and Anatomy at the Fortieth Annual

Meeting of the American Medical Association held at

Nexi-port, R. I., June 2j, 1&S9.

BY CHARLES C. HUNT, M.D.,

OF DIXON, ILL.

So unsatisfactory have been the results of the
various methods of treatment of sciatica that
any means whereby this painful disease maj' be
cured, or even palliated, will be welcomed by
professional men and laity alike. It has been
my good fortune, in the past five years, to be
able to give immediate and permanent relief in
many cases of sciatica, especially of the chronic
type, that had failed to obtain relief by any other
means than those I am about to describe. The
method is simple and, in my hands, has proved
in the highest degree effective. I can better illus-
trate by the recitation of a few typical ca.ses.

Mrs. K., a j'oung married woman, no chil-
dren, had pain along the line of the left sciatic
nerve for o\'er two years. It was so severe at
times as to confine her to bed for several days,
and at no time for many months had she been

1889.]

TREATMENT OF SCIATICA.

447

able to perform her ordinary household duties
without great suilering. I saw her as an oiBce
patient in May, 1884. Her general health was
considerably out of repair, owing to chronic en-
docer\'icitis, right lateral retroversion of uterus,
chronic sciatica of the left side, and consequent
anaemia. I was inclined to the view that the
uterine displacement and cervicitis, with their
attendant anaemia, stood in direct causative rela-
tion to the sciatica, and I accordingly placed her
on ferruginous tonics and resorted to such local
measures as the nature of the uterine disorders
indicated. After several months her general
health was much improved ; the uterine troubles
had disappeared, but the sciatica continued with
little or no material abatement. I then subjected
her for another two months to the usual routine
treatment for chronic sciatica, with no better suc-
cess. Prior to my seeing her she had been for
about eighteen months under the care of a very
able physician, from whose treatment she had
derived but little benefit. Early in November,
18S4, I was visiting another patient at this lady's
house. She informed me, on this occasion, that
the pain in her hip was worse, that her increased
cares had kept her much upon her feet, and she
had now become almost helpless from the parox-
ysms of pain, which tortured her during the day
and deprived her of her rest at night. Almost in
despair I said to her: " If you will lie in bed
two or three weeks and submit to such treatment
as I think proper, I may succeed in curing you.
I am not sure how matters will turn out. I have
never tried this before, nor do I know of anyone
else who has. In any event, it will do you no
harm." She was glad to submit to anj' reason-
able means that ofiered the least promise of relief.
I had it in my mind to see what could be obtained
by rest and extension, and as I had a Hodgen's
splint at hand, it occurred to me that these, to-
gether with suspension, could be very readily
gained by means of this most excellent apparatus.
I accordingly adjusted this splint in the usual
manner. In a few hours the pain had entirely
ceased. She enjoyed the first good night's rest
in over two years. At the end of a fortnight I
removed the splint and permitted her to get up ;
but as a precautionary mea.sure I left the adhesive
straps remaining, so that at night, or in case of
return of pain, she could attach a ten or twelve-
pound weight to the limb by means of a cord
passing over a pulle}- at foot of bed, in same man-
ner as we ordinarily make extension in fractures
of the lower extremities. This she kept on for
three weeks longer, attaching the weight at night.
The result was all that could be desired ; the
pain never returned after the first day. She was
discharged cured at end of five weeks. I had
the privilege of examining patient quite recently.
She informed me she had been perfectly well of
the sciatica ever since the splint was removed,
nearly five years ago.

Henry C. M., a young unmarried man of very
irregular habits. Had been a debauchee and
lain out nights in a state of drunken stupefaction.
Some two years prior to my seeing him, had con-
tracted a severe form of sciatica. Upon examin-
ing him, stripped, I found marked atrophj- of
muscles of left thigh and leg, mobility of the limb
much lessened, extreme tenderness on pressure
over line of sciatic nerve, general health tolerably
good. Had been under all sorts of treatment by
all sorts of persons without deriving any material
benefit therefrom. He was making a desperate
effort to reform. His circumstances, he thought,
would not admit of confinement in bed, and in-
sisted that I tr>' other means first, in hopes that
he might obtain relief without being subjected to
so severe an ordeal as the wearing of a splint
necessarily implied. The interrupted faradic cur-
rent, massage, nerve stretching, deep local injec-
tions of ether, etc., etc., together with such inter-
nal medication as suggested itself from time to
time during a period of several weeks, were fol-
lowed by only temporary alleviation. He finally
consented to have splint applied, which was done
March 11, 1886, at his home twelve miles distant.
The first few hours gave great relief, but the
dragging pain during the night became so intol-
erable that he telegraphed me next morning to
visit him without delay. Arriving at his bed-
side, I found that too much tension was the cause
of the diSiculty, and as soon as this was lessened
to a proper degree by the removal of the bed a
few inches in the direction of its foot, the trouble
ceased. He wore the apparatus two weeks, and
kept up extension at night four weeks more,
when he was discharged cured. I examined him
about a year afterward, and found that the atro-
phy had almost entirely disappeared, his sciatica
had not returned, and he had obtained perfect
use of the limb. Some months after this he felt
so jubilant over his restoration to health that he
"took a drink with a friend." This was the in-
itial step towards a grand spree, which lasted
until his death, some weeks afterwards.

Mrs. S., a large, fleshy woman, 55 years old,
always in good health except for the last year,
during which she had suffered from sciatica,
right side. October, 1885, applied the splint,
which was removed after a fortnight. Extension
by means of weight and pulley continued two
weeks longer, at the end of which time patient
was discharged cured.

W. C, blacksmith, sciatica left side, two and a
half years' duration. Dipsomaniac. Acute at-
tack, superimposed upon the chronic, caused by
injurj' while shoeing a horse. Applied splint at
once. Relief was immediate. Wore apparatus
thirteen days, night extension two weeks. Dis-
charged cured. I examined this case la.st week,
that is, five months after removal of splint. He
assured me he was entirely well.

448

TREATMENT OF SCIATICA.

[September 28,

Mr. S. Y. had been a severe sufferer from
sciatica of right leg for over ten j-ears. For last
two years has been comparatively free from it,
owing, as he thought, to three applications of a
strong Faradic current. Was thrown from his
wagon and sustained an injury of the right hip,
inducing an acute attack of great severity. At
first he would not consent to confinement on his
back ; insisted upon the use of electricity, as it
had "cured him before." After gratifying his
whim in this regard for several weeks, applied
the Hod gen, February i, i88g. By next day all
pain in the hip had ceased. Wore apparatus four-
teen days, night extension about ten days longer,
when he removed the adhesive straps of his own
accord. I am, at this writing, not fully informed
as to the result in this case. He has called at
my office several times since, but I happened to
be absent each time. At the time I removed the
splint, however, the progress was satisfactory.

EXPLANATION OF CUT.

K K. K K. the two arms of splint. E E, D D, sliding hooks on
anns to which lateral cords E B E and D B D are attached. H H.
cross-bar of splint, to which block covered by lateral straps is fas-
tened by strap P. N, wire bail. A B, suspending rope passing
over hook or pulley A, and returning is attached to itself by
wooden "check" W. O and S, lower ends of arms. R. adhesive
strap seen emerging from underneath roller at T and passing
over block H H, is reflected upon leg on other side.

But to recite further would be only recapitula-
tion. The.se ca.ses are not selected ones. They
are picked up at random from a list extending
over a period of five j-ears. No medicine of any

kind was administered to any of these cases dur-
ing the treatment by suspension and extension,
except an occasional laxative or cathartic. No
opiates were required. In all, the relief was
marked and decisive within from one to six
hours after the proper adjustment of the appa-
ratus. Recovery was completed in from two to
six weeks, except, possibly, in the last one, the
history of which I have just narrated as far as
known.'

The etiology, pathology, diagnosis and general
treatment of this morbid condition do not fall
within the scope and purpose of this paper.
Doubtless these departments will have been ex-
haustively considered in the paper to be presented
to this Section bj' Dr. Carpenter, of Kentuckj*.
My purpose has been solely to present a few
clinical facts which are new and interesting, to
me at least, at the same time cherishing the hope
that they may prove no less so to those to whom
I have the honor to relate them. I will only
add, in this connection, that from the first I was
surprised and gratified at the results obtained by
this simple procedure. Rest, suspension and ex-
tension are, it seems to me, the three cardinal
points in the treatment of this disease ; and after
an experience of five years I have nothing to add
to, or substitute for, the Hodgen splint, as the
most feasible means whereby these objects may
be fully secured.

The apparatus was devised by the late Prof.
John P. Hodgen, of St. Louis, during the War
of the Rebellion. Its object was to maintain ap-
position of the fragments in gunshot fractures of
the thigh while the wounds were being dressed.
Its use in simple fractures has never been gen-
eral. It consists of a one-fourth inch iron rod,
bent in two places at right angles, so as to form
two nearly parallel arms united bj' a transverse
bar (see "HH" in figure), and of sufiicient length
to reach from the hip-joint to about four inches
below the sole of the foot. These arms are
slightly bent at the knee, and the upper ends are
kept apart by a hea\-3- wire bail (N). Five or
six strips of heavy muslin roller, from three to
five inches in width, are passed from arm to arm
underneath the limb. These are fastened by
means of safety pins along the outer arm of the
splint, from the bail to near the ankle, so as to
allow the limb to rest upon them, as in a cradle.
Care should be taken to see that these strips press
equally all along the under surface of the limb.
Two strips of Maw's mole-skin plaster are adjust-
ed to the leg, as is usual for extension by means
of weight and pulley ; these straps are .separated
below the foot by the usual block, which latter
is now made fast to the cross bar of the splint by
means of a strong piece of adhesive strap at the
point "P." From the sliding hooks " EE " and

' Since preparing this paper S. Y. came in (June jot In and re-
ported himself entirely well.

1889.]

MEDICAL PROGRESS.

449

" DD " are two heavy cords, which are united at
" B " by a three-sixteenths inch rope, which pass-
es up over a hook in the ceiling and back upon
itself, where it is attached by means of the well-
known device represented in the figure at " LM."
The limb is raised or lowered bj- means of the
wooden check "W." The suspending rope,
"AB," should form, with a horizontal line, an
angle of about sixty degrees. To prevent the pa-
tient from sliding down in bed, the foot of the
bed should be elevated about four inches.

The late Prof Frank H. Hamilton, in his
justly celebrated work on " Fractures and Dis-
locations," declares, in regard to Hodgen's and
all other suspending apparatus, that "whatever
other excellences they may possess, this (exten-
sion) does not belong to them." How this dis-
tinguished author could have incorporated such
a palpable error in a work so carefully written, I
shall not attempt to explain. That this "sus-
pending apparatus," when properly adjusted,
docs produce extension, even to a degree greater
than one can bear, I have seen demonstrated over
and over again. In a case of oblique fracture of
the thigh of a very muscular man, with two
and a half inches shortening, I sat by the bed-
side and witnessed extension, by this means
alone, of sufficient power, without any ansesthetic,
to bring the fragments into place. Indeed, there
is danger of obtaining too much extension, as I
have already related. This unpleasant circum-
stance maj' be obviated b}- instructing the patient,
in case the tension becomes uncomfortable, to
slide a few inches toward the foot of the bed, or
have the bed drawn a few inches in the direction
of its foot.

In cases of adults, especially' of those beyond
the average length, the bed should be seven feet
long and without anj' foot-board ; otherwise the
lower end of the splint will press against the foot-
board and extension will cease.

The apparatus can be made in an hour by any
ordinarj' blacksmith. The wearing of it produces
no discomfort. The calls of nature can be at-
tended to with the least possible disturbance.
Patient may even sit in a reclining chair, while
his bed is being put in order, and it will do no
harm if the suspending rope is unhooked for an
hour or so at a time, while the bedding is being
changed, the patient, in the meantime, sitting in
a chair with limb (in splint) resting upon another
chair. It is well, however, not to remove tension
for this purpose until after one or two days.

While this method may not prove absolutely
successful in all cases and under all possible con-
ditions, yet it has, in my hands, been followed
by such uniformly good results that I feel war-
ranted in commending it to the favorable consid-
eration of all, and especially of those who, like
myself have failed to obtain satisfactory results
by other means.

MEDICAL PROGRESS.

Surgical Tuberculosis. — In a series of lec-
tures recentl}' delivered by Mr. Howard Marsh
at the Royal College of Surgeons of England, he
gives the results of his own experience in the
treatment of this disease :

As regards the general group of tubercular dis-
eases met with in surgery, when they are detected
early and are adequately treated by prolonged
rest, in not more than 10 per cent, do they de-
velop to any formidable degree. It is a rule with
but few exceptions in the lecturer's experience
that when, for example, a knee or an elbow,
which is the seat of tubercular disease of less
than three months' duration, is enclosed in well-
fitted splints and is kept at rest, the case gives
no further real trouble, and improvement, though
slow, goes on until the joint is apparently free
from disease, while after a longer period of rest
complete recovery is secured. The period re-
quired for treatment in early cases does not, as a
rule, exceed twelve or eighteen months. In
more advanced cases the same treatment will lead
to good repair. The treatment adapted for hip
disease has been that of prolonged rest, with
weight extension. In cases of suppuration all
abscesses have been opened as soon as detected.
An incision from an inch to an inch and a half
in length is made, matter is evacuated by gentle
pressure, and a small drainage tube, just long
enough to enter the cavity, is used for two or
three days and antiseptic dressings are applied.
In many instances the wound closes in two or
three weeks, sometimes sooner ; in others it be-
comes a sinus which discharges for a month or
six weeks and then heals ; in others still, suppu-
ration remains free for several weeks, or even
longer, and further openings have to be made ;
but at length, in a large majority of cases, the
wound heals and no further suppuration, except
in a very few cases, takes place.

Mr. Marsh proceeds to give an analysis of
seventy-six cases which had been operated upon
in the Alexandria Hospital, the patients having
been summoned for inspection a year and upwards
after operation. Of these seventy-six patients
thirty-seven were cases which had suppurated
and thirty -nine cases which had not suppurated.
Among the thirtv-seven there were two cases of
double disease, and in the thirty- nine there was
one double case. Of the thirty-seven suppuration
cases only four still had sinuses, and these v.ere
all small and superficial. The general results
were as follows : One was a perfect recovery, six
were excellent, seventeen were good, thirteen
were moderate.

Amount of shortening : Three no shortening ;
17 less than an inch ; 12 between i and 2 inches;
3 more than 2 inches.

450

MEDICAL PROGRESS.

[September 28,

Movement: One perfect ; 10 free ; 7 slight; 18
fixed ; I not observed.

Walking: Two perfect ; 22 well ; 13 indiffer-
ently.

Of the 39 non-suppurating cases 9 were perfect
recoveries, 9 excellent, 1 2 good, 9 moderate.

Shortening: Eight none; 19 less than i inch ;
1 1 more than i inch.

Movement: Nine perfect; 10 free; 10 slight ;
10 fixed.

Wall;ing: Twelve perfect ; 20 well ; 6 indiffer-
entl}' ; i not noted.

The lecturer believes his figures of results ob-
tained to be typical and in marked contrast to
those obtained after the operation of excision,
the mortalitj- in the former amounting to about
10 per cent., while at a moderate estimate the
mortality of the latter exceeded 20 per cent.
With these satisfactory results in view he feels
like advocating conservatism in treatment, and
the more so because the main defect of excision,
after all, will lie in the ultimate result, as regards
the usefulness of the limb. Thus, in children
the immediate result of excision of the knee ma3'
be all that could be desired, while the ultimate
result is unsatisfactorj- in that deformity ensues
and the functions of the limb are materially inter-
fered with. — Brit. Med. Journal, Aug. 3, 18S9.

Secondary Syphiudes of the Vagina. — M.
Balzer (Congres Internat. de Der. et de Syphil.,
Paris) dwells upon the importance of careful in-
spection of the vagina for the discoverj' of syphi-
lides. For this purpose the examination should
be preceded by vaginal irrigation. The vaginal
ampulla is their favorite seat. The papular form
is the more common, and it ma5* be isolated or
associated with the papules of the cervix. The
eroded form is also met with in the ampulla in
the form of macules or simple striae with a reddish
or whitish surface. Both forms usually' heal quick-
ly. When there are cervical plaques vaginal sj-ph-
ilides sometimes develop immediately upon con-
tact, notably in cases of uterine anteversion. In
the case of a prostitute who had had sj-philis for
more than four years there was a large mucous
plaque of the vagina which developed in this
manner, but which could onh- be seen after re-
placement of the uterus. The cervix was hyper-
trophied and ulcerated, but did not present a dis-
tinctively syphilitic appearance. It is reasonable
to suppose that plaques may develop in syphilitic
patients upon mere contact with a cervix that is
the seat of a chronic ulceration. The papular or
eroded syphilides are easily recognized and are
scarcely to be confused with certain flattened veg-
etations or soft papular chancres of the vagina.

In the middle jrortion of the vagina syphilides
are less frequent than in the ampulla. In one
case there were ulcerations, apparently deep,
which furrowed the vagina throughout the greater

part of its extent, but when the vaginal folds were
carefully stretched out it was found that in reality-
the ulcerations were only superficial. In another
case there was an ulcerous syphilide. The pa-
tient, who admitted having infected a person, was
carefully examined a number of times with neg-
ative results. Finall3', after an extremely care-
ful examination, two ulcers were found midway
in the vagina on the right side ; they were con-
cealed in folds of the mucous membrane, were
circumscribed, with indurated borders, and bled
readily. A mixed tonic treatment was ordered,
but the ulcers healed very slowly. It is almost
unnecessary to insist upon the gravitj' of vaginal
syphilides in view of the contagious character of
syphilis, but it is all the more important to search
from time to time for manifestations of the dis-
ease in other parts of the bodj-. — La Senmine
Med., August 28, 1889.

Cases of Entero- Vesical and Entero-
Tubal Fistul.E. — F. P. KuTHE ( Weekblad v. h.
Ned. tid. v. Geneeskiinde, 1889, No. 21), reports
the case of a man 25 years old, who had long suf-
fered from diarrhoea. All at once he noticed the
escape of gas from the penis during micturition,
at the same time fiscal matter appeared in the
urine. The communication was probably with
the ileum, since opiates did not prevent the ap-
pearance in the bladder of the fluid contents of
the intestine, although they produced constipa-
tion. Colotomy was, therefore, not available.
Direct operative closure of the communication ap-
peared to be the sole remedy. The patient being
sj'philitic, an antisyphilitic treatment was tried,
and, contrary to all expectations, was crowned
with success. The following j-ear the same con-
dition reappeared, but yielded to treatment of
mercury and iodide of potassium, the patient re-
maining cured at the end of seven years.

In the caseof entero- tubal fistula, the first indi-
cation was the discharge of gases, and an irritat-
ing fluid from the vagina. The diagnosis was
confirmed by the introduction of vaginal tampons
moistened with salts of lead, the reaction with
sulphuretted hydrogen being conclusive. The
daily introduction of iodoform bacilli led to a
moderate improvement. — Cent, fur Klin. Med.,
1SS9, No. 34.

Stenosis of the Trachea, Following
Tracheotomy. — {Virelioiv's Arehiv., B. cxvi,
H. I.) A child of 3J2 years that had been sub-
jected, two 3-ears previouslj-, to tracheotomy, was
obliged to continue the use of the canula on ac-
count of suffocative attacks. Finally attacks of
dyspnoea appeared during expiration, even with
the canula /;/ situ, and during such an attack the
child died. In such ca.ses of tracheal stenosis as
this the chief symptom is the appearance of suffo-
cation whenever an attempt is made to withdraw

1889.]

MEDICAL PROGRESS.

451

the caiiula. The reporter, having in a former re-
port given an account of the various forms of
tracheal stenosis upon a pathological-anatomical
basis, desires to deal at present with those
changes which are directly caused by tracheotomj-
and the canula. In spite of properly directed in-
cisions and suitably fitting canulte, granulations
form in the upper and lower angles of the wound
and, later on, form an obstacle to the removal of
the canula. Important changes in the tracheal
cartilage and walls may be the result of too large
or too small incisions, or deviations from the me-
dian line ; or, aside from these causes, may be the
result of unsuitable canulae. The reporter has
studied these relations in preparations of the lar-
ynx and trachea taken from children upon which
the operation has been performed, and has found
that, to a greater or less extent, the cartilage be-
comes necrotic or assumes a false attitude. When
the necrosed cartilage is removed, the defect
Tieals by granulation and, later, b\- cicatricial tis-
sue. Stenosis of the trachea is relatively more
frequent outside of the hospitals, where the opera-
tion has often to be performed in the midst of
trj'ing surroundings. In these instances particu-
larl}- he advises a careful control during the first
few days of the anatomical relations as a prophj--
laxis against the production of stenosis. — Cent./.
Klin. Med., 1889, No. 34. [

The Use of Pess.\ries. — Dr. J. B. W. Now- !
iiN, of Nashville, Tenn. {^Southern Practitioner),
sums up his objections to the use of pessaries in
the following terms :

1. They can only act as palliatives. If too
small the}' are expelled or cannot sustain the
womb, and if too large they exert injurious pres-
sure.

2. They keep up a continual irritation in the
vagina, acting as a foreign substance, producing
mucous, purulent and leucorrhceal discharges,
thus laying the foundation for fungus or cancer-
ous diseases.

3. Many forms of these instruments are liable
to produce .septic results.

4. They produce undue and permanent dilata-
tion of the vaginal walls by destroying the tonicitj'
of the parts.

5. If not frequently removed, they become
filthy and irritating.

6. They are liable to cause irritation of the
bladder and constipation.

7. Their application is often left to the laity.

8. By the obstruction which the)' offer to the
circulation, they produce engorgement, and it
may be ulceration of the surrounding parts, ex-
tending even to the production of a vesico-vaginal
or rectal fistula.

Goxorrhceal Arthritis. — Dr. A. Myrtle,
of Harrogate, Eng., reports two cases of this

character. In both there were the ordinarj'
S5'mptoms of rheumatic arthritis of verj' severe
degree, and in addition to this a remarkable
wasting of the muscles of the thighs and legs,
which was both sudden and persistent, confirm-
ing the views of some authorities that certain
centers of the cord and brain are partially par-
alyzed by the reflex S3-mpath3' existing between
them and the inflamed urethra ; the wasting of
the muscles in the limb not affected with the spe-
cial joint mischief is decidedly in favor of that
opinion. In the two ca.ses reported, the treat-
ment was eminently satisfactorj- and was as fol-
lows : Cotton, wool and flannel applied to the
joints ; two 12-ounce tumblers of old sulphur
water an hour before breakfast as an aperient,
and an 8 -ounce glass of the mild sulphur water
at mid-day. Later passive motion and slight
massage. Hot sulphur douche at the baths fol-
lowed \>y rubbing with camphorated oil. — Brit.
Med. Journal, Aug. 3, 18S9.

Ovariotomy in Rupture of a Multilocu-
L.AR Cyst. — M. Polaillon reports (Aa Semaiiie
Med.) the case of a woman in whom a diagnosis
of ovarian cyst had been made and who, while
raising herself in bed after taking a purgative,
experienced a crackling sensation in the abdomen
accompanied hy severe pain. During the three
following daj-s symptoms of peritonitis appeared,
with tympanites, vomiting and severe pain. On
the third day laparotomy was performed and a
multilocular cj'st weighing 3 kilogr. removed.
At the upper portion of the tumor one of the
pockets, which contained a blackish-looking fluid,
was found ruptured. There were well-marked
appearances of peritonitis. Fibrinous membranes
were removed and the toilette of the peritoneum
made with a warm antiseptic solution. The pa-
tient rallied well from the operation and bids fair
to make a good recover}'. J^I. Polaillon remarks
that in rupture of cj-sts the effusion, if serous, may
be reabsorbed ; if gelatinous it is not reabsorbed
and the patient is exposed to the dangers of peri-
tonitis ; in rupture of a myxosarcomatous cyst he
has seen a veritable graft of pathological tissue
upon the peritoneum.

Antipyrin. — -Antipyrin bids fair to become
an universal panacea. Dr. W. F. Wright, of
New York, says that he has employed it in
migraine, trigeminal neuralgia, ovarian neural-
gia, muscular rheumatism, hysteria, and certain
spasmodic conditions, in all of which he has
found it of distinctive value. He has also ob-
tained excellent effects from its employment in
the insomnia of exhausting and irritating dis-
eases, especialh- in combination with chloral.
By French authors it has been described as pos-
sessing valuable haemostatic properties ; thus,
Henoque considers that the drug produces a con-

452

MEDICAL PROGRESS.

[September 28,

striction of the vessels and the tissues, while
coagulating the blood. In epistaxis he uses it
in powder, solution, gau^e and ointment. Hinkel
(N. }'. Med. JoH7-nal, Oct. 30, 1888) has used a
4 per cent, solution with good effect in cases of
haemorrhage following operations on the nose.
He also finds that it exerts a sedative action in
cases of sneezing, coryza, etc., while combined
with cocaine it increases the topical action of the
latter, enabling it to be used with effect in
weaker solutions. Carl Lowe ( Thcr. Monatshefte,
1889, 169) has used antipyrin in ntany cases of
whooping-cough occurring in an epidemic, and
found it a very valuable agent except in a few
cases, in two of which the symptoms seemed to
be aggravated by its administration, and in one
of which the toxic effects of the drug were mani-
fested.

The Berliner Klin. Wochenschrift (J^o . 17,1889)
reports marked success following its introduction
in the treatment of whooping-cough, but also
takes occasion to point out the dangers of poison-
ing from its administration, a cumulative action
having been observed in some cases.

Suprapubic Cystotomy. — Mr. H. T. Her-
ring reports thirty- one cases of this character per-
formed by Sir Henry Thompson, who at the end
of 188S had completed a series of more than 1,000
cases in which he had operated upon the bladder
for calculus and for tumors. Of the thirty-one
cases of suprapubic cystotomy two were performed
by the old method and the remainder by the mod-
ification suggested by Garson and first introduced
into England by Thompson. The chief points of
this modified method were to commence with a
full}' }'et prudently distended rectum, followed by
a fair distension of the bladder ; a sparing use of
the knife ; the opening of the bladder by a small
incision sufiicient to admit the finger, but enabling
further enlargement to be made by dilatation only,
since after this the opening contracts and stitch-
ing is not necessary, and moreover appears to be
generally not advisable.

In the first series (two cases by old method)
both patients died. In the second series there
were eleven cases of tumor of the bladder and
eighteen cases of calculus. Of the eleven cases
of tumor only one was fatal, and that from pyae-
mia. Among the eighteen calculus cases there
were three deaths, exclusive of one in which
death was due to an attack of bronchitis and
asthma. The whole of these cases represent the
most advanced and the most complicated exam-
ples of disease, and were on that account not
amenable to lithotrity, or to a perineal .section of
any kind.

Typhlitis Caused by a D.vte Stone. — Dr.
E. G. Archer reports a case of a farmer, aged
35, who, when first seen on June 26th, was suffer-

ing from symptoms of intestinal obstruction. For
some time he had experienced constant uneasi-
ness in the bowels, for which he had taken aper-
ients, resulting the day before in copious evacua-
tions. The treatment consisted in opiates and
hot applications, followed by castor oil. On
June 28th a large accumulation of faeces was
passed, giving great relief to all the symptoms.
In this discharge a date stone was found. Im-
provement was only transitory and an abscess
formed, bursting into the bowel on July 5th,
after which the patient made a rapid recovery.
The patient had not eaten dates since the preced-
ing Christmas, and accordingly the date stone
must have been in the bowels for at least six
months. — Brit. Med. Journal, Aug. 3, 1889.

Spontaneous Version. — Dr. T. W Evans,
of Richmondale, Ohio, reports a case with the fol-
lowing notable particulars : The patient was first
seen June i6th, at 2 a.m. Up to this time she
had felt no pains, although there had been copious
discharges of liquor amnii on the previous da}'.
Upon examination a hand was found protruding
from the vagina in a dorso-posterior position.
The arm was easily replaced, after which the
head came down. Two hours later the patient
was again visited. At this time she was having
strong expulsive pains, and an examination re-
vealed a breech presentation. Labor terminated
favorably. — Medical and Surgical Reporter.

Snake Bites. — Dr. L. G. Lincecum, of Lam-
pasas, Tex., reports {^Southern Practitioner, Sept.,
1889) that he has treated more than one hundred
cases of bites inflicted by poisonous reptiles, and
that he has never seen a case result fatally that
was treated by the hypodermic administration of
permanganate of potassium and the administra-
tion of chloroform locally and by means of in-
halation. He gives the permanganate in one
and two grain doses.

Floating Kidney. — Dr. J. T. B. Berry re-
ports a case of floating kidney in a woman other-
wise healthy. Six weeks after the discovery the
patient was attacked by peritonitis, to which she
suddenly succumbed. Dr. B. presumes that the
peritonitis was set up by the escape of some fluid
into the peritoneum, possibly from an abscess of
the kidney, or from rupture of the ureter. — A''. O.
Med. and Surg. Journal.

Salve for Infantile Eczema. — Delapert
gives the following in the Revue dc Thcr. Mcd.-
chirurg. of Sept. i :

R. Boric acid 3 jss.

Vaseline 5j.

Balsam of Peru j^s. viij. ");.

Sig. — Apply the ointment frequently to all the
affected parts. — Medical News, Sept. 21, 1889.

1889.]

EDITORIAL.

453

Journal of the American Medical Association

PUBLISHED WEEKLY.

Subscription Price. Including Postage.

Per .\nnum, in .\dvance $5.00

Single Copies 10 cents.

Subscription maj' begin at any time. The safest mode of remit-
tance is by bank check or postal money order, drawn to the order
of The Journal. When neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
letters.
Address

Journal of the American Medical Association,

No. 68 Wabash Ave.,

Chicago, Illinois.
All members of the Association should send their Annual Dues
to the Treasurer, Richard J. Dunglison, M.D., Lock Box 1274, Phila
delphia. Pa.

London Office, 57 and 59 Ludgate Hill.
SATURDAY, SEPTEMBER 28, 1889.

PROFESSIONAL ORGANIZATION.

Receiith' we have been favored with several
annouiicements of new Tri-State and District
Medical Societies, every one of which may be re-
garded as a finger-board, pointing to a restless,
working element that permeates the entire medi-
cal profession. The omen is for good and indi-
cates a craving desire for a more thorough profes-
sional organization than now exists.

The first of these district organizations to arrive
at distinction is the Mississippi Valley Medical
Association, that has recently held its fifteenth
annual session at Evansville, Ind. The type and
character of the papers and discussions of that
meeting compare favorably with those of any
similar organizations of which we have knowl-
edge, while we have reason to believe that the
work to be done by the other and more recently
organized societies will be valuable, a credit to
their distinct organization and to our guild.

One of the notable outcroppings of the meet-
ing at Evansville was the expressed desire on the
part of nearly all of the members, that the Amer-
ican Medical Association would officially recog-
nize the Mississippi Valley Medical Association,
and all similarly organized district and tri-State
societies, as actual branches of that bod}-. The
importance of such a movement can scarcely be
overestimated, as it practically proposes a feasi-
ble plan for a unification of the entire medical
profession of this country.

It is easily understood that, on account of the
long distances that .separate the great medical
centres where the annual meetings of the Amer-

ican Medical Association are held, there is a con-
stant fluctuation and practical change of active
membership. Moreover, the American Medical
Association being in its organization a body com-
posed of delegates from affiliated State, county,
and other local societies, the same persons are not
everj"^ year sent as delegates, all of which con-
duces to a constant disintegrating process, that is
actively detrimental to the strength and efficiency
of this parent -organization of American physi-
cians.

Through the organization of district and tri-
State societies that are geographically limited in
area, which invite the presence and active coop-
eration of every member of the regular medical
profession within their bounds, it would be possi-
ble to obtain not only a professed, but an actual
allegiance of more than forty thousand active
members. Even this number is only about one-
half of those who claim to practice regular med-
icine.

In this more complete organization a certificate
of membership issued by any branch, should re-
ceive and have the same recognition as if it were
issued by the parent organization.

One of the grand purposes of this thorough
organization of branch asociations, would be the
ability to practicallj^ institute a system of collec-
tive investigations of disease, and of any depart-
ment of the sciences, which would in their results
be of inestimable value. In fact, the treasury
would warrant the inauguration of a S3-stem of
original scientific research that would not only be
a stimulant to every thinking worker in our do-
main, but a source of pride to every American
physician. It would be impossible to comprehend
the amount of good that may be accomplished in
this direction.

The members of the American Medical Associ-
ation, some six years ago, believed it to be in the
interest of the entire profession that it should have
a journal that would not only be the official organ
of the Association, but that it would in time be-
come the principal avenue of intercommunication
in the entire medical profession, and thus become
a practical bond of union. It now assumes its
functions in a direct effort to guide the profession
in a way that looks to a thorough harmony and
complete unification of the entire body of Amer-
ican physicians. The spontaneous growth, and
enthusiastic support of the geographical district

454

TREATMENT OF POTT'S PARALYSIS.

[September 28,

medical associations indicates a plan by which a
-methodical unification may be accomplished. It
is desirable that this ofiicial channel of intercom-
munication in the profession shall be placed in
the hands of every physician. This may be
brought about through the annual payment of
dues in the branch associations, in precisely the
same manner as adopted in the American Medi-
cal Association, so that every member would in
this manner obtain the Association journal. A
by-law providing that any member who has once
paid his annual dues of five dollars should on ex-
hibition of a certificate to that efifect be exempt
from a second payment, and onlj' required to pay
a small sum to defraj- the current expenses of the
additional meeting, or meetings which he may
attend.

In this manner the Association journal would
not onl5' be the official organ of the Ameri-
can Medical Association, but would also bear a
similar relation to all the branch associations, and
thus may it be made a veritable mirror, to reflect
the very best thoughts of the very best minds in
the entire realm of medicine. We need, we must
have a practical and harmonious unification of the
entire medical profession of this country.

•TREATMENT OF POTT'S PARALYSIS BY EX-
TENSION.

In the American Journal of the Medical Sciences,
May, 1889, Dr. S.Weir Mitchell relates how,
becoming dissatisfied with the progress of cases
of paralysis from spinal caries under the custom-
ary treatment, he had recourse to the device of
partial suspension by the head, which he believes
to have been first systematically practiced by his
father. Prof. J. K. Mitchell, with satisfaction to
himself and benefit to his patients. The exten-
sion is made by a sling suspended from a curved
iron made movable and set by a screw, which
can be attached to a chair, thus allowing the pa-
tient to sit up and, if necessary, to be taken out
of doors in that position. The amount of exten-
sion used is gauged by a spring balance, and,
beginning with a slight pull and regulating the
amount of force used by the patient's sensations,
maj^ be increased, in some cases, to as much as
seventy pounds, and used from four to six hours
in the day. By this means he has been able to
rectify curvatures and to restore motion, sensi-

bility and nutrition in cases which had been un-
successfullj' treated by rest in bed, the plaster
jacket and the usual topical and constitutional
treatment. He concludes as follows :

' ' My conclusions are that suspension should
be used early in Pott's disease.

"That, used with care, it enables us slowl}' to
lessen the curve.

"That in these cases there must be, in some
form, a replacement of the crumbled tissues.

' ' That unless there is a great loss of power,
the use of the spine car or chair, etc., of John K.
Mitchell enables suspension, especiall)^ in chil-
dren, to be combined with some exercise.

"That no case of Pott's paralysis ought to be
considered desperate without its trial.

" That suspension has succeeded after failures
of other accepted methods.

' ' That the pull probably acts more or less di-
rectly on the cord itself, and that the gain is not
explicable merely by obvious effects on the angu-
lar bony curve.

' ' That the now well-known influence of exten-
sion in Pott's palsy makes it probable that in
other forms of spinal disease not due to caries,
extension in various forms ma)^ be of use, as has
apparently of late been made clear.

' ' That the methods of extension to be used in
these and in carious cases may be verj' various,
only provided we get active extension.

" That the plan and the length of time of ex-
tension must be made to conform to the needs,
endurance and sensation of the individual case."

EDITORIAL NOTES.
HOME.

The Ohio State Dental Society will hold
its fifth annual meeting at Cleveland, on October
30, 1889.

C.\N.VDIAN Medic.\l Associ.\Tion. — The Can-
adian Practitioner, in an editorial on the recent
Annual Meeting of the Canadian Medical Asso-
ciation in referring to the representatives from
the United States, says :

"Our brethren acro.ss the imaginarj- line are
ever welcome at the meetings of our societies.
The United States certainly .<;ent a very able con-
tingent to Banff. Never has the Canadian Med-
ical Association had more distinguished visitors.
Among them were Drs. Currj' and Whittaker, of

1889.]

EDITORIAL NOTES.

455

Cincinnati ; Drs. Gibney and Bulkley, of New
York ; Dr. Barker, of Philadelphia ; Dr. Marcy,
of Boston ; Dr. Hannan, of Albany, and others.
They took an active interest in the proceedings
of the meeting and engaged freely in the discus-
sions when called on. We were glad to meet
them, sorry to part from them, and we hope they
will visit us again next year in Toronto. In the
meantime we have been asked to visit them. Let
us do so."

Dominion Medical Association. — Officers
elected for following year :

President, Dr. James Ross, Toronto.

Vice-Presidents, for Ontario, Dr. Bruce Smith,
Seaforth ; for Quebec, Dr. Lachapelle, Montreal ;
for Nova Scotia, Dr. Johnston, Sydney Mines ;
for New Brunswick, Dr. Holden, St. Johns ; for
Prince Edward Island, Dr. McLeod, Charlotte-
town ; for Manitoba, Dr. Spencer, Brandon ; for
Northwest Territories, Dr. Brett, Banff ; for
British Columbia, Dr. Edwards, Nanaimo.

General Secretary, Dr. James Bell, Montreal.

Treasurer, Dr. W. H. B. Aikens, Toronto.

Local Secretaries, for Ontario, Dr. Farley,
Belleville ;■ for Quebec. Dr. Elder, Huntingdon ;
for Nova Scotia, Dr. Muir, Truro ; for New
Brunswick, Dr. Raymond, Sussex ; for Prince
Edward Island, Dr. Warburton, Charlottetown ;
for Northwest Territories, Dr. Higginson, Win-
nipeg ; for British Columbia, Dr, Rutledge,
Moosomin.

The American Rhinological Association
meets at the Palmer House, Chicago, on October
9, 10 and II, 1889.

The Sanitary Condition of Los Angeles.
— We regret to learn that a proposition to issue
bonds for the construction of a sewer to the sea
has been defeated by a popular vote of the citi-
zens. The necessity for the successful carrying
out of some plan to relieve this fair city from the
noisome and sickening odors arising from the so-
called sewers now in existence, may be judged
from a paragraph which recently appeared in a
local paper :

" Los Angeles is a city of from 70,000 to 80,000
people. It is almost without sewers. More than
three-fourths of it has no sewerage at all. The
small sewers we have are choked and overflow-
ing, and foul matter is often forced out of them.
Sewer gas from leaks and overflowing sewers

floats in the business centers at night, and in the
residence portions the air is heavy with foul
odors and gases from neighboring cess-pools. The
'soil of the city is in general such that it does not
absorb the foul matter, and that renders the sit-
uation worse. In many parts of the city the
odor at nights from cess-pools is so strong that
residents are obliged to close their windows.
Children are dying with diphtheria as a result of
these cess- pools."

To longer delay action will be worse than crim-
inal. Mone}- should not count where the health
of the people is at stake. We trust that the press
of California will so arouse public opinion that
this blot on the escutcheon of the gem of the
Pacific coast may be removed, and Los Angeles
once more regain its reputation as a health re-
sort.

The American Railway Surgeons will hold
their next annual meeting at Kansas City, Mo.,
in May, 1890.

Typhoid fever is epidemic at Negaunee,
Mich. Over 100 cases are reported.

FOREIGN.

The Continental Anglo-American Medi-
cal Society. — The first general meeting of this
societj' will take place at the Grand Hotel, Paris,
on Monday' at 5 p.m., and the first annual dinner
will also take place at the Grand Hotel at 8 p.m.
on the same evening. The following gentlemen
are Honorary Presidents of the Society : Sir
Spencer Wells, Sir Joseph Lister, Dr. Richard
Quain, Prof Ball, Prof. Brown-Sequard, Dr.
Ricord, Dr. J. S. Billings, Dr. Fordyce Barker,
and Dr. Weir Mitchell. The Executive Commit-
tee includes the Hon. Alan Herbert, M.D., Dr.
Faure Miller, Dr. Chapman, Dr. Dupuy, Dr.
Barnard, with Dr. T. Linn (16 Rue de la Paix)
as Secretary.

Child Mortality in Dublin. — An extremely
interesting and suggestive paper, b}^ Dr. Grim-
shaw, Registrar- General for Ireland, entitled
"Child Mortality in Dublin," maybe found in
the July number of the Dublin Journal of Medi-
cal Science. The paper deals largely with the re-
lations subsisting between child mortality on the
one hand and drunkenness and crime on the oth-
er, and is based upon a careful tabulation of the
vast amount of statistics at the command of the
author. Among other matters of interest, Dr.

456

EDITORIAL NOTES.

[September 28,

Grimshaw establishes the fact that the mortality
of children in Ireland as a whole, is lower than
in England and Scotland, because the relative
proportion of the urban population in those coun-
tries far exceeds that of Ireland, while the death-
rate of town children far exceeds that of country
children; that notwithstanding the foregoing, the
child mortality of Dublin is comparatively high,
both in relation to that of the cities of England
and Scotland and that of the other large Irish
cities ; and that the extremely intemperate habits
of the lower classes in Dublin have much to do
with this high death-rate. The children of drunk-
en parents, says Dr. Grimshaw, are not born
healthy, and when born are neglected in every
conceivable way and are exposed to dangers from
reckless negligence which are almost inconceiva-
ble. A comparison between the rates of mortality
and the rates of drunkenness, as measured by the
criminal statistics of large towns, shows that there
is a close relationship between the two, the care-
lessness with respect to child life being shown by
the large proportion of children who die without
being medically attended during their last illness.

New Pamphlets on Hypnotism. — The recent
appearance of two pamphlets in the German
language on the subject of hypnotism is an indi-
cation that the interest taken in this subject is
by no means confined to the French physicians.
The first of these, by E. Baierlacher, Stuttgart,
is entitled "The Therapy of Suggestion, With
its Technique." The second, by F. Miiller, treats
of "Hypnotism and Suggestion, as Well as Their
Therapeutical Application."

Mr. Clark Bell, of the Medico- Legal Society
of New York, was recently tendered a reception
by the President and Council of the Society for
the Study of Inebriety, of London. A resolution
was also adopted congratulating Mr. Bell on his
services to legal medicine ; on the effect of the
discussions at the Medico- Legal Society of New
York on criminal procedure in cases in which
persons sentenced to death have been ultimately
respited on the plea of insanity ; on his eff"orts to
abolish physical restraint in the treatment of in-
sanity in the United States ; and on his pleas for
a reconsideration of criminal procedure in the
case of inebriate criminals, who were often really
irresponsible and subjects of a true disease calling
for medical and not penal treatment. Mr. Bell,

in reply, spoke of the excellent state of English
asylums for the insane, and dwelt strongly on the
urgent need for a more humane and intelligent
interpretation of the law as to inebriate responsi-
bility.— Brit. Med. Journal.

Color Blindness and Defective Vision. —
At the last annual meeting of the British Medical
Association Mr. Bickerton, of Liverpool, di-
rected the attention of the ophthalmological sec-
tion to the prevalence of color blindness in the
merchant marine, and the insufficiency of the
tests now employed for its detection. He proved
by the inexorable logic of facts that not ovXy has
this particular variety of impaired vision been
productive of serious mischief, but that defective
"far sight" in oSicers and look-outs must clearly
be held responsible for numerous disasters at sea.
The time seems to be now ripe for parliamentary
action, and Dr. Farquharson will ask the Presi-
dent of the Board of Trade whether it is the case
that a departmental committee has been appoint-
ed to consider the whole subject, and whether
their report will be presented to the House before
the end of the present session. — D>it. Med. Joui--
nal.

Reports of Epidemics. — The French Minister
of the Interior, with a view to receiving regular
reports upon the sanitary condition of all parts of
the country, and to be able to arrest, as promptly
as possible, the spread of epidemics, has requested
the Minister of Public Instruction to call a meet-
ing of the principals of schools, in order to estab-
lish a new plan of statistics. This will consist in
a bulletin setting forth the appearance of epidemic
diseases in the schools, which shall immediately
be forwarded to the sub-prefect under cover of
the Mayor of the commune. A quarterly report
of the epidemic affections which have made their
appearance during the preceding three months is
also to be made. These statistics will be revised
in the offices of the sub-prefects and transmitted,
through the various departments, to the Minister
of the Interior under stamp of the department of
''Assistance ct dc V liygilne puhliqiies.'" — Le Bulle-
tin Medical.

A St.vtuh has been erected in Courtrai, Bel-
gium, to Palfyn, the celebrated anatomist of the
eighteenth century and Professor of the Univer-
sity of Gand.

1889.]

TOPICS OF THE WEEK.

457

TOPICS OF THE WEEK.

THE MEDICAL STUDENT OF THE FrTURE.

An editorial in the British Medical Journal of Sept
7th makes special reference to the student of the future
From it we make the following abstract ;

We may assume without the least offense that most
men enter on the study of medicine as the means of ob-
taining an honorable living ; it is not necessary to pre-
tend to any higher motives, like that which should in-
fluence a student of divinity. Yet there is room, we
maintain, for the influence of the very highest motives
in the choice of the healing art as one's calling in life ;
and the influence is likely to have an actuall)^ greater
scope, and the end is often even more likely to be
achieved, when it is concealed by the friendh' covering
of the less exalted motive.

There are hundreds of medical men in our land to-day
who lead lives of the loftiest enthusiasm, working for
the good of their fellow-men, and blessing all within the
scope of their influence, pretending with a beautiful hu-
mility that they are only following their common busi-
ness, while they are actually ministering angels. A doc-
tor may live and work for fees and be respected just as
any other servant of the commonwealth ; he maj- also
live and work for humanity and the love of his neighbor
as though he were ordained for the proper work of the
ministry'. Grand and beautiful as was the work of
Father Damien amongst the lepers of Molokai, there is
no reason why a medical man should not have done as
much, or even more. " Nothing great," says Emerson,
" was ever achieved without enthusiasm," and we know
it to be so, whatever the hard, cold world may say,
which, in truth, does not greatly care for anything which
it cannot quite understand.

What is wanted is a noble ideal ; given this, it may be
exercised as freely in our profession as an)'where in this
world of ours. What a man seeks at his medical school
this October, that shall he find. Honors, they await
him ; emoluments, they shall come ; happiness, the great
enduring pleasure that comes from a sense of duty
bravely done, this too shall be his, at the price — at a
fixed price and no abatement ; to this let him make up
his mind as quickly as may be. Let him examine him-
self and know what it is he wants ; he can certain!}- ob-
tain it. Let the lower motive content him ; he will not
be disappointed. Medicine is rich enough to pay him
for his pains ; he shall have his house, his servants, and
his gig ; shall be justice of the peace, mayor of his town,
and be held in honor of men. A man, b}- indomitable
energy and perseverence, may get all lie wants. As
Hazlitt somewhere says, he could always gain admittance
to see any famous picture in any great man's home, not-
withstanding the darkest frowns of the servants ; and he
adds that he could, by similar means, have obtained any
post under Government which he might have set his
whole mind upon.

The thing, therefore, to be sure of at the outset in de-
voting one's self to medicine is the end proposed ; if self,
then not happiness of the highest sort also ; if peace of

mind and the purest sort of happiness be the end in
view, then to live and work for others, for the advance-
ment of the profession in its widest and grandest aspects,
is the only certain way to obtain them. Old Thomas
Vicarj', chief surgeon to St. Bartholomew's Hospital,
154S-62, says in his curious Anatomic of the Bodie of
Man, that the doctor must be learned, must know his
principles, be seen in natural philosophy, in grammar,
must speak congruity in logic, speak seemlv and elo-
quenth', know things natural and non-natural, and,
above all, be good-looking, for whose face is not seemlv,
it is impossible for him to have good manners.

All this implies much more than is demanded for the
mere cramming up for professional examinations. Be
liberal in your treatment of the most liberal of all pro-
fessions, and give at least as much as you take. How
few men ever think of paying the least fraction of their
indebtedness to science ! They consider this all arranged
for in their hospital ticket. Such men
Know, not for knowing's sake ;
Know, for the gain it gets, the praise it brings.
The wonder it inspires, the love it breeds.

No man striving only for his own happiness can ever
attain it, because he is in the midst of forces contending
against him, set in motion by ever}- other man of the
same determination. Count Tolstoi has admirably ex-
plained why this struggle for individual happiness must
necessarily fail of its purpose ; and Mr. Browning, in his
magnificent poem of "Paracelsus" — which should be
known by heart by every medical student of the thought-
ful sort — has pointed out how mere knowledge for a self-
ish end can never bring happiness, whatever else it may
achieve ; but that love, allied to knowledge, can trans-
form the soul to God-like beauty. We may long, like
Paracelsus in the poem.

To wring from Heaven some wondrous good for man ;
but it may not be given to many of us to do great things.
Of every medical man, however. Society — having in
view his great endowments, his privileges, his public
estimation, and the dignity of his calling — has the right
to expect maintenance of the fabric, if not its adorn-
ment ; and, as he is necessarily looked up to as a " doc-
tor," that he shall be a real teacher how to live the high-
est mental as well as the healthiest bodily life. As Sir
J. Crichton Browne pointed out recently, this can best be
done by imbuing our own minds with the prolific and
ennobling thoughts of the wisest writers of the past and
present ; for to teach we must learn. Some will say we
ask too much of the overtaxed medical student. Not so.
The mental enlargement we demand can be had as re-
laxation between the intervals of necessary studies. One
hour a day with the great poets and prose writers will
enable the student to do better work in the medical
school ; he will not lose his time by this form of dissipa-
tion ; and when he goes into the great world which lies
outside his hospital he ma}- find his own medicine and
that of his patients in the balm for troubled spirits which
the philosophers and poets of all time stand b\' to minis-
ter. We say he will not lose his time by this expansion
of his education ; it will serve to digest his technical
knowledge, to combine and blend his studies into a truer

458

TOPICS OF THE WEEK.

[September 28,

and sounder learning than can be tested by examination
papers or rewarded by degrees.

Let no student, therefore, think that so much anatomy,
physiolog}-, medicine and surgery-, signed up and certi-
fied for at school and college, suffices to make the medi-
cal man of to-day. In one of the most suggestive of the
inaugural addresses delivered in London last October,
that by Dr. William Ewart at St. George's Hospital, this
point was strongly emphasized. We cannot refrain from
recalling a sentence or tw'O. " .\mong the 3'ouths," says
Dr. Ewart, " who elect to follow this calling, many do
so in ignorance of what the choice implies. Of no other
profession is it more true that an easy entrance examina-
tion is unkind. Ours, nowada5'S more than ever, is an
exacting profession. Although neither genius, nor bril-
liancy, nor even talent are wanted, she claims energj',
physical and mental, capacity for sustained efforts,
earnestness, and a high moral tone."

A medical practitioner whose whole life is not that of
a persevering student has no business in the profession.
A man who knows nothing but what his curriculum en-
forces, and who makes haste to forget that as soon as it
has obtained him his license to practice, can onh' bring
discredit on the high-minded and cultivated men who
spent their lives in making smooth the path he has un-
worthiU- trodden. If medicine is to hold its high posi-
tion and retain the respect in which it is justly held, the
men who are coming forward for its emoluments and
distinctions must be equipped with all the richer learn-
ing which is required to enable them to hold their own
in a world which is daily becoming more highly cultured,
and which will certainly demand more of its medical ad-
visers. A mental outlook bounded by six-ounce bottles
and an intellect from which there is gradually fading the
scanty lore gathered at the medical school w-ith much
pain and but partial comprehension far too generally
characterise the middle-aged general practitioner of
to-day. He of to-morrow will need to know more, and
to know it in quite another way.

CREOLIN IN OBSTETRICS AND GYNECOLOGY.

Dr. Theophilus PARViNhas been employing creolin
very extensively of late. He finds it valuable in cervi-
cal catarrh, in which he applies it at intervals of three
days. In the strength of one teaspoonful to a pint of
water it is use wherever a vaginal injection is indicated.
Benzoated lard with the addition of 4 per cent, of creolin
makes a reliable antiseptic ointment, useful alike to the
obstetrician and gynecologist. Parvin makes use of this
in tamponing the vagina in cases of descent or posterior
displacement of the uterus. For this purpose a long
strip of absorbent cotton smeared with the ointment is
tucked alternately into the anterior and posterior cul de
sac until the vagina is packed either partially or com-
pletely as the case requires. Such a tampon has been
left i/i situ by Dr. Parvin as long as six days, at the end
of which time the only odor detected was that of creolin.
In obstetrical practice creolin possesses the advantage of
revealing itself both by sight and smell, thus obviating

the dangers which accompany' the use of sublimate and
carbolic acid, which are often used in too strong solu-
tious. Mixed with water in the proportion of one tea-
spoonful to the pint, creolin makes a milk-colored fluid.
— Practice.

THE USE OF .\NTISEPTICS BY COUNTRY SURGEONS.

The surgeon of the city, with all his expensive appli-
ances and machinery and skilled assistance, may find the
aseptic method of treating wounds practicable; but the
country practitioner who must forego those aids, and.
who finds his patient oftentimes in anything but aseptic
surroundings, must resort to other and simpler methods.

All my surgical instruments and dressings are carried
in one small hand-bag. I have carbolic acid, tablets of
corrosive sublimate and iodoform. Needles, knife-blades
aud other small instruments are kept in a 1-60 carbolic-
glycerin solution. After using and cleansing, they are
put back into this solution, and thus are always ready for
immediate use. Other large instruments are put into a
1-40 carbolic solution some time before needing them.
My bag contains silk on a reel, and drainage-tubing, both
in a 1-4,000 solution of corrosive sublimate. Sterilized
sponges are carried in a 1-1,000 corrosive sublimate solu-
tion, and suitable pieces of oiled silk are put in the same,
some time before using.

After the flesh adjacent to the wound has been thor-
oughly washed, both skin and raw surface are bathed in
a corrosive sublimate solution, the strength varying be-
tween 1-1,000 and 1-5,000, in inverse proportion to the
extent of the raw surface. After the incisions are com-
pleted, the cut surfaces .are washed for a considerable
length of time in a 1-4,000 corrosive sublimate solution,
hot enough to check bleeding, to blanch tissue, and to
render the parts thoroughly aseptic.

For ligature I use silk, and cut the ends short. If the
wound is a large one and necessitates the use of a drain-
age tube, I do not think that it makes much difference
whether or no the ligatures are cut short. But if the
wound be small, if there be no drainage tube, or if it be
early removed, I consider that the long ends of the liga-
tures prevent absolute healing in a short space of time.
These short silk ligatures either become absorbed or en-
capsuled. They give me no trouble, and I get healing
bv first intention through the full extent of the wound,
which is not closed until every particle of oozing blood
has ceased. For healing, I depend largely on the most
careful and accurate approximation of the parts.

After the wound is closed, and thoroughly washed with
a 1-4.000 corrosive solution, iodoform is used freely, as
wounds seem to heal more kindly with it than without it.
After this a piece of sterilized oiled silk large enough to
cover the wound is applied. This is used for two pur-
poses: to prevent the sticking of the dressings, and to
keep the plasters which cannot be rendered aseptic from
contact with the wound. Over this are placed several
layers of sublimate or carbolic gauze, then a large piece
of oiled silk to cover the whole, which is bandaged in
the ordinary way. Subsequent dressings I do, if possi-
ble, myself, and make them as few and far between as

1889.]

SOCIETY PROCEEDINGS.

459

maj' be. On redressing, the wound is general!}- found to
be so clean that the usual washing is simply a process of
dampening with an antiseptic solution.

Since I began the constant and S3-stematic use of anti-
septics, I have seen most cases heal without a drop of
pus. In simple amputation I have come to expect heal-
ing by first intention except around the drainage tube,
and solid healing by from twenty-one to twenty-eight
days after operation. As a rule, I greatly prefer the ac-
tion of corrosive sublimate to that of carbolic acid as an
antiseptic. But if I know of the existence of albuminu-
ria, or suspect any latent tendency to disease or conges-
tion of the kidneys, I am ver\- careful to avoid it.

It will be seen that my method is exceedingly simple,
so simple that it would hardly be a matter of interest ex-
cept for the fact that its very simplicit)- makes it practi-
cable, and this especially adapts it to the unassisted coun-
try surgeon. It is now something over two years since I
have seen a touch of surgical fever in my own practice,
and in uncomplicated surgical cases I have rarelj- seen a
temperature above 100''. I now get healing of large cut
surfaces bj- first intention, as a rule; formerly it was the
exception. — Dr. RobT. Burns, in Boston Med. and Surg.
Jour. — Weekly Medical Review.

SOCIETY PROCEEDINGS.

Xe^v York Academy of Medicine. — Section
on Ortlioptedic Surgery.

Stated Meeting, April 19, 18S9.

A. B. JUDSON, M.D., IN THE Chair.

PSOAS ABSCESS FOLLOWING POTT'S DISEASE.

Dr. v. p. Gibney presented a patient, a girl
14 j'ears 3'ears old, on whom he had operated for
double psoas abscess following Pott's disease of
nine j^ears' duration. The carious vertebras were
evidently consolidated when last November large
abscesses were discovered, and the patient was
brought under treatment. On the right side the
tumor was incised in Scarpa's space, and long
forceps were passed under Poupart's ligament
through the iliac fossa, and into the lumbar re-
gion, and a counter opening was made on the
forceps along the border of the erector spinae
muscle. Pieces of bone escaped with the pus.
The cavity was ctiretted and the bone scraped
gentl}-. With antiseptic dressing and injections
of carbolic acid solution 1-40, and i per cent
creolin solution, both wounds closed in a month.
The left side was then operated on b5' simple in-
cision and drainage. Large quantities of bone
detritus were scooped out with the finger. A
sinus still remains on the left side, from which a
piece of bone is occasionally discharged.

The case was exhibited as showing the advan-
tage of Owen's method over attacking simply the
sac and not the whole suppurating track.

Dr. Gibney believed it would have been bet-
ter to have treated both sides according to Owen's
method ; but in general he doubted the propriety
of doing this operation during exfoliation, which
would necessitate a subsequent operation. It is
also important that the patient should be in
pretty good condition.

Dr. R. H. Sayre had used injections of per-
oxide of hj-drogeu in large abscess cavities with
better results than from carbolic, or bichloride, or
boro-salicylic solutions.

Dr. Gibney said a similar experience had been
reported b}' Dr. \'ance.

Dr. Judson thought that an objection to oper-
ating on these cases was that for the natural in-
carceration of the pus and detritus, we submitted
an artiiicial opening, necessitating antisepsis to
hasten cicatrization. If these accumulations are
doing no harm, it is better to leave them for re-
moval by natural processes ; and if in due time
they perforate the skin, the general and local
conditions are ready to promote evacuation and
speed}- cicatrization.

Dr. J. A. Wyeth said that operation is indi-
cated when large abscesses are situated ou ex-
posed parts of the body, and liable to injury and
subsequent septic complications. He recalled the
case of a woman who, thirteen years after being
considered cured of Pott's disease, slipped and
fell, striking a large gluteal abscess. The acci-
dent speedily gave rise to symptoms of sepsis
with high febrile movements, and several opera-
tions under ether were necessarj^ for the removal
of bone detritus which was spread through the
gluteal muscles. The patient ran great risks, but
finally recovered. He had had other similar
cases. A psoas abscess behind the peritoneum
causing no trouble, should be left alone, but one
pointing in the thigh, back, or other exposed
situation, should be operated upon, as the dan-
ger of the operation is almost nil.

Dr. N. M. Shaffer was reminded of the his-
torj^ of a patient with Pott's disease and an ab-
scess occupj'ing the gluteal region and the an-
terior part of the thigh. The child fell, striking
the gluteal tumor. The immediate s^'mptoms
were alarming, but without the adoption of any
special treatment, the accident resulted iit the en-
tire disappearance of the abscess. If there were
any means of determining with certainty when
an abscess from Pott's disease contains bonj^ de-
tritus, it would be preferable to operate ; but
while spondylitis is still active, it is better to
postpone operating as long as possible. He re-
called a case of Pott's disease and hip joint
disease which he had been watching for several
years, where spiculse of bone as large as the end
of the finger were expelled in a sudden and vio-
lent attack of coughing. The bone was un-
doubtedly from the cancellous structure of the
sixth or seventh cervical vertebra. The patient

460

SOCIETY PROCEEDINGS.

[September 28,

was relieved at once, and physical examination
showed that ver\' little trouble had been caused
b}' the entrance of the bone through the lung tis-
sue into the bronchial tubes.

KNOCK-KNEE ; CLUB-FOOT ; DEFORMITY FOLLOW-
ING HIP DISEASE.

In a paper on " Osteotomj-," Dr. Wyeth re-
lated two cases in which he had corrected in- and
out-knee in the same patient bj' double osteotom-
ies. The patients were 3 '2 and 4 j^ears old
respectivelj'. Both were discharged entirely re-
lieved. Strict antisepsis was followed and the
limbs were dressed in plaster of Paris in a posi-
tion of over- correction. He prefers MacCormac's
incision on the outer side and just above the cap-
sule, since the saphena vein and anastomatica
magna arter\' are not endangered as in McEwen's
operation on the inner aspect of the thigh. He
also briefly related three cases in which patients,
aged 13, 18 and 26 years respectively, had been
relieved of the deformity following hip disease, j
and restored to good locomotion bj- operations on
the femur. The method pursued was Gant's
osteotomy below the lesser trochanter. The after ^
treatment had been Buck's extension and Hamil- '
ton's long splint. In one of the patients there
had been double hip disease. Two months after
the left femur had been operated on, the right
was operated on ; and four months after the date
of the first operation the patient was discharged
cured, with good locomotion.

He also related two cases in which congenital
talipes equino -varus of the most exaggerated
type had been corrected with good recoven,-, and !
with the feet in excellent shape. Tenotomy of
the tendo Achillis, tibialis anticus, and tibialis'
posticus was first done ; the first two subcuta-
neously, and the last b)' open incision, the ten-
don being dissociated from that of the flexor dig-
itorum, and divided on an aneurism needle. The
operation was completed b}' an osteotomy as fol-
lows : An incision was made on the outer side of
the dorsum, exactly over the point of greatest
convexity ; the tissues were lifted from the tarsus '
by an elevator, and a conical section including
portions of the calcaneus, astragalus, cuboid, and
scaphoid was removed. The rule should be to
remove all parts which prevent replacement of the
foot. The foot being brought into normal posi-
tion bj' eversion and rotation, aseptic dressing
and plaster of Paris completed the treatment, the
result of which was excellent.

Dr. Gibney said that the anatomical point
raised in the paper concerning supra-condyloid
osteotomies certainly commends to us the opera- i
tion of MacCormac. Although in- and out-knee
in the same subject is rare, he had seen many in-
stances of multiple deformity among Bohemians
and Italians. He had recently done a sextuple
osteotomy at one sitting, and is

united fracture of the right tibia, all the others
having united.

Dr. Judson thought that in congenital talipes
the reduction of the deformity by mechanical or
operative means is easj' ; but that is a small part
of the necessary treatment. So long as the pa-
tient is growing he must be under occasional ob-
servation, and if necessary made to wear for a few
months, at intervals of two or three years, a brace
fitted to the present needs, in order to prevent
threatened relapses. In the deformities of the
knee there is especial reason for preferring me-
chanical means of correction, because here we
have the advantage of the leverage found in the
tibia and femur, while in club-foot there is only
the tibia on one side, and on the other the short
and many-jointed foot.

Dr. H. L. T.\ylor said that late observation
of the results of treatment is of especial impor-
tance in orthopsedic practice. If surgeons and or-
thopaedists would report the condition of patients
five, ten, or more years after dismissal, a more in-
telligent choice of methods could be made.

Dr. Sh.^ffer said that his experience with
mechanical appliance in the treatment of talipes
leads him to think that manj- severe operations
are performed on patients .who could be better
treated bj' traction. He recalled a case in which
there was confirmed equino-varus, although three
or four tenotomies and five or six osteotomies
had been performed. He had applied the "ex-
ternal lateral stretcher ' ' and the patient is now
walking on the flat of the foot. He referred to
the interesting question whether osteotomj' is ad-
visable when there is motion in the hip -joint. In
a patient, on whom Dr. W. T. Bull had operated,
some motion was found after etherization. The
reduction of the deformity by osteotomy had been
followed by persistent traction with the hip-
splint ; and good position and slight motion had
both been retained.

Dr. Gibney believed that the presence of mo-
tion is not a contra-indication to the operation.
About six months ago he had performed Gant's
operation for a right-angled deformity. The
flexion had been reduced from 90° to 15°, and
the limb was retained at 15° of flexion by a trac-
tion apparatus for three or four months, when it
was removed and the patient allowed to walk
about with a high shoe. After about six weeks
the flexion had increased to 25° or 30°. Trac-
tion was re-applied, and the limb is being again
brought down. He recognized the necessity of
protective apparatus in order to retain or increase
the result secured by operation.

Dr. Wveth had operated in several cases
where there was motion and had refused to do it
in others. In a patient whom he had seen with
Dr. L. A. Sayre, there was considerable motion,
and he had done a tenotomy for temporarj- relief,
postponing osteotomy.

1889.]

SOCIETY PROCEEDINGS.

461

Dr. R. H. Sayre said that in the case re-
ferred to, improvement had followed the tenot-
omy, but an apparatus is necessary to prevent a
return of deformity. He thought that in some
cases suiBcient reduction of the flexion might be
brought about bj- section of the psoas and iliacus
muscles. This had been done in one case in
which, although the operation had been subcuta-
neous, injury of the vessels had been avoided.
By open section this danger would be avoided.

Dr. J. D. Wilson expressed surprise at the
frequent mention of elevations of temperature in
the historj' of Dr. Wj-eth's cases, which had been
treated antisepticall3\ Have our teachings been
too absolute, or do such temperatures reallj- in-
dicate imperfect antisepsis ?

Dr. Wyeth replied that the "temperature of
reaction," occasionally as high as 102°, occurred
in the first twenty-four hours, but it usually fell
to normal in forty-eight hours. Traumatism,
ether, shock, and the use of sublimate combine
to produce this reaction, which might still be
called an aseptic temperature. He closes the dis-
cussion by saying that the simplicity and safetj^
of osteotomy had been shown by the cases he had
reported. While no case of equino-varus treated
the first two years of life should require tarsotomy,
neglected cases will present themselves where
nothing but tarsotomy will give relief. The
operation may give considerable foreshortening
to the foot, but one can certainly correct the de-
formity, however great, by removing enough
bone ; and if this be properly done, he believed
it to be real consen'atism.

Association of American Pliysicians.

Fourth Arinual Meeting, held in the Ai-my Medical

Museum and Library, IVaslmigton, D. C,

Septe7nber 18, ig and 20, 1889.

Wednesday- — Morning Session.

The Association was called to order at 10 a.m.
by the President, Dr. Francis Minot, of
Boston.

The first business was the reading of the Pres-
ident's Address:

the progress of medicine during the last
fifty years.

The immediate causes of the great advancement
of medicine were the growth of physiologj- and
pathology, including bacteriology, and the im-
provements in clinical and laboratory teaching of
the present day, which have led to a better ac-
quaintance with the nature and causes of disease,
to a more rational and successful therapeutics,
and to the prevention by means of h}^giene of a
large number of diseases, including some of the

most fatal. These means have been greatly aided
by the progress of science in general and by the
conveniences of modern civilization, which ena-
ble observers from different countries to assemble
together for interchange of knowledge and expe-
rience. A large share of medical progress is also
due to the dissemination of knowledge by means
of well conducted journals which enable thousands
of practitioners who cannot leave their homes to
be constantly supplied with the most recent dis-
coveries relating to pathology and the diagnosis
and treatment of disease. The organization of
this Association is peculiarly adapted for the
progress of medical science, representing no one
section of our country, but including practitioners
from all parts of the United States and Canada,
whose experience, knowledge, obser\-ation and
ability are brought together for comparison and
for mutual instruction.

The President reported the death of the fol-
lowing members : Drs. H. D. Schmidt, New Or-
leans ; John C. Dalton, New York (honorary
member) ; Robert Palmer Howard, Montreal ;
and Edward T. Bruen, Philadelphia.

Dr. C. F. Folsom, of Boston, read a paper en-
titled

THE EARLY STAGE OF GENERAL PARALY'SIS.

The author first reported a number of cases il-
lustrating the early stage of the disease in which
the motor disturbances were verj' slight and might
readily be overlooked and escaped detection. The
striking loss of muscular control or power, gener-
ally considered a part of the disease, were not
found until a late period of the disea,se. The
mental symptoms consist in impairment of a pe-
culiar quality, often so slight as to be made out
with difficulty.

The disease arises most commonly under pro-
longed strain, particularly when associated with
unaccustomed excesses. At least two-thirds of
the general paralytics have had syphilis. The
relation of the disease with syphilis is too fre-
quent to be accidental. The disease is, however,
not a stage of .syphilis, and is not benefited by
specific treatment. The prognosis is probably not
so hopeless as it is generally considered to be.

The common early treatment is harmful. For-
eign travel is injurious. The onlj' hope of at
least partial cure or marked amelioration is in en-
tire mental and phj^sical rest.

Dr. Robert T. Edes, of Washington, report-
ed the case of a man suffering from pronounced
general paralysis, in whom the first symptoms of
the disease made their appearance some twenty
years ago. If the anatomical view of general
paralysis is accepted he did not consider it strange
that mental symptoms might precede the motor,
depending upon the seat of the lesions.

Dr. S. Weir Mitchell, of Philadelphia, was
sure that certain cases of general paralysis began

462

SOCIETY PROCEEDINGS.

[September 28,

most markedly with motor trouble, while others
began most decisiveh' with mental conditions.
In regard to sj-philis he agreed with the author,
except that he had seen cases due to syphilitic
disease in which cure had followed specific treat-
ment. He had also seen cure follow in a small
number of cases where the treatment was begun
in the early stages, but where the motor disturb-
ances and the mental incapacity were sufficientlj'
marked to render the diagnosis reasonably certain.
In all of these cases there had been a total aban-
donment of all previous pursuits with absolute
mental and physical rest. He agreed with the
author that foreign travel was often injurious.

Dr. James J. Putnam, of Boston, remarked
that the fact that .sj'philis acts in this disease not
by producing a direct lesion, but in an indirect
manner, justifies us in looking for other causes of
degeneration which might act iu a similar man-
ner. He asked if the reader had seen any cases
in which chronic lead poisoning was the apparent
cause of the general paralysis, and related a case
in which the imperfect and slow speech, the im-
perfect handwriting and the" expression of apath}'
and indifference suggested a diagnosis of general
paralj-sis. In this case there was, however, a his-
tory of drinking of water contaminated with lead,
and there were certain local symptoms indicating
lead poisoning.

Dr. \Vm. Pepper, of Philadelphia, believed
that he saw these cases from a diiferent standpoint
than that of Dr. Folsora. They came to him as
cases of dyspepsia, lithasmic disturbance and the
like, and are under his care for some time before
symptoms leading to recognition are developed,
sometimes for years before the paretic sj'mptoms
appear. He could not regard syphilis as in any
waj' essential in the causation of general paralysis.

In regard to the earh' stage of the disease, there
was not one sj^mptom mentioned by Dr. Folsom
or described by others as indicating the early
stage, which he did not often find in cases of ner-
vous lithsemia. There may be a grouping of
these symptoms or a discovery on the part of
the diagnostician which will enable a finer and
finer shade of these differences to be recog-
nized, which does constitute a basis of diagnosis.
He thought that general paralysis could be initi-
ated b}' manj' disturbing, depressing or irritating
causes, and that in its early stages and slight de-
grees it was capable not rarely of being entirely
cured. If these cases are permitted to go on with
neglect of hj-gienic habits and with excesses, sex-
ual, alcoholic or business, a notable proportion
will end with symptoms of general paralysis.

Dr. C. F. FoLsrai, of Boston, said in regard to
lead that while he had .seen cases in which this
agent had produced sj'mptoms similar to the ini-
tial symptoms of general paralysis, he had not
seen a case in which the terminal symptoms of
general paralysis had been produced. As illus-

trating apparent cures after specific treatment he
referred to a case in which the use of large doses
of iodide of potassium apparently produced com-
plete recoverj', and the patient returned to his
previous business. The symptoms after several
months reappeared and had continued to steadily
progress. Whether this is the result in all such
cases, he was unable to say.

Dr. James Stewart read a paper on

TETANY.

The details of the following case were referred
to:

The patient, a male, aged 40, has been troubled
during the past eight years with regularlj- recur-
ring attacks of tetan3\ He served as a soldier
during the American civil war. Suffered at that
time and subsequently from chronic dj-sentery
and malarial attacks. For upwards of ten years
he has been troubled with diarrhoea. Patient is
tall, emaciated and anaemic. The first subjective
symptom of his tetany is usually double vision,
which is quickly followed bj- the characteristic
contractions of the flexor muscles of the hands.
Occasionally the flexors of the fore-arms and the
abductors of the arms become spastic, muscles of
the face almost constantly suffer, muscles of the
lower extremities rarelj'.

The affected muscles are the seat, during the
attack, of fibrillary twitching. The attacks often
last several days (seven to twelve), unless termi-
nated bj' the ven,' free use of morphia.

The galvanic irritabilitj' of the nerves is found
to be greatly increased, also the mechanical irri-
tability of both nen-e and muscle. Knee-jerks
exaggerated during attack, absent in intervals.
CEdema of the hands and arms, with herpetic
eruptions frequently to be seen after particularly
severe attacks. The quantitj* of urine excreted
during attacks is usually normal in amount, and
contains urea and indican in great excess. Pa-
tient has been under observation for more than
three years, and it has been noticed during the
past two years that he has been getting gradually'
dull and apathetic. It takes him a long time to
answer questions, he complains of general numb-
ness, his face and lips are swollen, symptoms
closely resembling those seen in myxcedema.

Tetany may be divided into three varieties :

1. Epidemic or "rheumatic" tetany, common
in Europe, but extremely rare in America. The
course is acute and favorable.

2. Tetany from exhausting causes, as lacta-
tion, diarrhoea, etc. Course is chronic and favor-
able.

3. Tetany from removal of the thyroid glands.
Course generally is usually either quickly fatal
or chronic and incurable.

4. A form of tetany occurring in cases of dila-
tation of the stomach. Very fatal.

Infantile tetanj' is excluded from above di-

1889.

SOCIETY PROCEEDINGS.

463

vision, as what is so frequently called tetany in
infants is not that disease. No doubt true tetany
may occur in childhood.

Dr. John T. Carpenter, of Pottsville, Pa.,
read a paper on

TETANY .\ND A NEW THEORY OF ITS P.^THOLOGY.

The author defined tetany as a nervous disor-
der accompanied by tetanic spasm of an inter-
mittent character, which maj^ extend from the
extremities to the jaw and be reproduced during
the periods of intermission at will bj' pressing
sure on the trunk of the afl^ected nerve trunk or
over the blood vessel obstructing the circulation.

A historical version of the disease was given.
Tetanj- was regarded not as a special disease, but
as a sequel of precedent phenomena only. The
affection was regarded as the result of septic ab-
sorption. The diminution of cases of tetany co-
incident with the successful treatment and the
prevention of septic poisoning, was regarded as
an argument in favor of the connection between
septicaemia and tetanj'. Cases illustrating this
view were cited. The views previously held in
regard to the pathologj' of tetanj' were discussed
and considered as tenable.

Dr. Francis P. Kinnicutt, of New York :
I have seen but two cases of intermittent tetany,
both occurring in patients with dilatation of the
stomach. In one the dilatation was due to
pyloric stricture resulting from cancer ; in the
other there was non-malignant stricture. In both
of these cases the conditions were favorable to
absorption of poisonous matter.

Dr. F. T. Miles, of Baltimore, reported the
case of a young woman, aged 22 j'ears. vShe had
suffered from six to eight years from dilatation
of the stomach. She had vomited acid matter,
but never offensive. She had several times had
numbness of fingers and toes. She suffered her
first attack of tetany twenty-four hours before
her death. In this case the stomach had never
been washed out.

Dr. a. Jacobi, of New York, had been struck
with the stress laid by the readers upon sepsis as
the cau.se of tetany. In one of the cases reported
by Dr. Stuart which he thought was due to ab-
sorption of putrid material, the stomach was
twisted, and Dr. J. suggested that the intermit-
tent contracture was due to nervous influence, re-
sulting from the twisting rather than to absorp-
tion. He did not doubt that there were cases in
which .septic absorption produced such symptoms,
but when we recall the fact that the contracture
is temporary, we must conclude that the in-
fluences giving rise to that attack were also tem-
porary. Many of these cases are, I think, the
result of ner\'ous irritation. In some of the
cases reported I should attribute the condition to
ansemia.

Dr. J.\mes J. Putnam, of Boston, remarked

that the reported cases of tetany showed such a
varietj' of infectious sources, that it seemed
hardly probable that they should act in such a
similar manner unless there was something else
behind. Two or three things are to be con-
sidered : First, the influence of habit. The dis-
ease -set up by a variety of causes ma\' continue
as a result of habit. Second, the suggestion that
in such cases of disordered action we have to
deal with an over-sensitiveness of physiological
arrangement is important. In these conditions
we have the disordered manifestation of what is
really a function, but one not ordinarily rec-
ognized as it has no independent existence. It
would seem that in the absence of further knowl-
edge with regard to infection, and the manner
this infection arising from various sources may
act, we should insist upon the possibilities of ex-
planation which are presented to us by what we
know of the physiology and disordered physiol-
ogy of the nervous system, in attempting to ex-
plain conditions met with in this and similar dis-
eases.

Dr. James Stuart, of Montreal, said in con-
nection with the influence of peripheral irrita-
tion, that in the cases of dilatation of the
stomach where tetany had caused death, the
symptoms came on five hours after the stomach
had been washed out. This would point to irri-
tation rather than decomposition as the active
cause in this class of cases. There are many
other cases were infection could not enter.

Dr. John T. Carpenter, of Pottsville, said
in regard to anaemia as the cause of tetany, that
we should have to go back of the anaemia to the
cause that produced it. He knew of no cause
that would produce anaemia so surely as septic
absorption.

Afternoon Session.
Dr. a. B. Ball, of New York, read a paper
on

thrombosis of cerebral sinuses and veins.

The author first referred to the influence of the
following factors in the production of thrombosis :
I. Blood stasis ; 2. Vessel lesions ; and 3. Blood
changes. The anatomical conditions in the
sinuses that favor thrombosis were described at
length. A number of cases of marantis throm-
bosis of cerebral veins and sinuses in chlorotic
girls.

The symptoms were next considered. Much
importance has been attached to distension of ex-
ternal veins collateral to the internal veins sup-
posed to be affected, giving rise to haemorrhages
and oedema. These signs are frequently absent
and may be due to other conditions. The mo-
bility of the symptoms has been considered of
value. In these cases the cerebral symptoms
undergo strange alterations not seen usually in
other affections. Active delirium is exceptional.

464

SOCIETY PROCEEDINGS.

[September 28,

The depression continues but alternates with a cer- 1
tain amount of impro\-ement. Fever is absent at ,
first, and if present is to be attributed to complicat-
ing conditions. Paralytic symptoms of varying ex-
tent are usually present. With the exception of
the variation in degree the paralysis does not
differ from paralysis from other causes.

Dr. Willam OslER, of Baltimore, exhibited
two specimens illustrating the conditions de-
scribed by Dr. Ball. The first specimen was one
of extensive thrombosis of the lateral sinus occur-
ring in a man who died from phlegmonous ery-
sipelas of the cheek. There were no special
symptoms in that case.

The second specimen was from a woman dying
of consumption. It was thought that gradually
increasing coma and the onset of cerebral symp-
toms were supposed to be due to basilar menin-
gitis.

Dr. a. Jacobi, of New York, enumerated cer-
tain additional aiding causes. The first was a
disproportion between the white and red blood
corpuscles. The second cause was the relative
absence of muscular tissue in a number of the
veins. A third cause was absence of water in
the blood, often due to the withholding of suf-
ficient fluid in the diet of patients. The last
cause referred to was weakness of the heart.
When in exhaustive diseases the heart is allowed
to become feeble, thrombosis, with all its bad re-
sults, must be expected. It is certainly a good
therapeutic measured to stimulate and strengthen
the heart in every disease that will last long or
tends to terminate in exhaustion.

Dr. Wm. H. Welch, of Baltimore, said :
There is one point of great force in explaining
the production of thrombosis ; that is the possi-
bility that there is some form of intoxication
analogous to that produced experimentally by
various substances, such as the fibrin ferment.
Under such circumstances there is almost instan-
taneously extensive thrombosis wherever the fer-
ment reaches. Pathologists are aware of the fre-
quency with which thrombi, usually of a mixed
character, are found in the cerebral sinuses, par-
ticularly the superior longitudinal sinus, in cases
that have presented no symptom during life.

Dr. Samuel C. Busey, of Washington, D. C,
read a paper on

THE EFFUSION OF CHYLE AND OF CHYLE-LIKE,
MILKY, FATTY FLUIDS INTO SEROUS CAVITIES.

The object of the paper was to present the sub-
ject of effusion of chyle, chyle-like and fatty
fluids into serous cavities. It was limited to the
eff"usion of such fluids into the cavities of the
pleuro-peritoneum and tunica vaginalis.

Effusion into the pleural cavities, Chylo Thorax.
Of this, including the doubtful cases, there have
been ten cases reported. In five of these the

chyle poured directly from the thoracic duct.
The diagnosis in these cases can only be made
by evacuation and examination of the fluid. The
prominent symptoms are dyspnoea and accumu-
lation of fluid iu one or both cavities. The prog-
nosis is unfavorable and the treatment expectant.

Effusion into the tunica vaginalis testis. — The
case of galactocele reported by Vidal (de Caasis)
seems to have been the first observation of this
class of efi"usions. In two of the reported cases
the paludous orifices of the vessels from which
the lymph exuded were found. Since 1885 there
have been reported in this country thirteen cases
in which filaria were found, and two of these
were cases of lymphocele. It has not been
shown, however, that filaria are present in every
case of lymphocele. The recent invasion of por-
tions of the sub- tropical belt of this country bj'
the filaria, and the reports of cases of disease
with which the parasite has been ^o uniformly
associated, together with the fact that the mos-
quito has. been proven to be its intermediate host,
present consideration of the highest importance
to the profession and general public.

Chylous and oily ascites. — A tabulated state-
ment arranged chronologically, presenting a con-
densed summary of the reports of cases of chylous
and oily ascites, was given. The number of
cases reported was thirty-three. Primary rupture
occurred in but five cases.

The symptomatology of efi'usion of chyle into
the peritoneal cavity is not sufficiently distinctive
to difierentiate such cases from ordinary ascites,
and a diagnosis is only possible after examina-
tion of the evacuated fluid. Of the 33 cases 19
died, 9 recovered, and in 5 the result is not stated.
Of the 22 cases of chylous ascites proper 12 died,
5 recovered, and in 5 the result is not stated.
Meagre and unsatisfactory as are the clinical de-
tails of these cases, they point to two conclusions:

1. That a free and unobstructed channel of com-
munication between the venous system and the
chyle conveying vessels is essential to the proper
nutrition of the body and preservation of life.

2. That death following the partial or complete
obliteration of this communication is the result
of inanition.

Dr. Wm. OslER, of Baltimore, said that in or-
dinary post-mortem works it was not unfrequent
to meet with varices of the chyle vessels of the
mesentery covering the walls of the intestine.
Sometimes there are extravasations which may
form large chylous cysts.

With reference to chyluria he was positive that
there was a non-parasitic form. He had made
thorough examinations in one such case and
failed to find filaria. On post-mortem examina-
tion nothing was discovered. Also in a case of
lymph scrotum, he had examined the fluid and
the blood and had found no embryos. He laid a
great deal of stress upon these cases, as it is gen-

1889.]

DOMESTIC CORRESPONDENCE.

465

erally stated that these conditions are always
parasitic.

Dr. W. H. Welch, of Baltimore, exhibited a
specimen of chyle removed from the abdominal
cavity of a boy 12 years of age. He described
the chemical and microscopical characters of the
fluid, and dwelt upon the importance of dis-
tinguishing between chylous and fatty hydrops.

Dr. J. F. A. Adams, of Pittsfield, Mass., read
a paper on

SUBSTITUTES FOR OPIUM IN CHRONIC DISEASES.

The disadvantages attending the use of opium
are : i. In an overdose it is a poison. 2. In or-
dinary doses its benefits are largely offset by va-
rious functional derangements. 3. Its use involves
the danger of the opium habit.

Remedies that may be substituted for opium
for the relief of pain. The antipyretics, antipy-
rin, acetanilide, phenacetin and exalgiu have
well grounded claims to be regarded as rivals of
opium. They are, however, less certain and less
prompt, particularly when pain is very violent.
Antipyrin in five to ten grain doses had been
found valuable as an analgesic particularly in
headache, neuralgia and rheumatism.

Acetanilide he had found less active than an-
tipyrin. He used it in doses of seven or eight
grains. He had found it particularly serviceable
in lumbago and dysmenorrhoea. In the latter
condition one or two doses has afforded prompt
relief.

Salicylic acid and its sodium salt should be in-
cluded on account of their marked effect in the
relief of pain in rheumatism, particularly its acute
form.

Substitutes for ophim to induce sleep. — Paralde-
hyde is an excellent hypnotic, although rather
uncertain. Hydrate of amyl is generally prefer-
able to paraldehyde, being more reliable as well
as more agreeable. Sulphonal is more extensive-
ly employed than either of the above, and is
applicable to all forms of insomnia.

Chronic diarrhcva. — It is probable that no rem-
edy has been used in this affection so largely as
opium. The effects of this mode of treatment
have been far from satisfactory. Recently the
author had treated these cases antiseptically with
far better results. The remedy chiefly used has
been sodium salicylate in five to ten grain doses
three or four times a day. He had also used
salol with success.

Dr. G. M. Garland, of Boston, referred to
the value of the fluid extract of gelsemium as a
substitute for opium. In frontal headaches it
has an admirable effect. It is used also with ad-
vantage in difficult and painful menstruation and
certain forms of neuralgia. As a simple hypnotic
gelsemium answers well in cases of temporary
congestion with insomnia and headache. In hys-
terical conditions this agent will often induce

sleep in a short time. The drug is given in doses
of five to ten drops every half hour until the de-
sired effect is obtained or its phj'siological effect
is produced in diplopia and ptosis. These appear
sufficiently early to ser\'e as a warning.
\To be concluded.)

DOMESTIC CORRESPONDENCE.

LETTER FROM NEW YORK.

(from our own correspondent.)

Meeting of the Fifth District Branch of the A^ew
York State Medical Association — The E.xcursion
to Milford, Pa. — Mr. Rudolph Hering' s Report on
the Sewage System of Neiv York — The Suicide of
Dr. Tilden Brozcn — The Power of an Artificial
Electric Current to Destroy Life.

The seventh special meeting of the Fifth Dis-
trict Branch of the New York State Medical As-
sociation was held at Port Jervis, Orange County,
the last week in August. The place of meeting
was the parlors of the Fowler House, and the ses-
sion was one of interest both from a scientific and
social point of view. The first paper was bj' Dr.
W. B. Eager, of Middletown, on "The Use of
Concentrated Lactic Acid." He had employed
this agent with success in the case of epithelioma
and other conditions, and, in fact, wherever acetic
and nitric acids are generally used as escharotics.

Dr. J. H. Hunt read a paper on "The Treat-
ment of Typhoid Fever, ' ' with special reference
to the cold water method. It was accompanied
by carefully prepared charts, with details of tem-
perature, pulse, etc., and elicited a prolonged dis-
cussion, in which many valuable points were
brought out. Dr. Alfred L. Carroll, of New
York, exhibited a small and inexpensive appara-
tus, devised by himself, for the rapid estimation
of C0„ in atmospheric air. He said that the ap-
paratus generally used was more or less expensive
because the jar was accurately divided off into
cubic centimetres, and on account of the accom-
panying mechanical contrivances. This one was
made out of an ordinary pickle jar, a couple
of rubber or cork stoppers, two or three feet of
small rubber tubing, and three or four pieces of
best glass tubing. Dr. H. B. Swartout, of Port
Jervis, then read the notes of a case of empyema.
The patient was presented for examination by
those present, and the case was discussed at some
length. An elaborate paper by Dr. T. H. Man-
ley, of New York, who was unable to be present,
on "Injuries of the Skull, with some Observa-
tions on One Hundred and Fourteen Cases, was
read by title, on account of the lateness of the
hour, and the Branch then adjourned, after a very
interesting session.

Almost forty Fellows attended the meeting, and

466

DOMESTIC CORRESPONDENCE.

[September 28,

a considerable number of them remained over
night to go on a most attractive excursion to Mil-
ford, Pa., and the Sawkill Falls beyond, which
had been provided b}' the Committee of Arrange-
ments, of which Dr. J. H. Hunt, of Orange Co.,
was chairman. The company occupied two large
eight-seated wagons, and thoroughly enjoyed the
magnificent drive, over a road that might com-
pare in smoothness with those in Central Park,
through one of the most romantic regions in the
country. Milford has always been noted for its
exquisite scenery, which has long made it a fa-
vorite resort for artists, and on account of the nu-
merous rains during the past summer, the rich
foliage and the manj^ beautiful mountain streams
were at their ver}- best. The weather was delight-
ful, making every one feel in the most jovial spir-
its, and after their exhilarating drive to the north
Sawkill Falls, the party enjoyed to the utmost the
.elaborate and 'appetizing supper which had been
provided for them at the famous Fauchere House.
There was then a pleasant evening ride of seven
miles back to Port Jer\MS, after which everj'bodj'
was ready to sleep the sleep of the just.

The next morning Dr. Hunt furnished a sumpt-
uous breakfast in his little Memorial Hospital at
Port Jervis, and after the night's refreshing slum-
ber the company did ample justice to the many
good things provided by his bountiful hospitality.
It was a ver\- informal repast, and the occasion
was one of social pleasure which will long remain
green in the memories of those who were present.
The Hunt Memorial Hospital, which has oulj' re-
cently been erected, although small, is one of the
finest and most completely equipped in the State,
and its many admirable appointments and appli-
ances were inspected with much interest; after
which this pleasant outing came to an end, and
all parted well pleased with the success of the
seventh special meeting of the Branch.

About two years ago General Newton, Commis-
sioner of Public Works, secured the services of a
civil engineer of high repute, Mr. Rudolph Her-
ing, to make a thorough examination of the sew-
age system of the city, and his carefully prepared
and elaborate report — the only complete one on
the matter that was ever made, has recently been
submitted to the present Commissioner, Mr. Gil-
roy. In it Mr. Hering makes a detailed state-
ment of the present condition of the sewers, and
also expresses his opinion as to the measures that
should be adopted for their improvement and the
best means of keeping thera in good condition.
Upon the subject of flushing and cleaning he be-
lieves that rainstorms cannot be relied upon for
this purpose, and that repeated flushing with prop-
erly proportioned quantities of water is required
for pent-up .sewage. By this process, he says,
sewage may not only be kept much cleaner than
at present, but stoppages and floodings caused by
the accumulation of deposits can be reduced to a

minimum. Deposits become too firmly compact-
ed, he claims, to be carried off by the average
storm; while flushing, on the other hand, prevents
deposits from accumulating. In other cities, ac-
cording to the character of the district in which
the sewers are placed the periods of flushing vary
from once a fortnight to about once a year. In
some places automatic flush tanks are used which
discharge once or twice a day. The sudden dis-
charge of a large quantity of water seems to him
to be the thing desired. In the case of those sew-
ers in the older part of New York which cannot
be flushed because their interior surface is rough
and irregular, manual labor is the only remedy
until the}' can be rebuilt. Mr. Hering advises
that gates should be provided in the main sewers
in order to stop the ordinary flow of water for five
or six hours before flushing ; no other provision
being necessary for accomplishing this purpose.
The gates could be closed in the morning, and
opened in the afternoon. He claims that if all
the brick sewers were thus cleansed the j-early
expense would be about $11,000 ; while at pres-
ent only about one-twentieth of the brick sewers
are cleansed once a year, at an expense of over
$23,000.

Chief Engineer Horace Loomis, in charge of
the Bureau of Sewers, in commenting on this part
of Mr. Hering's report, has stated that he should
be very much pleased to give his device for flush-
ing a trial, but that the expense would be greater
than Mr. Hering supposed. "According to his
estimate," Mr. Lewis said, " it would cost about
$21,000 a year to clean' all the modern brick sew-
ers twice a 3'ear and all the pipe sewers four times
a year. For the construction of the gates which
he recommends, however, the original outlay
would be quite large. It would probably cost
about $250 each for the gates and flushing cham-
bers, and as a gate would be required for every
thousand feet, this would impose an expense of
$1,250 for each mile of sewer. As there are about
400 miles within the city, the original cost of pro-
viding for this manner of cleaning and flushing
would be $500,000, and the interest on that out-
lay ought to be considered a part of the expense
of operation. These figures will indicate that
whatever may be done in this direction will have
to be accomplished gradually."

Having mentioned one particular sewer which
he thought especially adapted to make an experi-
ment of the gate system in, he stated that if on
trial it should be found to be successful there,
there would be reason to hope that the depart-
ment might be allowed to extend the system to
other parts of the citj'. He then went on to saj-
that he could foresee more possible dangers from
the new system. Whenever sewers were extend-
ed through a low-lying district in which the cel-
lars were below the .sewer level, he thought a
flushing would make things very uncomfortable

1889.]

DOMESTIC CORRESPONDENCE.

467

for people living above these cellars. There
■would also have to be special care taken, he said,
that the flushing should take place when the tide
was just right. Moreover, a shower would be
liable to cause flooding when the gates were
closed, and he therefore thought that with any
such change in the sewer system back-water
valves ought to come into general use.

It is certainly a curious circumstance that so
soon after the inter\-iew with Dr. D. Tilden
Brown, referred to in The Journal of September
7th, the Doctor should have committed suicide.
On Wednesday night, September 4th, the unfor-
tunate man hanged himself in his barn at Bata-
via. 111. A few j-ears ago Dr. Brown was well
known to the medical profession in this State
and throughout the country. For twentj' years
previous to 1875 he was Superintendent of the
Bloomingdale Asylum, the department for the
insane of the New York Hospital, and was re-
garded as a high authority in mental diseases.
In 1875 a New York newspaper began a fierce
assault upon the Bloomingdale Asylum because
of alleged abuses existing there, and it is said
that this attack so affected Dr. Brown that his
health failed and his mind became unbalanced.
In this condition his wife took him abroad for
treatment. His insanity was of a mild form, and
in an Edinburgh asylum a partial cure was
effected. On their return to America he was
placed in an asylum in Illinois, where his wife
secured the position of matron for herself, and
here what was believed to be the complete cure
of the case was brought about. His son. Dr. F.
T. Brown, lives in this cit}'.

In an interview published since the suicide Mr.
Charles E. Strong, who for the past twenty years
has been one of the Board of Governors of the
New York Hospital, thus refers to Dr. Brown
and his sad historj' : "He was as competent a
superintendent as Bloomingdale ever had. At
the time of the exposure of alleged outrages there
the confidence of the Governors in his integrity
was never shaken. His only fault was that of
over-confidence in his subordinates. He was a
particularl}^ sensitive man, however, and it was
undoubtedl}' these attacks which made it neces-
sarj^ for him to go abroad for treatment. Since
his return to America he has been in constant
communication with his friends here. About
two weeks ago a New York newspaper printed a
sensational storj-, the substance of which was
that Dr. Brown, the old Superintendent of the
Bloomingdale Insane Asj-lum, who had himself
become insane in 1875 and gone to Edinburgh
for treatment, where it had been supposed by all
his friends that he had died, had been discovered
living on a farm at Batavia. If Dr. Brown has
committed suicide, I believe it was for the reason
that this storj-, in which the sadde.st portion of
his life was reviewed, was called to his attention.

and the shock brought back his old mental affec-
tion. He was highly respected in Batavia, where
he was practicing medicine with success."

Another of the now often repeated demonstra-
tions of the force of an artificial electric current
to destroy life was recently afforded in the dyna-
mo room of the East River Electric Lighting
Company in this city, where an experienced elec-
trician, the Superintendent of Construction of the
compan3', accidentall)' came in contact with the
current and was struck dead in an instant. It
was an alternating current and its force was in
the neighborhood of 1,000 volts, considerabh^
less than it is proposed to use in executing crim-
inals under the new law. The final argument
on the question of the constitutionality of this
law, a question which involves the disputed
power of an alternating current to kill, is about
to be held at Buffalo, and this case may have
considerable weight in the argument. In the
experiments there to be made it is proposed to
use an alternating current of from 1,500 to 2,000
volts, and it is contended by the contestants that
even this force would not be sufficient to sureh-
and instantaneously destroy life. p. b. p.

Mviltiple Gestation.

To the Editor: — The recent death of Mrs. Mi-
chael Dress, of Schuylkill Haven, recalls to my
mind the following facts concerning her life :

I do not know at what age she was married,
but during her marital relations she was the
mother of the rather remarkable number oi twaity-
ei'ght children at full term. The record of births
I do not recall, but I do know that out of this
number there were but two single births — the
balance were in twins upon several occasions,
triplets twice or three times, and quadruples once.
The quadruple birth the children lived to grow
up, and one of the number, a female, died from
traumatic peritonitis some few j^ears ago. The
mother was a large, stout woman, and reached
the age of over sixty j'ears. Her habits of life
were those peculiar to hard out-door work and
plenty of it'.

As this case possesses some features worthy of
record, I am glad to have possession of the facts
in view that the case may be made an item of in-
terest.

I presume it would properly come under the
head of " Progressive Uterine Fecundity."
Verj- truly,

D. W. Bland, M.D.

Pottsville, Pa., September 17, 1S89.

Prof. R.\y Lankester, who was attacked
with serious illness while in Paris, has, under
the care of Dr. Faure Miller, now completely re-
covered and has returned to England.

468

MISCELLANY.

[September 28, 1889.

MISCELLANY.

The Golden Belt District Medical Society will
hold its Fall Meeting at Saliua, Kau., on Thursdaj* next.
Sessions at 2 p. M. and 7:30 p. m.

Scarlet fever has become epidemic in Birmingham,
Eng. The situation is serious. Most of the schools are
closed, and the hospitals are so crowded with patients
that auxiliary wards must be opened.

The American P.sdiatric Society at Baltimore,
elected the following officers : President Dr. J. Lewis
Smith, of New York ; secretary, Dr. W. D. Booker, of
Baltimore ; recorder, Dr. William P. Watson, Jersey
City ; treasurer, Dr. Charles Warrington Earle, of Chica-
go, and Dr. L. Samuel Holt, member of council.

The Destruction of Mosquitoes. — The Microscope
says that Robert H. Lamborn has placed in the hands of
Morris K. Jessup, of the American Museum of Natural
History, New York, the sum of |200, to be paid in three
prizes of $150, I30 and J20, for the three best essays on
the destruction of mosquitoes and flies by other insects.
It is suggested that the dragon fly is an active, voracious
and harmless "mosquito hawk," and that it might, if
artificially multiplied, diminish the number of smaller in-
sect. A practical plan is called for in the breeding of the
dragon fly or other such destroyer in large numbers, and
its use in the larva, pupa or perfect state, for the destruc-
tion of mosquitoes and flies in houses, cities and neigh-
borhoods.

Diphtheria Epidemic— The prevalence of diph-
theria in Marion, Ind., has created such alarm that the
public schools were ordered closed last Monday for one
week. .A.bout a dozen deaths have occurred. The point
of greatest danger is believed to be passed, but the
schools were ordered closed as a precautionarj' measure.

An epidemic of a disease resembling dysentery has
been raging near Meadowville, W. Va. Twelve persons
have died. About twenty other cases are reported.

Jacob Rodgers died last week at Pittston, Pa., aged
III years. He was born near Pittsburg, January i, 177S.
He was in the war of 181 2, and was wounded at the
battle of Lundy's Lane. By his first wife he was the
father of fifteen children, and by his second of six. Nine
of the twenty-one are living, one of them being 82. Mr.
Rodgers had used tobacco for nearly 100 years. Until a
few months ago he read without spectacles.

Shelby County Medical Society. — The next meet-
ing of this Societv will take place on Monday, October
14, 18S9, at the Ray House, Shelbyville, Ind." The fol-
lowing papers will be read and discussed: " Management
of Normal Labor, with Particular Reference to the Em-
ployment of Antiseptics in Midwifery Practice," by Dr.
J. W. Green, Shelbyville; "The Use of Ergot in Labor,"
by Dr. S. L. Strickler, Boggstown; "Practical Obstet-
rics," by Dr. Johu Moifett, Rushville; " Delivery of the
Placenta, with Report of Cases of .-Vdherent Placentae,"
by Dr. M. R. Gilmore, Boggstown; " Management of
Shoulder Presentations," by Dr. Edward F. Wells, Shel-
byville; " Post-partum Hiemorrhage, with Report of
Cases," by Dr. J. W. Bowlbv, Marion; "Puerperal Ec-
lampsia, with Report of Cases," by Dr. T. R. Rubush,
London; "Management of the Perineum, with Report
of a Case of Rupture," by Dr. I. W. Trees, Smithland.

LETTERS RECEIVED.

Dr. M.J. Dudley, Sonoraville, Ga.; Dr. G. L. Mor-
gan, Wichita, Kan.; Dr. S. P. Heilman, Heilmandale,
Pa.; Dr. D. A. K. Steele, Chicago; J. B. Lippincot Co.;
Philadelphia; Munn & Co., New York; Dr. Landon B.
Edwards, Richmond, Va.; Dr. A. L. Hummel, Philadel-
phia; Dr. G. Betton Massey, Philadelphia; Dr. James H.
Jackson, Dansville, N. Y. ; Henrv Bemd & Co., St. Louis,
Mo.; Dr. C. C. Hunt. Dixon, 111; J. Walter Thompson,
New York; Dr. C. R. Reed, Middleport, O.; Dr. G. L.
Collins, Providence, R. I.; Dr. H. Cushman, Stanion,
Neb.; Ketteredge & Moran, Ann Arbor, Mich.; Dr. J.
W. S. Gouley, New York ; Mast, Crowell & Kirkpat-
rick, Springfield, O. ; Evening Bulletin, San Francisco,
Cal.; Dr. J. C. Wieson, Philadelphia ; Dr. F. M. Pendle-
ton, Magnolia, 111.; Dr. B. T. Fisher, Indianapolis,
Ind.; Dr. W. Freudenthal, New York; Dr. R. R.
Walker. Paris, Tex.; Doliber Goodale & Co., Boston;
Dr. Wm. C. Dabney, University of Virginia. Va. ; Dr.
Dwight L. Hubbard, New York ; Dr. Max Thorner, Cin-
cinnati, O.; Dr. J. H. C. Simes, Philadelphia; Oneita
Spring Co., Utica, N. Y. ; Roseberry Nutrolactis Co.,
E. Merck, New York ; Dr. Mary M. Cutler, Pomeroy,
O. ; Dr. I. E. Atkinson, Baltimore, Md.; Surgeon-General
John B. Hamilton, Washington. D. C. ; J. B. Lippincott
Co., Philadelphia ; Dr. L. H.Wood, Denver. Col.; Dr.
John S. Lewis. Dubuque, la.; Dr. K. JI. F. Sandberg,
Chicago ; Dr. R.J. Dunglison. Philadelphia ; Ward Bros.,
Jacksonville. 111.; Dr. F. M. Thomas, Samantha, O.; Dr.
A. K. Conrad, Portageville, Mo.; Dr. B. F. Hart, Mari-
etta, O.; E. Steiger & Co.. New York ; Dr. W. H. Ged-
dings, Bethlehem, N. H.; Dr. W. R. Tipton, Las Vegas,
N. M. ; Dr. Martha C. Holmes, New York ; Dr. George
A. Dixon, New York; Dr. F. King, New York; Dr. John
O. Roe, Rochester, N. Y.; The Lancet, London, Eng.;
H. Hornfeld, Berlin, Germany ; Parke, Davis & Co.,
Detroit, Mich.; Dr. A. M. Vail, Rock Rapids, la.. Dr.
Geo. T. Welch, Keyport, N. J. ; J. .'istier, Paris, France ;
George Kiel, Philadelphia; I. Haldenstein, New York ;
Dr. J. Haller, Lanark, 111.; Lea Bros. & Co., Philadelphia.

Official List of Changes in the Stations and Duties of
Officers Serving in the Medical Department. U. S.
Army, from September //, iSSg, to September 20,
iSSg.

Col. Andrew K. Smith, Surgeon U. S. Army, granted
leave of absence for fourteen dags on surgeon's certi-
ficate of disability, by direction of the acting Secretary
of War. Par. i,'S. 'O. 214, A. G. O.. September 14,
1889.

By direction of the acting Secretary of War, First Lieut.
Freeman V. Walker, .\sst. Surgeon, is relieved from
duty in the Dept. of Texas, and will, upon the expira-
tion of his present leave of absence, report in person
to the commanding ofiicer, Jackson Bks., La., for duty
at that station, and by letter to the commanding Gen-
eral, Div. of the Atlantic. Par. 2, S. O. 212, A.G. O.,
September 12, 1889.

Official List of Changes in the Medical Corps of the U. S.
Naiiy for the Week Ending September 21, iSSg.

Medical Inspector G. S. Beardsley, granted six months'
leave, with permission to go abroad.

Surgeon M. L. Ruth, order granting furlough revoked
and placed on waiting orders.

Medical Director Hudson. Medical Inspector Woods and
Surgeon Dickinson will continue as President and
members of an Examining Board for examination of
applicants for the position of .Vsst. Surgeon in the
Navy at San Francisco, Cal., until June 30, 1890.

THE

J ournal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.
PUBLISHED WEEKLY.

Vol,. XIII.

CHICAGO, OCTOBER 5, 1889.

No. 14.

ADDRESSES.

THE CHAIRMAN'S ADDRESS.

Delivered in the Section of Diseases of Children at the Fortieth An-
nual Meeting of the American Medical Association,
June, i88g.

BY J. A. LARRABEE, M.D.,

OF lottisvillp:, ky.

Gentlemen : — Again the bell has struck a warn-
ing note upon the horologe of time ; again we
have assembled for the purpose of contributing
our mite to a science which can no longer be
called "a conjecture," a science which challenges
the admiration of the whole civilized world,
lyike a "Grand Army of Veterans" we meet
around the campfire of the fortieth annual re-
union of the American Medical Association.
Permit me, then, to greet you as valiant captains
of a mighty host of warriors, each bringing the
trophies of successful battle with the common
enemy of mankind. I see before me those who,
amid frosts and snows of a northern winter, have
fought the savage foe whose wolfish grasp lay at
at the throat of the child ; those who, beneath a
semi-tropical sun, single-handed and alone have
fought the pestilence, which walketh in darkness
and which wasteth at noonday ; those who, along
the bold headlands of New England, have met
the enemy "upon the storm-swept hill;" those
who, upon the fertile plains of our western prai-
ries, have fought long and hard with the hydra-
headed monster of the soil. From the North and
the South, from the East and the West we meet
around the altar of legitimate medicine. Here
we renew our obligations to science. Here we
pledge anew our friendships and extend our ac-
quaintance. Here, also, we cherish the memory
of those who, having rested from their labors,
their works do follow them.

The decade just ended has been conspicuous
for the commemoration of historic events. Cen-
tennial anniversaries have been largely the order
of the day, and we have been especially favored
in that our meetings have been associated with
these pleasant gatherings. Those among us who
are so fortunate as to possess a record of revolu-
tionary ancestry are especially congratulated. It
is with commendable pride that we revert to the
fact, which ought never to be forgotten, that in

the long and perilous struggle for freedom, which
laid the foundation of the great American nation,
the noble profession to which we belong has al-
ways been in the front, not only of pioneer life,
but also in true, self-sacrificing patriotism ; that
the title of Doctor of Medicine shines forth like
stars in the emblazonry of our national escutch-

[ eon, from Joseph Warren, of Bunker Hill, to
Hugh Williamson, of Camden, and from Lexing-
ton to Yorktown. But the ground upon which
we meet to-day is still more precious to the his-

I torian. Not only does the pious, stern and re-
lentless countenance of the Puritan rise up before
us, but by the magic touch of the classic pen of
our own Longfellow the cold and silent finger of
the "skeleton in armor" is pointed backward
through the dim vista of the ages.

I well remember that when I was a boy and
sat upon the hard wooden benches of a little red
New England schoolhouse my sympathies were
always aroused by a picture in the leaves of a
well-worn history. That picture represented a
very small man with a very large hat and a very
long staff, and behind him followed seventeen as
forlorn and pensive-looking creatures as ever

j figured in print. It was Roger Williams and his
adherents being driven by religious persecution
and hatred to seek a home or to die in the wilder-
ness of Rhode Island. It is to this wilderness
that we have been invited, and to this wilderness

j we have come to participate, with a generous
and hospitable people, in the celebration of the
two hundred and fiftieth anniversarj' of its settle-
ment. In this history there is certainly food for
thought and for congratulation. For thought,
that manj' of the most important advances which
have been made in medicine and surgery have
been met by persecutions scarcely less vigorous

j and criticisms hardly less cruel. Old John Tal-
bot, for daring to recommend a new, nauseous
and bitter drug for the cure of His Majesty's
ague, is here to be remembered ; also (within the
recollection of living men) the ridicule and pro-
fessional ostracism, by the erudite editor of a
Philadelphia newspaper, of the quackish doings

, of the Boston doctors in using anaesthetics for
surgical operations ; and our own Ephraim Mc-
Dowell would have been driven into the wilder-
ness by foreign persecutors had he not already

470

RESTRICTION OF MEDICAL PRACTICE.

[October 5,

been in one. Congratulation, that an enlight-
ened civilization has so far increased our charitj^
that we are enabled to pursue in peace a science
which loves truth, invites fact and discards super-
stition ; that we no longer live in dread of a
"doctors' mob" against dissection or the gibbet
for vaccination. What place, then, more fitting
for the burial of professional animosities than
this I " Pathists " but poorly become men who
are searchers after truth. The broad title of
" Doctor in Medicine" should be the only dis-
tinction of those who should have no other rivalrj-
than a generous emulation of who can do the
best work and best agree.

The reformer is abroad in the land. His pres-
ence is felt in all quarters, from the halls of Con-
gress to the lyceum club, in the church, in the
political convention, and from "woman's rights"
to temperance ; on all subjects and on all occa-
sions he ' ' bobs serenely up. " It is not strange,
then, that medical societies should form no ex-
ception to the general rule. In our meetings he
seldom contributes to the scientific discussions —
never reads a paper. Ethical subjects offer a
peculiar and luring attraction, and to avoid com-
plete obscurity he proposes certain changes in
established customs, bj'-laws and constitution,
rules and regulations which no one ever found
any fault with, and which, in the harmonious
course of affairs, few knew to exist. These indi-
viduals would change some law at even,' meeting,
and were thej' to be so fortunate as to enter the
heavenl}- kingdom, would propose to change the
laws which regulate the universe itself

Pediatrics is not a forced specialty in practice.
It is not a branch torn from the tree of general
medicine and forced to grow apart from the par-
ent stem. The diseases of infancy and childhood,
while thej' pos.sess something (nomenclature) in
common with those of adult life, differ so widely
in course, duration and consequences that they
require especial stud3^ Very man}' excellent
practitioners, appreciating their want of famil-
iarity with infantile symptomatology, decline
positivelj' to attend to this class of practice ;
while many more, less honest in their convic-
tions, continue the practice, although distasteful
to them. Pediatrics presents to all an open field
and a rich harvest of useful knowledge to all who
will become earnest workers. Many of our med-
ical colleges afford no adequate advantages for
the medical student to become acquainted with
a class of patients who may constitute two-thirds
of a general practice. vShall this Section, so im-
portant and u.seful in its labor in the past, so full
of work for the future, be united like a set of lec-
tures in one of the.se colleges, thrown in at the
end of a course of obstetrics? An opportunity
will be given in the open session at this meeting
for you to decide. From this Section the greatest
possible good to the general practitioner may be

expected. From its deliberations will originate
wise and wholesome laws regulating matrimon}',
the propagation of healthful children, and the
banishment from society of diseases worse than
death. These, and manj' more considerations of
equal importance, would seem sufficient plea for
the separate existence of a Section in the purpose
laid out by its distinguished founder.

Notwithstanding the year has chronicled a
ver3' decided advance in infantile therapeutics,
the allegory of Addison — of the bridge of human
life^still applies : "The pitfalls are still seen
to be thickest near the entrance to the bridge."
Infantile mortality from preventable causes is far
greater than it should be. Your Chairman would
venture the suggestion that a standing committee
be appointed by the Section, whose duty it shall
be to prepare a report upon vital statistics in in-
fancy, said committee to be appointed each year,
and said report to be read at a specified time in
the meeting of this Section ; statistics which shall
constitute the basis of this report to be obtained
from reliable mortuarj' reports of cities and
towns, and also from the practice of those en-
gaged especially in pediatrics.

In conclusion, gentlemen, it remains for me to
express to you my appreciation of the high honor
j'ou have conferred upon me in calling me to pre-
side over your deliberations. Esteeming, as I
certainly do, the distinction you have placed
upon me, I am also keenly sensitive of my own
inadequac}'. Wholly unversed in parliamentary'
usages, I beg your indulgence and request j^our
kindly co- operation and assistance in the dis-
charge of the duties which shall devolve upon
the chair, that you maj' not have reason to regret
your too partial choice.

ORIGINAL ARTICLES.

THE LEGAL RESTRICTION OF MEDICAL
PRACTICE IN THE UNITED STATES.

Rt\id in the Section o/ State Medicine at the Fortieth Annual

Meeting of the American Medical Association, June, iSSg.

BY PERRY H. MILLARD, M.D.,

DEAN AND PROFESSOR OF CLINICAL SrRGERY, MEDICAL DEPART-
MENT UNIVERSITY OK MINNESOTA ; ACTING ASSISTANT SUR-
GEON TTNITED STATES ARMY ; EORMER SECRETARY
MINNESOTA STATE HOARD OF MEDICAL EX-
AMINERS ; EX-PRESIDENT MINNESOTA
ST.4TE MEDICAL SOCIETY. ETC.

Gentlemen : In reviewing the subject of med-
ical legislation, I am fully cognizant of encroach-
ment of a subject most fertile in theorj' and sug-
gestion, but quite devoid of illustrative beneficial
results ; a subject of vital importance to the
public and profession, yet receiving but little aid
and encouragement from either source in attempts
at reforms. The history of medical legislation in
this country shows, quite uniformly, that legisla-
tures are quite apathetic when requested to enact

1889.]

RESTRICTION OF MEDICAL PRACTICE.

471

laws regulating medical practice, and are most
loth to believe that the best interests of the pub-
lic are subserved by such laws, many even assert-
ing their belief that all legislation of this char-
acter savors of trades unionism. In our attempts
at medical reform, the demeanor of the profession
has likewise been most discouraging. We concede
to all the right of conservatism, but deem it the
duty of all good citizens to pass conscientious
judgment upon all issues of vital importance in
their chosen avocations.

The history of medical legislation is quite in-
structive. The United States is the only coun-
trj' among civilized nations devoid of adequate
medical legislation; even the Chinese are protected
by efficient medical legislation, and in our Scandi-
navian countries the minimum time of study is
seven years. The history of medical legislation
is most ancient. We ascertain b}^ research that
in 1237 the College of Salino instituted a series
of regulations to the effect that no one should
practice physic who had not studied philosophy
three years and physic five, and had obtained the
license of the College after undergoing an ex-
amination at the end of such period. Very simi-
lar regulations were shortly thereafter adopted by
the English University, and the standard of med-
ical knowledge and education was thereby con-
siderably raised and a great impetus given to the
pursuit of medicine. The first degrees in medi-
cine were granted in 1384. We find by compari-
son that 150 years before degrees or diplomas
were granted, the universities licensed to practice
only after the candidates had pursued philosophy
three years and physic five, and that 650 years
thereafter 70 per cent, of the colleges of the
United States onlj' require two courses of lec-
tures and three years of study. Fearing I may
be charged with unfairness in my comparative il-
lustration, I will direct your attention to the
somewhat suggestive fact that all the colleges of
to-day require that our boys be of good " moral
character. ' '

The first law regulating the practice of physic
was enacted in 151 1. The practice of medicine
at this time was largely conducted by the igno-
rant portion of the artisan class. Medical de-
grees, however, were held in high esteem by the
people. The progress of medicine in the .seven-
teenth centur>' has been ably pictured by Macau -
ley in his " History of England," vol. i, page
310. "Medicine," he says, "which in France
was still in abject bondage, and afforded for
Molliere an inexhaustible subject for ridicule, had
in England become an experimental and progres-
sive science, and every day made some new ad-
vance, in defiance of Hippocrates and Galen. The
attention of speculative men had, for the first
time, been directed to the importance of sanitary
police. To that period belong the chemical dis-
coveries of Boyle and the first botanical re-

searches of Sloan. One after another, phantoms
which haunted the world through ages of dark-
ness, fled before the light, and astrologj^ and al-
chemy became jests. Upon research I find that
in ancient times medical legislation and higher
medical education progressed hand in hand.
Upon research, I am unable to find that any
court or legislative body in the British Isles or
Continental Europe ever questioned the propriety
of effective medical legislation.

The experience of the various States in the
United States is, however, suggestive. Previous
to the present decade, no State in the Union pos-
sessed an efficient medical practice act. The laws
in existence in the few States possessing the same
were too inefficient to merit mention at this time.
The most efficient of them only required the filing
of a copy of a diploma with some office of record,
generallj' a clerk of court or <"ounty clerk. Many
of these diplomas were purchased outright, as
was afterwards proven in the famous Buchannan
diploma cases.

The first State to pass a law based upon rational
principles was North Carolina. The efficiency
of this act was practically emasculated, as the bill
possessed no penalties. Among the earlier acts
of the present decade were what was known as
the Illinois Act. This act provided for the is-
suance of a license by submission of a diploma
from a school of medicine recognized by the
board. This act was, in my opinion, quite as
radical as could have been enforced at the time
of its enactment. The essential features of this
bill were copied in the subsequent practice acts
of Minnesota, from 1882 to 1887, Missouri, Iowa
and West Virginia. The practice acts of the
above-named States were retroactive in their fea-
tures or provisions, and were applicable to up-
wards of 15,000 physicians. The gentlemen en-
trusted to execute the law in these States are the
only persons that can actually recognize the ob-
stacles and intolerable embarrassments encoun-
tered in the execution of the act in the above
named States. We received most captious criti-
cism and encountered formidable opposition from
the sources we least expected, namely, the pro-
fession itself This criticism and opposition did
not come from the narrow-minded cynic alone, but,
to the shame and disgrace of the profession, from
a large number of our medical institutions, some
of which, we regret to mention, were manned by
men of eminence and great learning, but had
carelessly, for financial reasons only, given cog-
nizance to an opposition to a reform that was en-
titled to an undivided support and encouragement
from every member of the profession from the
Atlantic to the Pacific. Of the nine attempts to
repeal the present Minnesota Medical Practice
Act at the last session of the legislature of Min-
nesota, a majority of the professed amendments
emanated directly from the medical colleges

472

RESTRICTION OF MEDICAL PRACTICE.

[October 5.

themselves. The profession, gentlemen, is not '
cognizant of the great trials encountered in
bringing about a fair degree of efficiency of the
present inefficient acts. To John H. Ranch be-
longs the greatest credit in making the so-called
Illinois Act efficient in different States. He is
the true father of the coming reform, and we are
onlj' following in his footsteps. His influence in
this matter has been most potent for good, and
has directed the attention of both the profession
and public of the great need of the present at-
tempted reform. We trust he may be spared to
witness a practical application of his labors. The
States possessing quite ideal medical practice
acts at present are, Minnesota, Montana, Vir- j
ginia and North Carolina. The Minnesota Act '
is superior to that of the other States in that it
requires that all persons desiring a license to
practice shall have taken at least three courses of
lectures of not less than six months' duration
each. These requirements, in addition to the
examination, make a tolerable safeguard for the
public. In the future legislation bj^ different
States, I believe the profession can safely incor-
porate the main features of this act in their at-
tempted legislation. It was drafted bj' me after !
five years' experience as executive officer of the
former Minnesota Practice Act, and two years'
successful operation in Minnesota has proven its
merits. In the last two 3'ears this board has ex-
amined ninty-nine applicants for a license to prac-
tice and rejected thirty-five. All persons graduated
since 1886 must furnish evidence of having at-
tended three courses of lectures of not less than
six months' duration each. As a result of this
law, the sixtj'-four physicians that have been
licensed to practice in Minnesota the last two
years are nearlj' all graduates of McGill, Univer-
sity of Michigan, University of Pennsylvania,
Chicago Medical College, and University of Min-
nesota. As an illustrative comparison, under the
old Minnesota Act, which was the same as the
present acts of Illinois, West Virginia, Missouri
and Iowa, I licensed 146 physicians in 1885, and
280 in 1886, while the present board licensed
sixty-four phj'sicians from July i, 1887, to July
I, 1889.

As a result of efficient medical legislation Min-
nesota possesses a smaller ratio of physicians to
the population than any State in the Union. In-
stead of one physician to every 750 inhabitants,
the last medical census shows but one to ever>'
1,300. Through the courtesy of the Secretary' of
the Minnesota Board, I am permitted the first
public announcement of these figures. I may
state, however, that they are not made public
with a view of promoting emigration. It is a
pleasure to announce that both the profession
and the public are quite uniformly supporting the
law.

The profession is at present awakening to the

necessity of efficient medical legislation. The
fields are fertile and the harvest shall be plentiful;
the handwriting is on the wall, and the interpre-
tation is easilj' read. The people have awakened
to the fact that there are twice as many practi-
tioners of medicine in this countrj' as are com-
mensurate with its legitimate wants. The num-
ber being as one to every 750 in the United
States ; one to every 1,660 in Hungarj' ; one to
every 1,639 in Italy; one to every^ 2,932 in Aus-
tria; one to ever>' 3,225 in Germany; one to
everj' 3,780 in France, and one to every 7,909 in
Sweden. The great number of medical men in
this country makes competition very sharp, and,
in consequence, people too frequently suffer from
dishonorable practices. My own observation
teaches me that the people of this country take
too many drugs ; this is particularly true of the
American born citizen. The people are also cog-
nizant of the fact that the methods of medical in-
struction in this country is deserving of severe
censure.

The report of the Commissioner of Education
of the United States shows that in 1886 there
were but $2,671,490 in the grounds, buildings
and apparatus of the 130 medical colleges of the
United States. That the productive funds of the
same were $266,193, and the annual income from
investments only $22,000. Less than a dozen of
these schools are in any way endowed. How
best to prevent the flooding of this countrj- with
half educated medical men, is a vital question to
both the public and profession at this time. After
years of experience and observation in this coun-
try and Europe, I can unhesitatingly assert my
conviction that our only remedy lies in efficient
medical legislation. We are well aware that
many of our medical colleges are honestly en-
^ deavoring to raise the standard of acquirements,
and that in consequence their students have de-
creased in numbers and they have received but
little encouragement at the hands of the profes-
sion itself. I believe that the adoption of a med-
ical practice act in each State, possessing the fea-
tures of the bill favored by the Commission on
Uniform Medical Legislation, of which I have
i the honor to be Chairman, will afford the people
i and an overcrowded profession the much desired
' relief. This committee recommends to this As-
' sociation for consideration, a bill calling for a
State Board of Examiners to be appointed by the
governor. A bill requiring that all persons com-
mencing practice shall undergo an examination,
at the hands of said board, that is both scientific
j and practical, but of sufficient severity to test the
candidate's fitness to practice medicine. Before
being allowed to compete for a license by exami-
nation, the candidate must submit a diploma from
a recognized medical college that requires a pre-
liminarj' entrance examination upon the follow-
; ing named branches, to-wit. : English grammar,

i889.]

RESTRICTION OF MEDICAL PRACTICE.

473

composition, geography, history, arithmetic,
algebra, physics and the natural sciences, to-
gether with at least one of the following lan-
guages ; Latin, French or German. In addition
a curriculum requiring attendance upon at least
three full and regular courses of lectures before
graduation, of not less than six months' duration
each.

A bill providing that license may be refused or
revoked for chronic inebriety, criminal abortion
and gross unprofessional conduct. Also, that all
licenses be a matter of public record by being re-
corded with a clerk of court or some officer of
public record.

I believe, gentlemen, that the best interests of
the public and profession will be subserved by
efficient legislation, as recorded b}' this commit-
tee. Opposition at this time is evidence of a
selfish motive, or a fatal weakness, if emanating
from any special school of practice. Experience
has proven that the so-called mixed boards have
worked in harmony in the different States possess-
ing the so-called Illinois Act, or rather the act
recognizing a diploma as entitling the possessor
thereof to registration. If a bill is passed by the
different States calling for an examination of all
applicants for a license, I can easily forsee a radi-
cal change in the character of instruction afford-
ed by a majority of the medical colleges of this
countr3\ The reputation of colleges will not de-
pend .so much upon the number of students as
upon the actual character of the instruction af-
forded the students. Such is the case in Europe,
and should be the case in America.

In conclusion, gentlemen, let me bespeak for
our noble calling a higher appreciation at the
hands of the public. Our destinies are the pro-
duct of our own action. I believe the future can
be made more desirable than has been the past ;
as we sow, so shall we reap. I know it is in our
power to afford the public a better profession, and
realize that the best interests of the public will be
subserved thereby. Let us endeavor to reduce
the number of medical colleges, and, at the same
time, raise the standard of instruction afforded.

Dr. N. S. Davis, of Chicago, said that the sub-
ject of the paper was a most important one. The
laws should be sufficiently harmonious in the
various States to enable one, after once qualifying,
to practice medicine in any State. They would
be eligible to a license for practice in any other
State without another examination. The objec-
tionable feature of the Illinois State law is the
fact that the diploma itself enables one to obtain
license to practice. The medical colleges should
be made to rival each other in the character of
the work done by them. The student endeavors
to get through his college work in the shortest
possible time and at the least expense. From
one-half to two-thirds of the students try to find

the cheapest and easiest college. Teaching and
licensing should be in separate hands. A high
grade of preliminary education should be de-
manded. The State Board should be appointed
by the governor with the concurrence of the
senate.

Dr. Gihon, U. S. N., was of the opinion that
preliminary education is the most important con-
sideration.

Dr. Smart, U.S.A., accorded with Dr. Davis re-
garding the requirements preliminarj' to practice.

Dr. Sc.\mmon, of Tennessee, agreed with Dr.
Davis in the main, but thought the board should
not be appointed by the governor, but be elected
by the phj^sicians.

AN ACT Entitled, An Act to Regulate
THE Practice of Medicine and Surgery,
TO License Physicians and Surgeons, and
TO Punish Persons Violating the Pro-
visions Thereof.'

Be it etiaded by the Legislature of the State of

Section i. The Governor shall appoint a
Board of Examiners, to be known as the State
Board of Medical Examiners. Said Board shall
consist of nine members. The appointees shall
be persons of recognized professional ability and
honor. The term of office of said Board shall be
three years, or until their successors are appoint-
ed ; provided, however, that the members thereof
shall be divided into three classes, each class to
consist of three persons. The first class shall
hold office under said appointment for one year,
the second for two years, and the third for three
years from the date of their appointment. It is
further provided that no member of said Board
shall serve more than two terms in succession.
No member of any college or university having a
medical department shall be appointed to serve
as a member of said Board.

Sec. 2. Said Board of Medical Examiners
shall elect a President, a Secretary and a Treas-
[ urer. It shall have a common seal, and the Presi-
dent and Secretary shall be empowered to admin-
ister oaths in taking testimony upon any matter
j pertaining to the duties of said Board. Said
Board shall hold meetings for examinations at
' the Capitol Building of this State the first Tues-
day of January, April, July and October of each
year, and at such other times and places as the
Board shall deem expedient. Said Board shall
keep an official record of all its oieetings ; also an
official register of all applicants for examination
for a license to practice medicine and surgery in
this State. Said register for license shall show
the name, age and last place of residence of each
candidate, the time he or she has spent in medi-
cal study, in or out of a medical school, and the
names and locations of all medical schools which

' Copy of Act submitted by Committee on Medical I.epfislation,
and read in the Section of Slate Medicine at the Fortieth .\nnuai
Meeting of the American Medical Association, June, 1S89.

474

RESTRICTION OF MEDICAL PRACTICE.

[October 5,

have granted said applicant any degree or certifi-
cate of attendance upon lectures in medicine.
Said register shall also show whether such appli-
cant was rejected or licensed under this Act.
Said register shall he prima fade evidence of all
matters therein contained.

Sec. 3. All persons hereafter commencing the
practice of medicine or surgery, in any of its
branches, in this State, shall apply to said Board
of Medical Examiners for a license so to do. Ap-
plicants for examination shall be divided into
three classes, to wit : Persons graduated from a
legally chartered medical school not less than
five years before the date of application for a
license ; second, all other persons graduated from
a legally chartered medical school, and medi-
cal students taking a regular course of medical
instruction. Applicants of the first class shall
submit to examination upon the following named
branches, to wit : Materia medica and therapeu-
tics, obstetrics and gynecology, practice of medi-
cine, surgery and surgical anatomy. Those of
the second and third classes shall submit to ex-
amination upon anatomy, physiology, chemistry,
materia medica and therapeutics, histology and
pathology, hygiene, practice of medicine, surgery,
obstetrics and gynecology, diseases of eye and [
ear, medical jurisprudence, and such other j
branches as the Board may deem advisable. The
questions for examination of applicants of the
first and second classes shall be the same in
branches common to both. Said Board shall not
license graduates of later date than January i,
1890, until satisfactory proof is furnished that
the applicant has studied medicine and surgery
three years before graduation ; attended at least
three full courses of medical lectures, of not less
than six months' duration each ; is of good moral
character and over twenty-one years of age.
Applicants of the third class, upon completion of
two full courses of lectures, of not less than six
months' duration each, can be examined upon
the following named branches, to wit : Anatomy,
physiology, chemistry, histology and pathology,
and materia medica and therapeutics. If said
examination is satisfactory to said Board, it may
issue a certificate that the applicant has passed a
final examination in these branches. All exam-
inations shall be both scientific and practical, but
of sufficient severity to test the candidate's fitness
to practice medicine and .surger}'.

Sec. 4. All examinations shall be in writing,
unless otherwise requested by applicant. In all
oral examinations the questions and answers
must be of a fundamental character and, except
in therapeutics, such as can be aiKswered in com-
mon by all schools of practice. If said examina-
tion is satisfactory the Board shall, provided
that the applicant shall beat the cost and trouble
of securing the presence of such dean or presi-
dent, and that this shall not interfere with the

regular conduct as to time and place of the ex-
amination, issue a license entitling the applicant
to practice medicine in this State. The votes of
all examiners shall be by yes or no and written,
with their signatures, upon the backs of the ex-
amination papers of each candidate for the respec-
tive branches. A license shall not issue unless the
applicant passes a satisfactory' examination on at
least two-thirds the branches required by this Act.
Said examination papers shall be kept on file by
the Secretary' of said Board, and shall be prima
facie evidence of all matters therein contained.
All licenses shall be signed by the President and
Secretary of said Board, and shall be attested by
the seal thereof. The fee for examination shall be
$15 for each applicant of the first and second class-
es, and $20 for each applicant of the third class. It
shall be paid to the Treasurer of the Board and
applied towards defraying the expenses thereof.

Sec. 5. The Board may, by a unanimous
vote, refuse to grant or revoke a license for the
following named causes, to wit : Chronic and
persistent inebriet}', the practice of criminal abor-
tion, or for publicly advertising special ability to
treat or cure diseases which, in the opinion of
said Board, it is impossible to cure. In com-
plaints for violating the provisions of this section
the accused person shall be furnished with a copy
of the complaint and given a hearing before said
Board, in person or by attorney, and can finally
appeal from the decision of said Board to the ap-
pointing power thereof

Sec. 6. The person so receiving said license
shall file the same, or a certified copy thereof,
with the Clerk of the District Court in and for
the county in which he or she resides, and said
clerk of the court shall file said certificate, or
copy thereof, and enter a memorandum thereof,
giving the date of said license and the name of
the person to whom the same is issued, and the
date of said filing, in a book to be provided and
kept for that purpose ; and said clerk of the court
shall each year furnish to the Secretary of said
Board a list of all certificates on file in his office,
and upon notice to him of the change of location
or death of a person .so licensed, or of the revoca-
tion of the license granted to such person, said
clerk shall enter, at the appropriate place in the
record so kept by him, a memorandum of said
fact, so that the records so kept by said clerk of
the court shall correspond with the records of
said Board, as kept by the Secretary thereof. In
case a person so licensed shall move into another
county of this State, he or she shall procure from
the clerk of the court a certified copy of said
license, for which no charge shall be made, and
then file the same with the Clerk of the District
Court in the county to which he or she shall so
remove. Said clerk shall file and enter the same
with like effect as if the same was the original
license.

1889.]

ABDOMINAI. HERNIA.

475

Sec. 7. This Act shall not apply to commis-
sioned surgeons of the United States Arm3% Navy
or Marine Hospital Service, to physicians or sur-
geons in actual consultation from other States or
Territories, or to persons temporarily practicing
under supervision of an actual medical preceptor.

Sec. 8. Any person shall be regarded as prac-
ticing medicine or surger3% within the meaning
of this Act, who shall append the letters M.D. or
M.B. to his or her name, or repeatedly prescribe
or direct, for the use of any person or persons,
any drug or medicine or other agencj' for the
treatment, cure or relief of an}- bodily injury, in-
firmity or disease. This Act shall not apply to
dentists or midwives in the legitimate practice of
these branches exclusively.

Sec. 9. Any person practicing medicine or
surgery in this State without first having ob-
tained the license herein provided for, or contrary
to the provisions of this Act, shall be deemed
guilty of a misdemeanor and, upon conviction
thereof, shall be punished by a fine of not less
than $50 or more than $100, or bj- imprisonment
in the County Jail for a period of not less than
ten or more than ninety days, or by both fine and
imprisonment. Justices of the peace and the re-
spective municipal judges shall have jurisdiction
of violations of the provisions of this Act. It
shall be the dut}- of the respective county attor-
neys to prosecute violations of the provisions of
this Act.

::» Sec. id. All Acts or parts of Acts now exist-
ing not in accordance with the provisions of this
Act, are hereby repealed.

Sec. II. This Act shall take effect and be in
force from and after its passage.

Signed :

Perry H. Mili,.4RD, Ch'n, St. Paul, Minn.,
HosMER A. Johnson, Chicago, 111.,
R. H. Plummer, San Francisco, Cal.,
C. W. Dulles, Philadelphia, Pa.,
Geo. H. Belt, Boston, Mass.,

C0711. on Uniform Medical Legislation of the Atnerican
Medical Association.

ON THE CONNECTION OF CHRONIC DIS-
EASES OF THE UPPER AIR-PASSAGES
WITH ABDOMINAL HERNIA. •

Abstract 0/ a paper read in the Section of Laryngology and Otology

at the Fortieth Annual Meeting of the American Medical

Association, held at Neivport, R, I., June, iSSg.

BY W. FREUDENTHAL, M.D.,

PHYSICIAN TO THE GERMAN POLIKLINIK. N. V.

If it be true that ' ' necessity is the mother of
invention," then no period was more suitable for
that great invention, the laryngeal mirror, than
the present one.

The tendency of modern civilization is to im-
prison us closely within the walls of our cities
and houses. As a result we find an increased
tendencj- to the development of diseases of the

air-passages, together with various less conspicu-
ous sequelae. As an example of these I may
mention abdominal hernia. As regards the origin
of ruptures caused bj- nasal affections, I made the
following remarks before the German Medical
Society of New York fZur Aetiologie der Unter-
leibsbriiche. N. Y. Med. Prcssc, Oct., 1888):
' ' If primarily we consider this question from a
purely theoretical standpoint, nothing is easier
than to prove the possibility of the origin of a
hernia from an affection of the nose, in the same
way as, long ago, it has been considered proven
as the result of a bronchial affection. The force
of the cough, pressing the abdominal contents
against already non-resistable parts of the lower
abdomen, increases the susceptibility to the for-
mation of a hernial sac, and afterwards a hernia,
and this is accomplished b}^ intensified and oft-
repeated action of the intra- abdominal pressure."

Intra-abdominal pressure has played a great
role in former j-ears, especially in Germany.
Modern surgeons have again rescued it from
oblivion ; into which it seemed to have fallen.
Already in Rust's " Handbuch der Chirurgie "
(vol. 8, pp. 360 ff. ) we read that even when a
hernia at last suddenly appears, after a more or
less violent exertion, still its origin has been pre-
pared by oft-repeated pressure of the contents
through a slow but long continued dilation of
the peritoneum.

A further practical use of this idea was made
bj' Friedberg (Vierteljahrschr. f. prakt. Heilk.
Prag. 1864), who .showed the connection between
the origin of hernias and congenital phimosis in
boj's. The patency of the processus vaginalis
peritonei can not, according to him, be a sufficient
cause for the origin of herniae, as this has
been found open in many cadavers without a her-
nia being present. Still, however, this can give
the predisposition which only awaits some excit-
ing cause to produce a hernia. This idea of the
origin of a hernia from a marked case of phimosis
has, of late, been taken up and is held by quite
a number of writers, especially by Kempe, Os-
born (who also gives an explanation for the
greater frequencj' of right-sided herniae in infants),
Hans Schmid, and Karewski. Now, compare
the pressure upon the abdominal contents induced
by a phimosis, with that of chronic diseases of
the upper air-passages. "When the nasal secre-
tion is normal, the pressure upon the abdominal
contents is so slight that it need not be regarded.
When, however, .... pathological changes take
place .... then the expiratory straining to remove
the pent-up secretions increases with the constant
and ever changing inability to get rid of it."
[See above cited paper.] The expiratory efforts
must, therefore, become verj' .strong and continu-
ous. A man with hypertrophy of the turbinated
bodies, or with a nasal catarrh, or with a strong
pharyngitis granulosa, will hawk, clear his throat

476

ABDOMINAL HERNIA.

[October 5,

and blow his nose under certain conditions all
day long ; or, in other words, he will constantlj'
increase the intra-abdominal pressure. A child
with a phimosis will do this at the most once
ever}' hour and, as I think, in a manner relatively
much weaker.

If we examine this theor}' somewhat more
closely, the question which everybod}- naturally
will ask is this : Is there a greater frequency of
hemise in countries where nasal diseases abound ?
The jV. V. Med. Record answered this in the
negative, and afiSrmed that in Germany 82 out of
1,000 conscripts are rejected on account of hernia,
in France 65, in Italy 76, while in the northern
army only 50 were not taken on account of her-
nia, although nasal diseases in the United States
are extraordinarilj- common. I refuted these
statements by publishing complete statistics of
the Austro-Hungarian monarch}', as a substitute
for the German, from whom statistics could not
be obtained, and came to the conclusion that the
ratio of North America, a country much troubled
by 7iasal diseases, to Austria, much less i?i/ested
with them, is as jo to 14.. In other words : Her-
nia is in the United States three and a half times
as frequent as in Austria.

Reasoning from aualogj' I conclude that in
Germany 82 out of 1,000 are not rejected on ac-
count of hernia. I shall to-daj' give you the con-
tents of a table to which my attention was kindly
called by the director of the Kaiserliches Gesund-
heitsamt in Berlin.

It is as follows (Verofifentl. des K. Gesund-
heitsamtes, 1887) :

Were examined iu the Depart-

Rejected, ratio

Year.

ments of the i-i5thArmy
Corps.

per 1,000.

1876

786,054

128.2

1877

782,482

114.1

1878

822,412

105.6

1879

857.374

IIO.O

1880

875.480

1093

18S1

864.812

90.1

1882

851,801

S5.8

1883

869,572

78.7

1884

884,250

76.7

1885

900,849

74-3

Average for the ten years, 96.6.

According to this average, therefore, there
were rejected out of 1,000 conscripts, on account
of physical and mental defects of all kinds, alto-
gether p6.6 ; in the last four years (1883-1886)
even less than 80. That we, therefore, should
meet with such a high average (as 82) for the
ruptured alone, is bj' no means correct. In my
opinion the proportion ought to be even more
favorable than in Austria ; for, as a statistical re-
port of the Royal Bavarian Ministrj' of War of
the year 1883 shows (Zeitschr. des K. Baj'er-
ischen Statist. Biireau, Miinchen, 1884), there
were rejected, "on account of infirmities of the
abdomen (mostly ruptures)," 1.4 per cent., or 14
per 1,000. If we subtract the less frequent other

abdominal diseases, we get for hemiae alone a
number that is decidedly below 14. As these
proportions in the other parts of Germany are
alike, perhaps even better, we ma}' conclude, with
a probability bordering on certainty, that also in
Germany, in accordance with the less frequent
occurrence of nasal diseases, hernise are found
only one- third or one-fourth as often as in the
United States, the country of nasal diseases, «« r,
e'Sox>/y.

Concerning Italy and France, I have received,
through the kindness of both consulates at New
York City, more accurate data.

In Italy, where people do not suffer much from
na.sal diseases, the figure was said to be 76. In
reality the conditions are as follows :

Males of 20 years rejected from military service
for abdominal hernia :

Number of those called,

Year.

exclusive of those rejected

Rejected for
hernia.

Ratio

for defects of stature.

per 1,000.

1858

250,699

4.052

16.2

1859

270,304

4,282

15.8

i860

224.340

4.40:

18.0

1S61

254.867

4,264

16.7

1862

273.064

4,506

16.5

1863

303.423

5,080

16.7

1864

297,742

4.796

16.1

1865

304,559

5.026

165

1S66

317.031

5.260

16.6

1S67

301,769

5.129

17.0

Average for the 10 years, 16.61.

France also has not, as was aflSrmed by the
Record, 65 per 1,000, but only the following
figures :

Ratio per 1,000: Year 1879, 23.2; 1880, 22.1 ;
1881, 21.3; 1882, 22.3; 1883, 22.9; 1884, 22.7;
1885,23.2; 1886,24.1; 1887,23.2; 1888,23.9;
average, 22.89.

Thus we find the relations exactly as we ex-
pected to find them. In Italy, where, at least as
far as I know, nasal diseases are less frequent
than in France, out of 1,000 conscripts 16.61 are
rejected on account of hernia ; in France, on the
contrary, 22.89. -^^ these data furnish another
proof for our theorj', I could not omit bringing
them in addition.

As you are perhaps aware, I furthermore tried
to prove that where tiasal diseases decrease, the
number of ruptures must also be diminished. I
based my statements especially on the results of
the excellent investigations of Brj'son-Delavan
(A^. }'. Med. Journal, November 12, 1887), who,
in accordance with the experience of Zucker-
kandl, E. C. Morgan, F. Donaldson, Jr., J. N.
Mackenzie and others, has proven that among
primitive types deformities of the septum are
verj' rare. On the other hand I showed that
these races, at the same time, have but verj' rare-
ly a hernia, and I called attention to the report
of the Provost Marshal -General, that none of the
121 Indians drafted in the last war had a hernia,

1889.]

ABDOMINAL HERNIA.

477

and none nasal trouble. These conclusions were,
according to my knowledge, opposed by nobody.

Not quite the same happened as to the third
question at issue, I finally tried to show that
just those people are especially prone to hernia
who are least exposed to inclement weather, lead-
ing a sedentary life, and who surely have not to
carrj' or to lift heavy burdens. In support of my
affirmation I then cited the report of the Provost
Marshal- General again (Statistics, Med. and An-
thropological, of the Pr. M. Gen.'s Bureau, etc.,
by J. H. Baxter, Washington, 1875).

In this report we have a tabulated statement
of the frequency with which hernia occurs among
men engaged in seventy-five varieties of occupa-
tions. The smallest percentage is found among
soldiers, namely 28.8 per 1,000. Next to them
come the tanners and curriers, coppersmiths, stu-
dents, iron-workers, etc. The latter (iron-work-
ers) show the very interesting number 32, while
inn keepers, whose occupation, in proportion to
these, can be called an extremelj' easy one, reach
the highest point, namely 101.5 per 1,000. To
the same category belong editors, engravers and
others, whose percentages range from 95 to 98 per
1,000, and who are by no means as much strained
physically as soldiers, coppersmiths, sailors and
the like. Tanners and curriers show the number
29.4, while teachers have almost twice the num-
ber, viz : 56.6 ; and dentists, who remain indoors
almost the whole day, show even 79. From
these data I thought myself correct in drawing
the conclusion that people who, through some
special kind of occupation, are apt to acquire a
post- nasal catarrh, or other diseases of the upper
airtract, are more subject to hernia than others.

To this Dr. Schapringer, in a review published
in the A/onaissc/ir./. O/ire/i/ici/k/aidr, Jan., 1889,
replied that people suffering from hernia at the
time of selection of their trade never elected to
become smiths or the like, but rather engravers,
etc. It would, therefore, be the hernia that
created the engraver, and not vice versa, the
business of an engraver that produced a hernia.
Dr. Schapringer, furthermore, thinks that the
above tables are of a doubtful value as long as
they do not contain details about the first appear-
ance of the hernise. Now, gentlemen, I can not
fulfil his desire, nor do I even think it necessarj',
as we have statistics about the time of the first
appearance of a hernia in great abundance.

According to consonant investigations made
by the most prominent writers on this subject
(Malgaigne, Cloquet, Kingdon, Wernher, Albert,
etc.), it is stated that in males hernia occurs mo.st
frequently between the thirtieth and fortieth
years of life. What does this fact mean? It
teaches us the following : A young man, after
having chosen his occupation, which, as a rule,
takes place in his twentieth year, or even before
that time, and after having followed this occupa-

tion say for ten years, certainly shows by this
time the primarj' effects of such occupation. A
soldier, a coppersmith or an iron-worker will
have developed his whole muscular system com-
pletely by this time — he will rarely show a ten-
dency to catarrh ; hence a greater rarity of herniae.
A tailor or an engraver, on the other hand, you
will be able to recognize easilj' from the debility
of his constitution. He has already, especiallj^
in a climate favorable to it, a post-nasal catarrh,
hypertrophied mucous membranes in the nose,
etc. , etc. ; and he has also, in a proportion by far
surpassing the other occupations, hernia. We
see, therefore, that it is the occupation which
creates the hernia, and not vice versa.

Allow me to mention briefly two more facts in
corroboration of this. I have before demonstrated
that from the soldiers of the German army, in
spite of their hard physical training, the average
of those rejected for hernia is not more per year
and per 1,000 than 1.05. As I, however, know
now — my tables, I am sorry to say, are not so com-
plete as to be published — the proportion is such,
that with the increasing age of serv^ice the fre-
quencN' of hernia decreases. Thus we see that
bodily straining, gymnastics, out-of-door exer-
cises, etc., can be considered as the best prophy-
lactics agamst heniia:.

It was, furthermore, said that in mountainous
regions ruptures are more common than in low
countries, and this supposition was based on the
belief that the labor in ascending the mountains
must increase their frequency. The only author
whom I am able to cite on this subject is no less
an authority than Malgaigne. According to his
statements, however, in France the reverse is the
case, since just in the mountainous parts ruptures
are infrequent, while they are quite common on
large plains and on the shores of the rivers. We
see, therefore, that just where the humidity of the
climate is able to cause many nasal troubles,
again the herniae are increased in frequency.

According to my personal experience, which,
however, was not exactly directed to this ques-
tion, I can only say that I have seldom seen so few
hernise as I met while in mountainous regions.

Another question to which I would allude is
this : How is it that hernise are more common
in males than in females ? The explanation
which I have to offer is that while the intra-
abdominal pre.ssure is increased in men and
women by coughing, the efforts are more vio-
lently performed in the case of the former.

In view of all these proofs which I advanced,
I hope you will find some truth iu my theory,
and I shall not \.xy your patience with enumerat-
ing a number of less important facts which are
in favor of this theory. In concluding my paper,
which I have read upon the kind invitation of
your Secretary', allow me only to collate the re-
sults of my observations up to date :

478

ABSCESS OF THE ANTRUM.

[October 5,

1. Of 500 ruptured, ad hoc, examined by me
{Monatsschr.f. Ohrenheilk., November, 1887, f. f.)
there were found 143 with strong diseases of the
upper air-passages that made surgical interference
absolutely necessary.

2. Among about eighty members of a family
also examined bj- me (Joe. cit.), almost all had
diseases of the upper air-tract, and one-third had
hernias.

3. Where nasal diseases are less frequent,
there, as we have seen, also less herniae are found
(see Indians).

4. According to the frequency of diseases of
the upper air-passages, hernia was found, of each
1,000 conscripts in the United States, in 50 ; in
France, in 22.89 ; in Italy, in 16.61 ; in Austro-
Hungary, in 14.09, and in Germany probably in
even less than 14 per 1,000.

5. Hard physical work, ascending mountains,
lifting of heavy loads, etc., never give the pre-
disposition to herniae ; but, on the contrary, such
occupations which involve diseases of the upper
air- passages.

6. In women herniae are rarer than in men,
on account of the weaker stress used in pressing
down the intra-abdominal contents during the act
of hawking, clearing the throat, and the like.

1042 Lexiugton avenue.

DIAGNOSIS AND TREATMENT OF
ABSCESS OF THE ANTRUM.

Read be/ore the Section of Laryngologv and Otology, at the Fortieth

Annual Meeting of the American Medical Aisociation, at A'ezo-

port,June, iSSg.

BY J. H. BRYAN, M.D.,

OF WASHINGTON, D. C.

The antrum is that triangular-shaped cavity in
the superior maxilla, sometimes found extending
into the malar bone forming a .second cavit5\ It
is lined by mucous membrane continuous with
that of the nose, and it is occasionally thrown
into folds forming partial septa, a fact of consid-
erable clinical importance. It varies in size ac-
cording to the age and sex of the individual,
being small in children, and larger in the male
than in the female. It diminishes in size in old
age and after the loss of the teeth.

Of the surgical affections of the antrum, sup-
purative inflammations play the most important
part. Until within recent years abscess of the
antrum was regarded as rather an uncommon
affection, but we now know that it exists much
more frequently than was formerly supposed. It
occurs generally after the second dentition ; al-
though there is one case recorded by P. B. Ped-
ley,' of a girl 8 years of age, where the abscess
was due to caries of a temporary canine tooth.

Among the causes of ab.scess of the antrum
may be enumerated : i. traumatism ; 2. the acute

■ Lancet, Feb. 16, 1889.

infectious diseases, such as measles scarlet fever
and smallpox ; 3. syphilis ; 4. an extension of
the inflammation from the lining membrane of
the nose ; 5. extension of the inflammatory pro-
cess from the suppurating pulp of a tooth result-
ing from dental caries. Authorities differ as to
the most common of these causes. Zuckerkandle,
for example, believes that it is more often due to
an extension of the inflammation from the nose ;
while others regard disease of the teeth the prin-
cipal factor in the etiology. I am of the opinion
that the form of inflammation of the antrum
characterized by a sero- mucous secretion, and
known as hydrops anfri, is the result of an exten-
sion of a catarrhal inflammation of the nose. On
the other hand, that form which is more chronic
in character, and is accompanied by a muco-
purulent secretion, is the result of an extension
from the teeth.

The under surface of the antrum is separated
from the alveolar process by a thin lamella of
bone, which is formed with the development of
the permanent teeth ; occasionally, however, it is
absent, and the roots of the teeth are then likelj' to
extend into the antral cavity. Its floor is in close
relation to the roots of the first and second molar
teeth ; and when the cavitj' is unusually devel-
oped the roots of the first and second bicuspid teeth
are brought in contact with it. Lying in such
close proximity to the floor of the maxillan,' sinus,
the teeth when diseased are likely to transmit the
septic process there, and set up a suppurative in-
flammation.

The symptoms of this affection varj- with
the intensity of the inflammation. In a few
cases there is distension of the walls of the supe-
rior maxilla and swelling of the cheek of the
affected side ; pain in the infra-orbital region, and
at the inner angle of the orbit ; tenderness on
pressure over the canine fossa, and occasionally a
crepitating sensation imparted to the fingers, due
to a springing of the distended walls of the
antrum ; a narrowing of the field of vision, due to
pre.ssure on the floor of the orbit, a symptom, ac-
cording to Ziem, much more frequently associated
with affections of the ethmoid cells, and a valu-
able point in the differential diagnosis between
abscess of the antrum and of the ethmoid cells.
In some cases there is a discharge of fetid pus
from the nose, generally unilateral and of long
standing. Long continued secretions of pus from
the nose, especiallj' when confined to one side and
associated with caries of the molar teeth, should
always direct our attention to the antrum as the
source of the trouble. A suppurative inflamma-
tion of the nose is an extremely rare affection.
Stoerk has described such a disease, occurring as
an epidemic among the Gallician Jews.- It may,
however, occur from infection, as for example,
from gonorrhoeal poison.

- Krankliictcn des Kelilkopfes, p. i6i.

1889.]

ABSCESS OF THE ANTRUM.

479

There are four possibilities, after eliminating
wounds, and inflammations following the acute
exanthemata that may give rise to pus in the
nasal chambers: i, foreign bodies, including
nasal polypi ; 2. diseases of the bones ; 3. secre-
tion of pus from the antrum of Highmore ; 4.
secretion of pus from the frontal sinus and from
the anterior ethmoid cells. The secretions from
the anterior ethmoidal cells may enter the middle
meatus, along with those from the frontal sinus,
through the infundibulum, while the secretions
from the posterior cells find their wa}- into the
pharynx along with those from the sphenoidal
sinus.

If the pus should continue to flow after the re-
moval of the polypi, or foreign body, we are then
likely to have either an abscess of the maxillarj'
sinus, of the frontal sinus, or of the ethmoid cells.
Occasionally it is difficult to differentiate between
these, for in each case pus is found in the middle
meatus extending along the inferior border of the
middle turbinated bone. When this body is suf-
ficiently contracted, which can be accomplished
by an application of a 20 per cent, solution of
cocaine, the middle meatus will be brought into
full view, and pus found in the hiatus semi-lunaris.
If it is not possible to bring about the contraction
of this bodj' by cocaine, then the hypertrophied
or swollen tissue should be destroyed by means
of the cauterj', or chromic acid. The opening of
the frontal sinus will be found just below and in
front of the ostium maxillare in a funnel-shaped
depression — the infundibulum. Owing to the
close proximit\' of these two openings it is verj'
difficult to discover from which the pus flows.
Hartmann, of Berlin, has suggested the following
device to ascertain the source of the secretions :
After drying the parts thoroughly with absorbent
cotton, he drives a blast of air through the affect-
ed nostril by means of a Politzer air-bag. By this
procedure he claims to be able to aspirate the pus
from the sinus and thus discover its source. An-
other point in the differential diagnosis is that
abscess of the maxillarj' sinus is of comparatively
frequent occurrence, while that of the frontal
sinus is rare.

The most positive means of differentiating be-
tween these two affections, is by making an ex-
ploratory puncture, as suggested by Moritz
Schmidt." He places a small pledget of cotton
saturated with a 20 per cent, solution of cocaine
under the inferior turbinated body, about its mid- i
die, and allows it to remain in until the parts are
thoroughly anaesthetized ; then raising the end of
the turbinal body, he pierces the thin wall of the
antrum with a sharp-pointed and cur\^ed syringe.
The point of the instrument should be not too
fine, so that it will bend or break when making
the puncture. There is no pain following the
operation and it is entirely devoid of danger. This

3Berl. Klin. Wchschr.. Dec. lo, iSgS.

little instrument should be employed in all doubt-
ful cases, and its use will, I think, tend to prove
that the affection is much more common than is
generally supposed. The indications for treat-
ment are to let out the pus and drain and disin-
fect the cavity until the inflammation subsides.
If the abscess should point anywhere it should be
evacuated at that place.

A great deal has been written recently with
regard to the surgical treatment of these cases,
and it is interesting to note the tendency on the
part of modern surgeons to deviate from the well-
tried practice that has stood for nearly a century,
and to return to the original suggestion of John
Hunter, and the practice of Jourdain — to evacu-
ate these abscesses through the nose.

For nearlj- a century the practice has been to
enter the antrum from the mouth. The opera-
tion that has met with the most favor is that
known as Cooper's — through the alveolar process.
In case a molar tooth is present it should be ex-
tracted and the opening enlarged ; or if, as fre-
quently happens, the tooth has been extracted at
some previous time, the alveolar process should
be perforated at that point. This is best done bj^
means of a small trephine, attached to a surgical
engine, or to the electric motor. The instrument
should be directed slightly forwards and inwards.
This operation has the advantage: i. that of
draining the antnim at it most dependent part,
and that the cavity can be readilj' cleansed by
syringing ; 2. that it can be performed without
the aid of an anaesthetic — a few drops of a 4 per
cent, solution of cocaine injected into the gum
being sufficient to completely anaesthetize the
parts. Its disadvantages are : i. the liability of
food and bacteria from the mouth to enter the
sinus and assist in keeping up the suppuration ;
2. the occasional necessity of extracting a sound
tooth.

If the front wall of the antrum should bulge
forward in the canine fossa, then the operation
known as Desault's should be performed — resect-
ing a small piece of bone from the fossa. Other
surgeons have opened the antrum through this
fossa by means of a trocar, and Fergusson recom-
mended an ordinary carpenter's gimlet.

Another operation through the mouth is that
devised by Bertrandi, who opened the antrum
through the hard palate, when a slight bulging
of that bone showed a tendency on the part of the
abscess to open at that point.

Hartmann, of Berlin, revived, in 1884,3 meth-
od proposed by Jourdain in the early part of the
present century, of washing out and disinfecting
the antrum through its natural opening, the os-
tium maxillare, in the middle meatus. This pro-
cedure is also recommended by Stoerk, and they
claim to have cured a number of cases in this way.
The disadvantages of this procedure are great
and the results .so uncertain that it will never be

48o

ABSCESS OF THE ANTRUM.

[October 5,

generally used ; for the antral opening in the
middle meatus is situated so far above the floor
of that cavity that it cannot be thoroughly
drained, and it would be impossible to wash out
through a tube of small calibre the thick colloid
secretions that are so often found in these ab- j
scesses.

The antrum is a pneumatic extension of the
nasal chamber and communicates normally with |
it. When for any reason this communication is 1
shut off the operation that would restore its
natural condition would seem the mo.st rational
one to select. Jourdain opened this sinus through '
the infundibulum, in the middle meatus ; but
this operation never became popular, because,
owing to the high situation of the po'.nt selected
for making the opening, it was difficult to perform
it. It is, moreover, not unattended with danger,
owing to the possibility of wounding the floor of
the orbit.

Mikulicz advi.ses that the antrum be opened
through the lateral wall of the nose at a point j
where it is thin and easily perforated.^ He uses j
a special instrument for the purpose, which con-
sists of a sharp, double- cutting knife attached to
a handle bent at a blunt angle. It has a flange,
so as to prevent its being shoved in too deep.
The parts having been thoroughly anaesthetized
with cocaine, the instrument is passed into the
nose, and when about the middle of the inferior
meatus, it is turned outward and by firm pressure
is made to penetrate the thin wall of the sinus.
By a to and fro movement the opening can be made
as large as desired. [

This operation has the advantage of draining
the cavity at its floor, and the opening being easily
accessible it can be readily syringed out ; the se- 1
cretions pass through the nose, instead of into the
mouth, and there is little danger of the entrance
of foreign particles into the antrum to keep up
the suppuration. This operation is, however, not
practicable : i . when the nasal chambers are of
abnormally small calibre ; 2. when there is a
deflected septum ; and 3. when there is marked
hypertrophy of the inferior turbinated body. The
principal disadvantage of the operation is that it
leaves a ragged edge in the wall of the antrum,
against the margins of which the nasal secretions
are caught, and becoming dried and hardened may
cause an ulceration when an attempt is made to
remove them.

The local treatment is very important, the suc-
cessful i.ssue of the case depending largely upon
the solutions used, and the care with which they
are applied. The cavity should be irrigated or
syringed gently with mild disinfecting and stimu-
lating lotions daily until all suppuration has
ceased, when the main opening may then be al-
lowed to clo.se.

The fetor that almost invariably accompanies

AArchiv. fiir Ktin. Chir., Her!., xxiv, 626.

these conditions is best overcome b}' means of a
solutionof permanganate of potash, after which
the cavity should be syringed with a weak solu-
tion of common salt and carbolic acid. If the
solutions are applied through an opening in the
alveolar process, great care should be exercised
not to drive them too forcibly against the roof of
the cavity, for by so doing distressing pain may
be produced in the eye.

This treatment will, in many cases, be all that
is required ; but in the more obstinate forms of
inflammation the local application of the peroxide
of hydrogen will be found very efficacious ; or,
better still, glycozone, a mixture of the peroxide
of hydrogen and glycerine. In this preparation
we have the combined effect of the glycerine,
which abstracts water from the lining membrane
of the cavity and keeps it constantly flushed, and
the peroxide, which destroys its septic contents
and, at the same time, stimulates the inflamed
membrane to healthy action. The following are
notes of four interesting and instructive cases
that have come under ra}- observation :

Case I. — Mrs. E. presented herself for treat-
ment March 3, 1887, giving the following his-
tory : She has had frequent attacks of coryza,
and for a number of years has suffered from hay
fever. Two years ago she had considerable
trouble with the second molar tooth in the upper
jaw on the left side, which the dentist broke in
attempting to remove it, leaving the roots in the
gum, and they, from time to time, have caused
her pain. About a week prior to consulting me
she caught a severe cold at a funeral ; since then
she has suffered intense pain in the face and in
the ear ; for several days there has been a watery
discharge from the no.se. Examination : The
left side of the face is very much swollen, and
there is some distention of the anterior wall of
the superior maxilla ; pres.sure upon the affected
side of the face is very painful and gives a crepi-
tating .sensation to the fingers ; the no.se is tightly
blocked on the left side, the right side partly
open ; the first and second biscupid teeth are ab-
sent on the left side, the roots of the second mo-
lar remaining and deeply imbedded in the gum ;
the remaining teeth are in good condition ; secre-
tions from the nose are watery in character ; ex-
amination of the left ear shows a small fistulous
opening in external auditor},' canal just under
the annulus tympanicus, about midway of its
anterior inferior quadrant, but having no connec-
tion with the middle ear : mt. normal in color ;
hd. \\.

On March 4th I perforated the antrum through
the canine fos.sa by means of an ordinary trocar
and inserted a Knapps mastoid drainage tube,
small size. There was a profu.se muco-purulent
flow following the operation. The cavity was
washed out with a warm .solution of common salt
and carbolic acid. After the third syringful had

1889.]

ABSCESS OF THE ANTRUM.

481

been injected the solution passed out of the nose.
There was little or no odor present. This treat-
ment was pursued daily for ten days, when the
secretions ceased entireh\ The drainage tube
caused some irritation in the cellular tissue of
the cheek, and was removed at the end of the
seventh day. Two days after the operation the
nose opened on both sides, so that a rhinoscopic
examination could be made. The mucous mem-
brane of the left side was deeply congested and
very sensitive, the mildest applications causing
paroxysms of sneezing. There was also an ul-
ceration of the septum about the size of a silver
three-cent piece, laying bare the cartilage. By
the use of detergent sprays the inflaramatorj-
condition subsided, and the application of a solu-
tion of nitrate of silver (gr. v, ad. .? j) to the ul-
cer caused it to heal, completely covering the
cartilage.

Case 2. — Mr. , U. S. N., presented himself

in the spring of 1888, complaining of a naso-
pharyngeal catarrh of long standing, and stated
that he was sceptical as regards a cure. He com-
plained principally of a profuse secretion of the
nose, and when in the reclining position the se-
cretions dropped into his throat, causing him
great annoyance.

On examination the inferior turbinals on both
sides were markedly hypertrophied, so much so
that no satisfactory examination of the upper
part of the nasal chambers could be made. The
septum was slightly deviated to the left in its
upper part. The vault of the pharynx was
bathed with a white secretion, but there was no
swelling or hypertrophy in this region. The
hypertrophied tissue was reduced on both sides
by means of the galvano -cautery and chromic
acid. The left middle turbinal body was then
found enlarged, leaving only a fissure between it
and the deflected septum. Pus was found in
this fissure and in the middle meatus, reappear-
ing as soon as it was wiped away with absorbent
cotton.

Upon further inquiry he stated that in 1867 he
had some trouble with the second molar tooth in
the upper jaw on the left side. The nerve was
killed and the tooth filled without removing the
dead pulp. After suffering for two years with
frequent small abscesses around the tooth the
filling and the decomposed tissue were removed.
He dates the nasal discharge from six months
after the first filling was put in. He has never
had any pain in the face, but it is somewhat
fuller on the affected side. The nasal discharge
has been constant and very annoying.

Being unable to decide whether there was an
abscess of the ethmoid cells, complicating the
antral condition, the case was referred to Prof.
Harrison Allen, who diagnosed an abscess of the
maxillary sinus. At this point my relations to
the case terminated, for he was transferred to his

attending phj'sician. Dr. Rixey, U. S. N., through
whose courtesy I am allowed to continue the re-
port of the case.

The second molar tooth was extracted and
found badly ulcerated at its roots, the opening in
the alveolar process was enlarged and the cavity
syringed with warm, disinfecting solutions, bring-
ing away a great quantity of very fetid pus and
mucus. The treatment has been carefully car-
ried out under Dr. Rixej''s direction with marked
improvement in his condition. Although there
is some secretion still, sufficient to require the
cavity to be washed out once a day, he is com-
parativel}- comfortable. He wears a gold tube
in the alveolar opening, covered by a plate, so as
to prevent any of the secretions passing into the
mouth.

Case :;. — Mrs, P., admitted Sept. 10, 1888,
complaining of a fetid discharge into the mouth
through an opening left by a recently extracted
tooth. She gave the following history : For a
number of years .she has been afflicted with nasal
catarrh, for which she received treatment from
numerous physicians without any benefit. About
three j-ears ago the secretions from the left side
of the nose became so profuse that her life has
been a burden. She frequently complained of
toothache, and a week ago she had the second
molar tooth on the left side extracted. Since
then the nasal secretions have greatly diminished,
but a great quantitj' of foul pus is passing con-
stantly into the mouth. She complains of con-
stant nausea and loss of appetite, and is obliged
to mop the gums constantly, so as not to swallow
the pus. There has never been any swelling of
the face, and the patient does not recall having
had any tenderness on that side of the face. Pres-
ent condition : She has an anxious expression ;
complexion sallow ; tongue furred ; pus was ob-
served flowing freely from the opening in the
gum ; a probe passed readily into the antrum ; no
swelling or pain on pre.ssure on the affected side
of face. Examination of the no.se shows a col-
lection of thin pus in the middle meatus along
the lower border of the middle turbinal on the
left side ; the right side shows no abnormal con-
dition.

The opening into the antrum was enlarged and
the cavity sj'ringed with a solution of permanga-
nate of potash. Immediately there came from
the left side of the nose a great quantity of fetid
and dark green pus, partly fluid and some of
thicker consistency. The odor was almost un-
bearable. The cavity was washed out daily with
a solution of common salt and carbolic acid for
nearly three weeks, when the discharge ceased
entirely and the opening into the antrum was al-
lowed to close.

Case 4. — Capt. , U. S. A. First seen Feb.

I, 1889. Complained of nasal catarrh, from
which he has been suffering for a number of

482

ABSCESS OF THE ANTRUM.

[October 5,

years. When a cadet at West Point the nerve of
the left second molar tooth was killed. Two
years later the tooth broke off and a piece of raw
cotton was taken out of it in a very fetid condi-
tion. He never had any trouble with his nose
prior to that time. There has always been more
or less pain in the left side of the face since the
tooth was filled. About two years ago the secre-
tion of pus from the nose became very annoying,
dropping back into the pharynx when he is in
the reclining position.

Examination shows the left side of the face to
be somewhat fuller than the right. There is a
suffusion of the conjunctiva of the left eye which
has existed for some time. The second molar
tooth in the upper jaw on the affected side is ab-
sent ; the other teeth are in good condition.
There is a thin purulent secretion from the left
side of the nOse, which is most abundant in the
middle meatus ; it recurs rapidly after removal.
The mucous membrane on the affected side of the
nose deeply congested. The alveolar process
was opened by means of a small trephine, 3 mm.
in diameter, attached to a surgical engine, the
gum having been previously anaesthetized by the
injection of a few drops of a 4 per cent, solution
of cocaine. The cavity was readily reached, and
it was then syringed out with a warm solution of
bicarbonate of soda. A great quantity of fetid
pus, mixed with a thick yellow colloid mucus,
came out through the nose. There was some
bleeding following the operation, but that soon
ceased. The antrum was washed out daily for
ten days with a solution of common salt and car-
bolic acid, when the odor ceased, but with little
effect on the quantity of secretion of pus. The
treatment was then changed to a solution of
boracic acid, with no marked improvement fol-
lowing . One application of a solution of bichloride
of mercury (1-2500) was made, but owing to the
severe pain it caused it was not tried again. I
then used a solution of the peroxide of hydrogen
with some benefit, but as the improvement was
not as rapid as could be desired I was advised to
try glycozone. Each application was followed
for several hours afterwards by a profuse waterj'
discharge from the nose. The improvement, af-
ter the use of this application, was marked from
the outset, and in ten days after its first applica-
tion all suppuratioii had ceased, the opening in
the alveolar process was allowed to close, and the
patient was discharged cured.

My experience with glycozone is limited, and
I can only judge of its efficacy in this one case ;
but it seems to me to possess advantages that we
have long been in need of in treating these
chronic abscesses of the maxillary sinus.

Dr. J. O. Roe said : It is my opinion, based
on my own experience, that abscess of the an-
trum is more often caused by diseases in the nose

than by diseases of the teeth. I can now recall
eight cases of abscess of the antrum that have
come under my care. In four of these cases the
abscess was caused by, or associated with, nasal
polypi, and there was no disease of the teeth.
In three of the other cases the disease was asso-
ciated with, and apparently caused by, dental
caries. In two of the four cases associated with
nasal polypi the abscess was not suspected before
the polypi were removed, the fetid discharge be-
ing attributed to retained secretion that had be-
come decomposed. In every case there was more
or less nasal disease. In the study of these cases
I concluded that the nasal difficulty had a marked
influence in the production of the disease in the
antrum ; first by the irritation in the nose, caus-
ing a turgescence of the lining membrane of the
interior of the antrum ; secondly, by the direct
extension of the disease from the nose into the
antrum over the continuous surface, and thirdly,
by closure of the nasal opening into the antrum
by the disease in the nose, thereby causing a re-
tention of the discharge excited by the congestion
or disease in the antrum.

Dr. Lippincott was under the impression that
purulent disease of the antrum was frequently
due to morbid conditions of the teeth. Abscess
of the orbit not infrequentlj' has for its raison
d'etre a suppuration process originating in the
antrum ; and in a large proportion of orbital ab-
scesses arising in this way the primary cause has
been dental caries.

Dr. E. Fletcher Ingals, of Chicago, had
treated several cases of the kind. One had been
cured after about three weeks' treatment, having
been washed out repeatedly with peroxide of
hydrogen through the normal opening into the
nasal cavity. However, he had three cases under
observation where every form of treatment had
been inefficient in checking the purulent dis-
charge. They had worn tubes in the alveolar
process for periods of five, three and two years
respectively, and in neither did there appear to
be any dead bone, as the discharge was not offen-
sive. He thought that an opening at leasts mm.
in diameter should be made, to allow the intro-
duction of a tube and free discharge.

Dr. Daly, of Pittsburg, President, said he had
had some experience in the disease of the antrum
referred to in the paper just read, and had writ-
ten a paper upon a series of such cases, which he
read before the American Laryngological Asso-
ciation some eight years ago. He was in the
habit of opening the antrum through the alveolar
process. A surgical engine is not necessary for
this. He had once gone into the antrum through
the .socket of a tooth by means of a small bevel-
pointed screw-driver belonging to a gun case. It
ought to be borne in mind, however, that the
operation is not without danger. One of the
brightest men that has ever adorned the Ameri-

1889.]

UTHOLAPAXY IN CHILDREN.

483

can medical profession died a day or two follow-
ing an operation on his antrum — a man whose
teachings have since become regarded as revela-
tions made far in advance of his time and profes-
sion. I refer to the late Dr. Beard, of New York.
The surgeon who operated on Dr. Beard gave
me, shortly' after, an account of the operation,
which was done with his customary care and
skill. The opening was large and made into the
antrum by means of the dental engine. Within
twenty-four hours after the patient had a chill
and other symptoms of septic infection, and died,
creating an irreparable loss to the medical pro-
fession. The after treatment is necessary to be
continued with the utmost care and asepticism
for a long time, and not among the least useful
and efficient cleanser is one that is nearly always
at the hand of the patient, wherever he may be.
I refer to soap and water. The third case upon
which I operated went to the far West after a
few weeks' care, having with him a prescription
for an anti.septic fluid which was ordered to be
used several times a day. The patient lost the
bottle, or broke it, and as a dernier ressorf used
soap and water, found it efficient and continued
it until the discharge ceased at the end of six
months. He has for eight years remained quite
well.

Dr. D. Brvson Del.wan, of New York, re-
ferred to a case of abscess of the antrum which
had resisted a great variety of treatments at skill-
ful hands, in which the application of the gal-
vanocautery to the mucous membrane of the
middle turbinated body of the affected side was
followed by marked temporary relief

Dr. Bryan agreed with all that had been said,
and further stated that the obstinacy of these
cases was, he thought, largely due to incomplete-
ly wa.shing out the cavity, leaving septic matter
between the partial folds of mucous membrane,
which is sufficient to start up the inflammation
again after it had apparently .subsided.

LITHOLAPAXY IN CHILDREN.

Read in the Section of Surgery and Anatomy, at the Fortieth Annual
Meeting of the American Medical Association, June, 18S0.

BY DUDLEY P. ALLEN, M.D.,

VISITING SURGEON TO LAKESIDE HOSPITAL AND TO CH.ARITY

hospital; consulting- surgeon to ST. ALEXIS' HOSPITAL,

CLEVELAND, OHIO.

In accepting the invitation of our President to
discuss before this body the subject of litholapaxy
in children, I have felt no slight degree of hesi-
tation. In the region of country where I reside
— Cleveland, Ohio — stone in the bladder is of rare
occurrence, so that no one surgeon .secures a large
number of cases for operation. However, having
resided in the Massachusetts General Hospital,
and having seen during three years the evolution
of the operation of litholapaxy in the hands of

Henry J. Bigelow, and having followed it care-
fully abroad as performed by Guyon of Paris, Sir
Henry Thompson of London, and other surgeons,
and having added to this some experience of my
own in operating upon children — I shall venture
briefly to open this discussion, hoping to elicit
from others opinions which will be of value to
us all.

Though the operation of litholapaxy on chil-
dren is a recent one, the success with which it has
been performed must, beyond all question, place
it among the established operations. Introduced
into the Indore Hospital of India by Surg. Major
Keegan, it had, according to the latest statistics
which are within mj' reach, been performed by
him and his associates in 114 cases, with four
deaths. One of these deaths was of a patient
with very advanced kidney disease, where opera-
tion was earnestly solicited onl}' in the hope of
securing relief from suffering. A second death
resulted from three attempts to crush a calculus
formed about a tilli stalk. Whether or no these
two cases be deducted from the number of deaths,
as perhaps they might be with fairness, the result
is a brilliant one. To be sure, the last report of
Surg. Major Freyer gives 165 successful consecu-
tive lateral lithotomies on boys under 16 j'ears of
age; but he reports sixteen successful consecutive
litholapaxies, and favors the operation in suitable
cases. To emploj- this operation to the exclusion
of all others would of course be an error. There
are, however, many cases in which it is especially
adapted. To point out these cases, and the ele-
ments of importance belonging to the operation,
is the object of this paper. In doing this we will
compare litholapaxj' with lateral, median and
suprapubic lithotomy.

In comparing litholapaxy to lateral lithotomy
it must of course be acknowledged that Freyer's
165 successful consecutive operations upon boys
is a more brilliant record than that obtained by
any other method. These figures represent, how-
ever, the result of vast experience, and are, so far
as we know, the best ever obtained. It is not at
all impossible that time and experience may yield
similar success to litholapaxj'.

The removal of large stones from boys bj' lat-
eral lithotomj' is associated with dangers of bruis-
ing, hsemorrhage, and possible injury to the re-
productive apparatus. Too great size is also a
bar to litholapaxy in children, on account of the
difficulty in removing the fragments of the crushed
stone through the necessarily small evacuating
tube It is in these cases of large calculi that
the suprapubic operation has its advantages, as
well as in cases of disea.sed bladder or encysted
stones.

In case of small stone, median lithotom}' is an
excellent operation, and is a formidable rival to
litholapaxy in the field to which the latter is es-
pecially adapted. In this connection a letter

484

LITHOLAPAXY IN CHILDREN.

[October 5,

which I have recently received from Dr. J. G.
Kerr, of Canton, China, may be of interest. I
take especial pleasure in reading his letter before
this body, on account of the admirable work done
by this missionar}' physician in operating on cal-
culi— some account of which was recently pub-
lished in this country. He writes : "I have not
practiced litholapaxy in children. In most of the
cases I meet with in boj's, the stones are large,
and I would be disposed to crush only in cases
where the stone was very small. I would prefer
the operation I practice, and have performed in
many cases, simple incision of the membranous
urethra, and extraction of the stone with a small
pair of forceps, dilating slightly the opening in
the bladder. The operation is simply an incision
into the urethra and as devoid of danger as any
operation for stone can be. Mj* experience in
lithotomy, lithotrity and litholapaxy amounts to
between 700 and 800 operations, etc." I omit
the remainder of the letter for lack of time, but
surely the opinion of a surgeon of so great expe-
rience and recognized ability must weigh stronglj-
in favor of the operation of median lithotomy for
small calculi in boys.

Before speaking of the advantages peculiar to
litholapaxy' as compared with suprapubic lithot-
omy, I think you will be interested to hear a let-
ter which I have received from Professor Freder-
ick Petersen, of Kiel, German}-, under date of
June 3. As you all know, he is the originator of
the operation of suprapubic lithotomy as at pres-
ent performed, an operation which has secured
such brilliant results as to entitle him to the ad-
miration of all surgeons and the thanks of hu-
manity. His letter, translated, is as follows :
" With litholapaxy in children I have no experi-
ence, since I always do the cutting operation, and
in difficult ca.ses give the suprapubic operation the
preference. When possible after removal of the
stone, I unite the bladder with a double line of
catgut sutures. The upper portion of the inci-
sion in the abdominal wall is united by sutures
of silkworm gut. Through the lower portion of
the abdominal incision are placed superficial and
deep silkworm gut sutures, but these are not tied.
This lower portion of the wound is tamponed with
iodoform gauze, which remains three days, when
it is removed and the sutures are tied — thus fully
closing the wound. No catheter is placed in the
bladder, but the patient is permitted to pass his
water if he is able to do so; otherwise it is drawn oflF
by a catheter as required. Mit der Lilholapaxie
kann ich mich noch ittimcr nichl hefrciniden."

Agreeing then, as all must, that there is much
in favor of the various cutting operations, and
that there are cases suited to each of these meth-
ods, let us compare them with litholapaxy. One
advantage of litholapaxy over other operations is
that it is not a cutting operation. Of course, from
the standpoint of good surgery', this should weigh

little in its favor. This much, however, is true :
There is no small proportion of cases in which an
operation where cutting is required will be long
delayed ; whereas, should the public understand
that calculi can be removed without cutting they
will bring to the surgeon at a much earlier period
children suffering with stone, and thus render its
removal more easy, whatever plan may be adopt-
ed. Cutting operations, however, have another
and greater disadvantage. Thus far, union of the
bladder by first intention after cutting has been
rare, by any method save the suprapubic, and in
this operation it is not the rule. Though the
drainage of the bladder may have its advantages
in securing a healthier condition of that viscus, it
has the ver>' serious disadvantage of soiling the
patient's bed, rendering him verj- offensive for a
longer or shorter period and, when the bladder
fails to heal for a considerable time, as is not in-
frequently the case, resulting in sores that are
painful and troublesome. The difference in com-
fort to the patient, and the time he is confined to
the hospital, is also considerable. The average
number of days spent in the hospital in Keegan's
cases of litholapaxy was 5.7. The average which
he gives after lithotomy was 17.61. The average
days in hospital of Freyer's cases after litholapaxy
was 6.12. We are unable to give a sufficiently
large number of cases of suprapubic lithotomy,
performed by any one operator on children, to es-
tablish any reliable percentage as to time, and it
is evidenth- unfair to this operation to judge it by
statistics gathered from various sources. Though
a certain percentage of cases heal by first inten-
tion, I think it is beyond all question that up to
the present time no operation for stone confines
patients to their beds for so short a time as litho-
lapaxy. In many cases after litholapaxy' in chil-
dren, the patients are free from all discomfort on
the third day, and are up and around. Lithola-
paxy cannot in any way injure the reproductive
apparatus, but very likely the danger of this re-
sulting from lateral lithotonu' has been overesti-
mated.

The advantage gained by ability to see the in-
terior of the bladder, as is done in suprapubic
lithotoni}', is urged in favor of that operation. It
is to be remembered, however, that the bladders
of bo\'s are, as a rule, in a more healthy condition
than those of adults, and that encysted stones are
uncommon, so there is rarely any necessity of
seeing the interior of the bladder. It has been
objected, too, that stones recur more frequently
after litholapaxy than after cutting. However,
Keegan says that of his 114 cases operated be-
tween 1 88 1 and 1886, not a single one has re-
turned -SO far as he knows, and he adds that had
there been a recurrence of the stone it is quite
probable that his patients would have returned to
him.

A case of my own, bearing on this point, may

1889.]

LITHOLAPAXY IN CHILDREN.

485

not be out of place. A boy was cut for stone in
March, 1884, and again in April, 1 886. In about
one year after the second operation the boy began
again to suiier from symptoms of stone, and in
February, 1888, I performed litholapaxy. The
boy's sufferings had been terrible, vesical tenes-
mus being frequent, and so severe as to cause his
cries to be heard all over the neighborhood. The
boy slept verj- little, and I have rarely seen a pa-
tient in a more pitiable condition. Since the per-
formance of litholapaxy the patient's relief has
been complete. Should there be any return of
the calculus there certainly will not be the hesita-
tion to undergo another operation for crushing
that there was in the case of cutting. The suc-
cess of this case may have been due to the after-
treatment. After recovery from the operation I
washed out the bladder twice each week during
nearly two months with a solution of argenti ni-
tratis, varying from '3 to I gr. to water .siv. This
is, I am convinced, a wise plan of treatment, and
has resulted in this case much more successfully
than did the previous cutting operations. It seems
to me as reasonable to treat a bladder with cvsti-
tis by washing it out, after litholapaxy, as thus
to treat cystitis from any other cause, and I fully
believe that by this method all the advantages
can be gained that are now claimed for drainage
after lithotomy, without the accompanying disa-
greeable features of bad spells, a filthy bed and
irritated skin.

One great difficulty in litholapaxy is the small
size of the instruments which mu.st be used.
These are larger than would be supposed possible.
There are, however, variations in the size of the
urethra in different boys. Boys from 7 to 8 years
usually admit a 10 to 11, English .scale. Some'
cases occur, however, where even after incising
the meatus, the urethra is so small that suitable
instruments cannot be inserted. Obviously in
these cases lithotomy is the proper operation. '

As to whether hard or large stones should be
crushed is a question. Certainly there are limi-
tations in both these directions. Though a stone
can be measured as to size with some degree of
accuracy, still all who have performed litholapaxy
have found stones which gave the same measure-
ment by the lithotrite varj' greatly in weight and
volume. This is easily explicable in considera-
tion of the different diameters by which a stone
may be seized. Concerning the densit)' of a stone,
it can hardly be possible to form any definite
idea of many calculi, until the operation of crush-
ing has begun. It is not rare to seize a stone with
a lithotrite, and feel the blades of the lithotrite
sink into the stone, and then come upon a hard
centre, which is crushed with much greater diffi-
cultj'. Were one to find a large and verj' hard
stone, it would doubtless be well to abandon lith-
olapaxy, and perform lithotomy — and the size of
stone upon which an operator may venture must

be measured .somewhat by his experience and
dexterity.

Before considering the technique of the opera-
tion, we may quote from a letter from Mr. G.
Buckston Brown, for many years associated with
Sir Henry Thompson, and himself a surgeon of
large experence in operations on stone. Under
date of May 26, he writes: "I respond with
pleasure to your request. I was, I believe, the
first publicly to draw attention in our London
medical press to the excellent work done by Surg.
Maj. Keegan of India, the pioneer of lithotrity in
children. I think I cannot do better than enclose
you an extract from my article on the choice of
operation." .... "Now, however, that lithot-
ritj' at one sitting — by which is meant the crush-
ing and complete evacuation of the calculus at a
single operation — is accepted as yielding in the
adult far better results than the older or many
sittings method, it is not unlikely that the single
sitting operation maj' prove superior even to lith-
otomy in children, for if efficiently carried out,
lithotrity will no longer be open to the objections
formerly urged against it. . . . The surgeon raaj-,
therefore, choose for himself between lithotomy
and lithotrity if called to operate upon a boy ;
but if ine.xperienced in lithotrity, he will perhaps
do well to decide in favor of the former."

We will now consider the operation itself, and
first as to instruments. Their size must varj- with
the case to be operated upon, ranging from 6 or 7
to 10, English scale, and, as has already been
stated, the age of the boy is not a sure indication
as to the size of the urethra — since in young chil-
dren it is sometimes quite capacious. With in-
struments of so small size the importance of hav-
ing them of the most reliable manufacture will at
once be apparent.

Since it is desirable to use a lithotrite as large
as can safely be inserted, it is imperative that its
size should not be increased before withdrawal ;
consequently, provision must be made against im-
paction. Were impaction of the blades with de-
bris to occur, serious damage might result in their
withdrawal. On this account it is found best to
construct the lithotrite so that the male blade
shuts into the fully fenestrated female blade, ren-
dering impaction impossible. This complete fen-
estration of the female blade has one disadvantage
in my experience, viz.: in crushing a hard stone,
pieces which are too large to pass through the
small evacuating tube may be repeatedly pushed
through the fenestrated female blade without
being crushed. When this difficulty has arisen,
I have overcome it by inserting a small lithotrite
with a flat unfenestrated female blade, having no
fear of impaction in crushing the few small pieces
which may remain. With a few motions of this
lithotrite, I have accomplished what I had failed
to do after working with the completely fenestra-
ted blade for a considerable time.

486

I.ITHOLAPAXY IN CHII.DREN.

[October 5,

The small size of the evacuating tube shows '
the necessity of finely crushing the stone, and it
is desirable that this be done with as few inser-
tions of the lithotrite as possible. Frequent with-
drawal of the lithotrite may cause congestion and
swelling of the mucous membrane of the urethra,
and consequent difficulty and danger in the inser-
tion of instruments. A recent letter from Guyon
of Paris may be of interest as bearing on the ques-
tion of crushing. He writes : ' ' Calculi are verj'
rare in our country among children, especially I
those of the better class. My hospital service is j
one of adults ; consequently I have performed
lithotrity only twice on children under 5 years of
age. One of these patients had a verj' small
stone ; the second had a stone which measured 3
centimeters. Lithotrity gave an excellent result.
I am a strong advocate of lithotrity among chil-
dren, but only of lithotrity at one sitting Not to
empt}- the bladder completely of fragments, but to
leave them, is a gross surgical error. There are
but the two methods — either lithotomy or lithot- i
rity at a single sitting. I find, however, the term
litholapaxy a misnomer. It supposes the aspira-
tion of the fragments to be the chief role. It is
the crushing which is the chief role, and lithotrity
is the important thing. I am a strong advocate i
of aspiration, but this is only a complement, a
grand perfecting of the operation to be sure, but
it is not the operation, and as a result one does
not perform litholapaxy, but lithotrity. It is
thorough cru.shing which renders possible suc-
cessful evacuation, and this is especiall}' true with
children, since with them one cannot employ large
tubes for the evacuation of the fragments." Stand-
ing as Guj-ou does, one of the first surgeons of
the world in the line of genito-urinan,- surgery,
his opinions are entitled to much consideration.

As in adults, so in children, the facility with
which a stone is crushed depends largely upon its
density. I show you here specimens of both hard
and soft stones which I have removed from chil-
dren b}- litholapaxy, and I have found that a
small hard stone requires far more time in crush-
ing than a soft stone of much larger size.

In withdrawing an evacuating tube it is impor-
tant to bear in mind the possibility of a fragment
of stone being caught in the eye of the tube. To
draw this through the urethra of a child might
cause serious damage — as well as to lose a frag-
ment in the urethra.

The narrow size of the meatus in many ca.ses
renders its incision desirable, since less damage is
done by its incision than by forcing instruments
through it. All manipulations in the child's blad-
der require the greatest delicacy, and the dexter-
ity and care of the operator will undoubtedl}- in-
fluence greatly the success of his operations. .

I show you here two litliotrites, the long one
made by Codraau & Shurtleff, of Boston, with a
Bigelow lock; the short one made by Wies, of

London, with the old lock. Without question
the small instrument has its advantages in being
lighter, more easily manipulated, and perhaps
less likely to do damage bj' prying upon the neck
of the bladder while working. The Bigelow lock
is, however, vastlj^ superior to the other, since the
same movement with the right hand which locks
the instrument begins the crushing and decreases
greatly the liability of losing the stone from be-
tween the blades.

So far as difficulties of operations in children
as compared with adults are concerned — though
the operation requires much dexterity' and, on ac-
count of the size of the instruments, is perhaps
more difficult, on the other hand the bladder is
less frequently in a seriously diseased condition.
There are no enlarged prostates, pockets or pro-
jecting- bands to give trouble ; diseased kidneys
are less frequently a complication, and the recu-
perative power of children is greater than in
adults.

To summarize, then, we would say that beyond
question the operation of litholapaxy in children
is one which must be recognized. It is particu-
larly suited to medium and small-sized stones, and
though median and lateral lithotomj- are very suc-
cessful in such cases, we believe litholapaxy will
be equally so in skilled hands, and that, beside
safet}-, it has the great advantage of absence of
cutting and of the filthy condition of the patient.
Suffering is commonly verj- slight and is confined
to a few days, and it is not infrequent for patients
to be up and around on the third or fourth day.
Patients will not hesitate so long before the crush-
ing as the cutting operation, and should the return
of the stone be more frequent after crushing than
after cutting — as is by no means shown to be the
case — a second operation will be more easily per-
formed than the first, on account of the size of
the urethra increasing with the age of the patient.
I The condition of a boy's bladder is certainly more
likely to be favorable to litholapaxy than that of
an adult.

Our idea would be that large and hard stones
should be removed by the suprapubic operation,
especialh- if for any reason it is desirable to see
the interior of the bladder. Medium and small
stones are favorable for removal by litholapaxy,
unless for some reason the urethra be smaller than
normal. The operation of median lithotomy is a
favorable one in cases with small stones, but an
operator skilled in litholapaxy would do well to
choose the latter.

In cases of medium-sized stone, with a urethra
not sufficiently large for the introduction of proper
instruments for crushing, lateral lithotomj- is in-
dicated.

Dr. R. p. Harris, of Philadelphia, has been
elected an honorary member of the American
Gynecological Society.

1889.]

MEDICAL PROGRESS.

487

MEDICAL PROGRESS.

Treatment of Pulmonary Phthisis. — At a
special meeting of the Allegheny County Medical
Society, held August 20, 1889, Dr. Iy.\NGE re-
ported a new method for the treatment of pulmo-
narj' phthisis. We quote from him as follows :
The method consists of the inhalation of vapor-
ized mercury and iodine. Of the results of this
method I have nothing to saj'. I cannot forget
that grass has not j-et grown upon the grave of
gaseous enemata, and I am aware that many men,
manj' years and manj' cases are required to pro-
duce evidence of the usefulness of any remedy
or method in the treatment of anything, even
when the remedy or method possesses usefulness.
I report this method because I desire co-workers.

It suggested itself to me that vaporized mer-
cur)', if brought into more or less direct contact
with the bacillus of Koch, might destroy this,
and that iodine, if applied directlj' to the ulcerat-
ing surfaces of lung tissue might effect a more
powerful beneficial action than that resulting
from its ordinary method of administration. I
have had, and still have, the valuable assistance
of Dr. Tinglej- in the preparation of apparatus
and in devising ways and means by which these
vapors may be satisfactoril}' administered to
patients. This has presented many diffculties.
A principal one is, that I know of no manner as
yet by which a definite, a known quantity can be
given. The vaporized mercurj' salts are resub-
limed and deposited upon the cooler parts of the
apparatus. This is particularlj- true of the in-
haling tube, which is always the coolest part of
the apparatus. The consequence of this is that
patients receive always an unmeasured, an acci-
dental quantity of these salts or vapors, and not
a quantity which is measured or known. To
this fact are due two accidents, namel5', that one
very feeble patient was violently purged, and an-
other was salivated. However, we hope to over-
come this defect of apparatus and to be able .soon
to give patients exact quantities of these salts.
The desideratum is an inhaling tube which will
bear the temperature necessary to hold the mer-
cury salts vaporized up to the lips of the patient,
and which at the same time shall be flexible.
Flexibility is almost a necessity ; a feeble patient
cannot breathe deeply and persistently from a
-stiff tube, a glass tube such as I now use.

I have found that the only salts of mercury
available for this purpose are the red oxide and
calomel. All others are reduced before being
volatilized. I began with the iodide of mercurj-.
This and all others when used result in the vapor
of metallic mercury onh-. I have found no ob-
jection, however, to the use of metallic mercury,
only it is to be noted that when other salts than
calomel and the red oxide are used, the patient
receives the vapor of metallic mercury.

Can the vapor of mercur>', or anything inhaled,
reach the bacilli in a tuberculous lung ? Those
bacilli, which are in consolidations, provided
such consolidation is connected with a per\dous
bronchial tube, those in lung cavities furnished
in the same manner, those in the bronchial tubes,
those in the alveoli, and those in the sputum may
be reached by this vapor, or by anything which
may be deeply and persistently inhaled. But
these bacilli are comparatively inert ; they are
harmless ; they have alreadj- accomplished their
mission of destruction, and are being extruded
from the body. Those whose destruction is very
much more desirable, those which have not yet,
but which certainly will, produce consolidation
and .softening, i. e., destruction of lung tissue,
those in the pulmonary connective tissue, and the
lymphatic sheaths of the blood vessels, can these
be reached by anything that may be inhaled ?
Again, if we grant that in a certain patient
every bacillus has been destroyed, this is by no
means s)-nonymous with his cure. Evidences of
this fact are presented dailj' ; patients die of non-
tuberculous phthisis verj' readily. And the tu-
berculous patient with every bacilli in his lungs
destroyed, possesses still that fatal predisposition,
and will be reinfected.

It is a question also whether mercurial vapor
is a germicide. No one will denj- this property
to corrosive sublimate. But corrosive sublimate
is not volatilizable, and volatilized mercury, vo-
latilized calomel, and red oxide, are very differ-
ent substances indeed.

Despite these theoretical objections I am en-
couraged to proceed with this treatment of
phthisis, and when I have perfected the apparatus
and have a series of cases certainly tubercular, as
demonstrated by the discovery in the sputum of
the bacilli, which Dr. Matson has kindly con-
sented to do for me, I shall report again to the
Society.

The Diuretic Action of Caffein in Com-
bination WITH Paraldehyde. — Their attention
having been drawn to the excellent e.xperimental
studies made by Von Schroder concerning the
diuretic action of caffein, \. Cervello and G.
Caruso- Pecoraro {Sicilia Med.) have tested its
effects in the human .subject. The first patient,
a woman, 40 years of age, exhibited a moderate
degree of intra-peritoneal exudate, the result of
venous stasis from a heart lesion. A combination of
caffein with paraldehyde resulted on the first day
in an increase in the excretion of urine from 900
ccm. (the previous amount) to 1,690 ccm. By
the eleventh day the amount had been increased
to 2,100 ccm., and the ascites had markedly di-
minished. In like manner a similar result was
effected in the case of an individual 22 years old,
who also suffered from a heart lesion. In a case
of chronic diffuse nephritis with marked oedema,

488

MEDICAL PROGRESS.

[October 5,

the patient's condition was considerably improv-
ed by the administration of caifein and paralde-
hyde the quantity of urine passed increasing
from 800 com. to 2025 ccm. Quite as favorable
as this was the result produced in a second and
similar case of nephritis. This combination of
remedies has also produced absorption in sero-
fibrinous pleuritis, with abundant exudate and
no tendencj- to spontaneous resorption.

The paraldehyde is given either in capsules or
solution in doses of 2-3 grm. two or three times a
da}' ; the caffein in doses of 0.25-0.5 grm. The
paraldehyde should alwaj'S be administered to-
ward evening in order that its soporific effects
may be felt at bedtime. In ascites following cir-
rhosis of the liver, the usual and favorable diuretic
effect of the caffein was not obtained. — Central-
blatt f. Klin. Med., No. 34, 1889.

Report of Ten Operation Upon the Kid-
neys.— (E. DovEN, before the Academie de Med-
icine.) These ten operations were performed by
the lumbar method. Three patients upon whom
nephrectomy was performed died. In two of
these there was old renal tuberculosis, and the
opposite kidney had undergone amyloid degen-
eration. The third had suffered from attacks of
hectic fever for six months and the kidney con-
tained a large calculus. In all three cases the
operation presented great difficulties on account
of the size of the purulent kidnej-, as well as the
extent and firmness of the adhesions. The re-
moval of the kidney in the other cases operated
on was relatively easy and recovery occurred
without the slightest complication. One of these
had undergone an operation for the establishment
of an uretero-cutaneous fistula fortj^-two days be-
fore the nephrectomy, the left ureter having been
divided during an ovariotomy. I

Two other cases are of particular interest. One
was that of a woman 42 j'ears old, who submit-
ted in June, 1887, to removal of a tuberculous!
kidney together with the upper third of the de- ;
generated ureter ; today she is in perfect health.
In another case, two years after removal of the
right kidney (which was reduced to a fibrous t
shell containing more than 100 calculi) it became
necessan,' to perform nephrotomy and lithotomj'
on the left side on account of a calculus deeply
engaged in the ureter. This intervention was fol- ,
lowed by complete success.

In two operations nephrorrhaphy was per-
formed through a simple vertical incision. The |
kidney was fixed to the quadratus lumborum
and the musculo-en-aponeurosis by four sutures,
which were pressed as deeply as the pyramidal
region ; the fatty capsule was resected ; the re-
sults have been excellent.

In cases of lithiasis nephrotomy is indicated,
being preferable to nephrectomy, because a very
small bit of renal tissue becomes precious when

the second kidney is affected. Incision followed
by curetting of the cheesy foci should be pre-
ferred to nephrotomy in cases where there is a
very large and very adherent tubercular kidnej'.
Le Bulletin Medical.

Cause of Local Recurrence after Ampu-
tation OF Breast for Carcinoma. — (^Lothar
Heidenhein in Langenbeck's Archiv fur
Klinische Chirurgie, vol. 39, Heft i.) In mak-
ing a most thorough and complete study of sev-
eral thousand microscopic sections taken from the
cut surface of eighteen different breasts, removed
by Prof. Kuster, he has come to the following
conclusions : That although in each case the cut
surface was a considerable distance from the
tumor, in nine cases portions of the fascia of the
pectoralis major, which remained, certainly con-
tained microscopic collections of carcinomatous
cells, in three others this condition was possible
although not proven, while six cases seemed to
be free from remnants. The clinical observations
of these cases so far corresponds ven,- closelj' to
this. He found that the invasion of the sur-
rounding tissue took place through the lymph
channels and along the lymph spaces surround-
ing blood vessels and in the connective tissue
trabeculae, but reaching the fascia of the pecto-
ralis major they filled this structure, but did not
penetrate the muscle except in advanced cases,
hit this fascia can be removed only by taking icith
it a layer of the muscle. This is the practical
point which will probablj' save hundreds of cases
from having recurrence of mammar}- cancer in
the future. The article covers 70 pages and is of
very great scientific and practical value. The
author also confirms other previouslj' observed
facts.

An Aborted Ovum of Three Months' De-
velopment.-— In the Obstetrical Societj- of Vien-
na, Prof. Gustav Braun exhibited an aborted
ovum of three months' development, in which
the relation of amniotic bands to arrested foetal
development was susceptible of beautiful demon-
stration. The foetus itself was macerated : the
cord 9'.> cm. long, which was torn during birth,
passed from the umbilical ring under the left ax-
illa to the neck, around which it took a turn and
then passed around the right shoulder, which ap-
peared as though ligated by it. There were also
fibrous bands in connection with the fingers and
toes. Prof Brauu thought that the relative
shortness of the cord was the cause of death, and
that if development had advanced spontaneous
amputation would probably have occurred. —
Ccnt.fHirGyn., 1889, No. 34.

Yellow Fever is epidemic in many localities
in Cuba, the mortality being relative!}- high,
especially in Havana.

1889.]

EDITORIAL.

489

Journal of the American Medical Association

PUBLISHED WEEKLY.

Subscription Price. Including Postage.

Per Annum, in Advance $5.00

Single Copies 10 cents.

Subscription may begin at any time. The safest mode of remit-
tance is by bftnk check or postal money order, drawn to the order
of The Journal. When neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
letters.
Address

Journal of the American Medicai, Association,

No. 68 Wabash Ave.,

CHIC.4GO, Illinois.
All members of the Association should send their Annual Dues
to the Treasurer, Richard J. Dunglison, M.D., Lock Box 1274, Phila
delphia, Pa.

London Office, 57 and 59 Ludgate Hill.
SATURDAY, OCTOBER 5, 1889.

THE CAUSES OF WASTE IN CONSUMPTION.

Loss of tissue is so characteristic of pulmonary
tuberculosis that it has given the popular name
to the disease. Not the fat alone of the body is
thus affected, but it is also observed in the mus-
cles and organs. This loss of weight is so early
a S3'mptom that there would seem to be an inhe-
rent tendency in the disease in this direction.
Still, a little consideration shows there are certain
conditions capable of causing waste independently
of any inherent influence in this direction. In
most cases even of incipient phthisis there is a
positive want of sufficient nourishment to supply
the needs of the organism. This is due generally
to a loss of appetite amounting to actual aversion
for food, as well as to defective assimilation. In
some, however, the appetite remains good, but
either the digestion is imperfect or the system is
incapable of appropriating the nourishment sup-
plied. There is, therefore, in these patients pro-
found anaemia. Yet, the fact that many times
anaemic individuals, who are not consumptive,
take on fat, apparentlj- as the result of incomplete
oxidation, would seem to indicate that the anae-
mia of phthisis is linked to some subtler cause of
wasting, some molecular defect of the tissues,
some cheiuico-physiological peculiarity.

Later on in the development of this malad)'
there are certain very apparent causes of the ema-
ciation, chief among which is fever. That fever
causes an increased destruction of the tissues is
proved by the augmented excretion of carbonic
acid, according to Landois, of from 70 to 80 per
cent., and by the increase in the amount of urea.

uric acid, and other solid constituents of the urine.
The urea is increased from one-third to two-thirds
and the potash may even reach many times its
normal amount. But not only does fever directlj^
influence the consumption of tissue, it also still
further impairs appetite and digestion, in this
way favoring waste. An indirect proof of the
deleterious effect of an elevated temperature, and
an indication for treatment, is afforded bj' the fact
that when the body temperature becomes perma-
nently reduced to the normal, the weight of the
patient is apt to increase or at least remain sta-
tionary.

Another potent factor in promoting emaciation
is profuse sweating. This symptom is complained
of because productive of so much discomfort and
exhaustion. It is serious, however, for another
reason, viz. : because it robs the system of much
valuable material. More than i per cent, of the
perspiration is made up of solids, organic and in-
organic, and when it is considered that 2 lbs. of
liquid leave the body in twenty-four hours in the
form of insensible perspiration, it becomes intelli-
gible how serious must be the loss from the night
sweats of the consumptive. To be sure, the great
loss of fluids thus sustained can be rapidly recov-
ered from by the ingestion of more fluids, but the
salts contained in the perspiration are sadly missed
by the system, and, if not replaced, form a posi-
tive source of waste.

In most cases, particularly those at an advanced
stage, the profuse expectoration is an additional
cause of emaciation as well as of loss of strength.
Even when there is no blood in the sputa, the
.system is subjected to a heavy tax to contribute
the leucocytes, mucus and other elements com-
posing so large a part of the expectoration.
When, moreover, haemoptysis occurs, very decid-
ed impetus is given to the wasting process, and
the patient appears to fall away before one's very
eyes. Such also is the case if there supervenes
suddenly one of those obstinate diarrhoeas that
torment the consumptive. A patient, who may
have regained a comparatively normal daily tem-
perature and seems to be actually taking on a lit-
tle flesh, will upon such an exhausting discharge
grow suddenly gaunt and haggard and progres-
sively fail despite all measures to the contrary.

In conclusion it may be said, the conditions
that influence wa.ste are the verj' phenomena
which stamp this disease with its peculiar char-

490

LAWSON TAIT ON FIBROIDS OF THE UTERUS.

[October 5,

acter. There can be no consumption without
waste any more than there can be fever without
elevation of bodily temperature, and in some this
loss of tissue is so out of proportion to symptoms
explaining it, that there would seem to be some
subtle cause existing in the very nature of the
disease which defies analvsis.

LAWSON TAIT ON FIBROIDS OF THE UTERUS.

A few weeks ago we called attention to the
views of Thomas Keith on Apostoli's treatment
of uterine fibroids by electricity. It is, perhaps,
no more than fair to give place to the rejoinder
of the most prominent advocate of the purely
surgical method of dealing with this condition.
In a lecture, published in the British Medical
Jou7-nal of August 10, 1889, Mr. Tait calls at-
tention to the fact that hysterectomy, which Mr.
Keith seems to consider the only alternative treat-
ment, is only required in a small proportion of
cases, and that the great majority can be satis-
factorily treated by the comparatively safe and
simple operation of bringing about the menopause
by extirpation of the uterine appendages. He
claims that " the complete and permanent efficacy
of this method of treatment has been established
by evidence beyond all cavil ; in fact it stands
■unrivalled in the history of modern surgery,"
and states that his mortality in 262 consecutive
cases has been only 1.23 per cent. To the opera-
tion of hysterectomj^ he expresses as strong a re-
pugnance as Keith ; but, although he does not
expressly discuss this point, he evidently has lit-
tle faith in the efficaci^ of electricity in cases
which call for the severer measure.

To electricity he objects that it is tedious, and,
notwithstanding Keith's statements to the con-
trary, may be very painful, citing a case, treated
in Paris, in which electricity was used thirty-
three times during a period of three months, and
thirty-one times the patient was under ansesthe-
sia. That it sometimes fails when administered
bj' thoroughly competent persons, he has had
evidence in cases which have come into his own
hands, and there is danger of losing precious time
in unsucce.ssful treatment.

He complains that Keith furnishes many state-
ments, but few facts, and wishes for precise in-
formation in regard to the mortality of the elec-
trical treatment, the permanency of the results

secured, and the comparative convenience and
expense of the two methods.

He concludes \>y quoting what he calls the
"prodigious statement" of Keith, that in 10 per
cent, of his cases of hj'sterectomy the operation
was followed by insanity. On this point he says :
' ' In not one of ray hysterectomies has insanity
followed the operation. I have seen insanity fol-
low removal of the appendages for myoma in two
cases, but in one the patient was insane from the
moment she came out of the chloroform, and she
was " queer " before she went under it."

In view of such results as Tait has achieved it
is not surprising that he should have little in-
clination to change the methods which have
proved so successful in his hands. If any value
is to be allowed to evidence, however, it can
hardly be doubted that very satisfactory^ results
have been attained by the electrical treatment.
Martin, of this city, at the meeting of the Illinois
State Medical Society, May 22, 1S89, reported
one hundred consecutive cases treated by Apos-
toli's method, without a death, with complete
cure in eight cases, symptomatic cure in sixty-
eight others, and decided improvement in the
symptoms of most of the remainder. If such re-
sults can be secured by this method and should
prove permanent, it is likely that many women
will prefer, even at the cost of some pain and in-
convenience, to avoid a mutilation which is re-
pugnant to their feelings and, besides the inevi-
table result of sterility, is not always exempt
from other unpleasant consequences. Glaevecke,
of Kiel, found that a depressed, low-spirited con-
dition was generally obser\'ed after removal of
the ovaries ; in three cases out of fortj'-three in-
sanity followed the operation, proving permanent
in one. Sexual desire and pleasure were dimin-
ished in nearly all the patients, and the disturb-
ances usual at the menopause were prolonged, in
a number of cases, for four or five years.

Brilliant as have been the results of surgery in
the relief of this affection, it can hardlj' be said
that they leave nothing to be desired, and any-
thing which promises the benefits without the
drawbacks of the operation with which Mr. Tail's
name is .speciallj- associated is worthy of careful
trial. It is hardly probable that electricity will
wholly supplant operative treatment, but it maj-
well be that when both have been thoroughly
tested it will appear that each has its appropriate
field of usefulness.

1889.]

EDITORIAL NOTES.

491

EDITORIAL NOTES.
HOME.

The American Public Health Associ.\-
TiON. — The seventeenth annual meeting of this
Association will convene at Brookl3'n, on Octo-
ber 22, 23, 24 and 25. From a review of the
topics to be presented at that meeting, a list of
which will be found on page 504 of the present
issue, and from the prominence of those who are
to engage in the discussion of these subjects pre-
sented, we have reason to believe that the meet-
ing will be one of unusual interest. We shall en-
deavor to present our readers with as full a re-
port of its proceedings as the columns of The
Journal will permit.

The Medical Colleges in Chicago opened
last week with a large attendance of students.

Proposed Public Baths for Chicago. — The
Trade and Labor Assembly some months ago pe-
titioned the citj' council for a system of public
bath houses. The matter was referred for inves-
tion, and Chief Tenement Inspector Young has
prepared plans. He favors bath houses built on
the cottage style, 100x55 f^^t, each to contain
forty-one dressing rooms and an office for the
keeper. The cost will be about $3,000 each. The
water at one end will be four feet deep and five
at the other end. The slope to be gradual. Mr.
Young thinks that one should be anchored in
each of the park lakes in the city, and others
along the lake shore. The report will be sent to
Commissioner Purdy and by him referred to the
council.

The American Academy of Medicine, of
which Dr. Leartus Connor, of Detroit, is presi-
dent, and Dr. R. J. Dunglison, of Philadelphia,
secretary, will hold its annual meeting in Chica-
go, on the 13th and 14th of November.

Work of the Geological Survey. — Major
J. W. Powell, chief of the geological survey, was
in Chicago last week, after fifty-five days' work
as advisory member of the senatorial committee
investigating irrigation in the West. The commit-
tee began work at St. Paul and concluded its labors
at Ogallala, Neb. It visited the Dakotas, Oregon,
Montana, Washington Territory, Idaho, Utah,
Nevada, California, Arizona, New Mexico, Texas,
Indian Territory', Kansas, Colorado, Wyoming,
and Nebraska — every State containing arid lands.

Eighty meetings were held and 200 witnesses
heard. Major Powell thinks over 100,000,000
acres of land can be irrigated successfully. The
resolution under which the committee was ap-
pointed did not contemplate appropriations for
building reser\'oirs and artificial lakes — merely
a thorough survey of the territory, that the work
may be done b}' private enterprise. Major Powell
thought Congress would never take charge of the
construction of the ditches and reservoirs. The
survej' of Illinois, particularly along the pro-
posed line of the drainage canal, is progressing,
and will probably be completed in another j^ear.

Prize of the Physiological Society. — Dr.
Wier Mitchell has placed at the disposal of the
American Physiological Societj' the sum of $200
as a prize for original work in nerve ph3'siology,
which work shall have been done after January
I, 1886, and before October i, 1890. At the lat-
ter date the competition closes, and essays must
be in the hands of Dr. H. Newell Martin, secre-
tary of the Society. The award will be made by
the council of the Societj'. The subject, which
has been selected by Dr. Mitchell, relates to the
rate of nerve transmission in man, and the cir-
cumstances which cause that rate to var\'.

Medical Society of Virginia. — At the
twentieth annual meeting of this society, held in
Roanoke, September 3, 4 and 5, 1889, the follow-
ing officers were elected for the ensuing year : Dr.
Oscar Wile3% of Salem, president ; Dr. J. M.
Estill, of Tazewell Court House ; Dr. Alfred C.
Palmer, of Norfolk, and Dr. Casper C. Henckel,
of New Market, vice-presidents ; Dr. Landon B.
Edwards, of Richmond, recording secretarj^ ; Dr.
J. F. Winn, of Richmond, corresponding secre-
tary- ; and Dr. Richard T. Styll, of HoUins, treas-
urer. Dr. John S. Apperson, of Glade Spring,
was chosen to deliver the address to the public
and profession during the session of 1890. Dr. C. T.
Lewis, of Clifton Forge, was selected as the leader
of the discussion of the selected subject for 1890 —
' 'The Treatment of the Summer Diarrhoea of Chil-
dren." Dr. R. F. Young, of Love's Mill, and
Dr. P. B. Green, of Wytheville, were nominated
for commission as members of the Medical Ex-
amining Board of Virginia, to fill vacancies oc-
casioned by two resignations. Rockbridge Alum
Springs was selected as the place for the annual
session of 1890, some time between the 25th of

492

EDITOJlIAL NOTES.

[October 5,

August and the 5th of September, as the Execu-
tive Committee might hereafter determine.

Jelly-Fish Sting. — The Medical Nen's says
that bathers who have encountered the long ten -
tacles of a medusa will be pleased to know that
the "sting," or erj-thema, may be speedil}' re-
lieved by the application of water rendered alka-
line by common washing soda, in the proportion
of an ounce of soda to about two quarts of water.
Dr. B. M. Richardson states in the Asclepiad for
September, that he has personally tested the
efficacy of the treatment, and has also used it suc-
cessfully in several severe cases.

The Natural Mineral Springs of the
United States. — An important meeting of gen-
tlemen interested in the natural mineral springs
of the United States, was held at Washington
last week, and a temporary organization effected
by electing Thomas Tomlinson president and Dr.
A. Emfield secretarj^ and treasurer. The attend-
ance was large, and a general convention was
called to meet at Chicago, November 19. A com-
mittee was appointed consisting of James W.
Inches, D. L. Sterling, and Alfred Moore to
formulate a plan of permanent organization, and
to report at the Chicago meeting.

How Much Should a City Pay its Health
Officer? — The Michigan State Board of Health
has recently published a paper by its Secretary,
Dr. H. B. Baker, in which he asks the question
how much the average city or village can afford
to pay its Health Officer. He answers this ques-
tion in this way : Statistics which can not be
questioned prove that in those localities in Mich-
igan where the recommendations of the State
Board of Health are carried out about 80 per
cent, of the deaths from diphtheria and scarlet
fever are prevented by the thorough isolation of
all infected persons and the thorough disinfection
of all infected persons, things and places. Statis-
ticians usually value a person in the prime of life
as worth to the community about $1,000. Dr.
Baker thinks that in a village of 1,500 inhabit-
ants a health officer can easily save the lives of
two children and one grown person in each year,
and he concludes that such a village can well
afford to pay its health officer $2,000 for the pre-
vention and restriction of scarlet fever, diphtheria
and typhoid fever, and make money by the trans-
action.

foreign.
Yellow Fever in Sp.\in. — Reports have been
going the rounds of the papers relative to an al-
leged epidemic of yellow fever at Vigo. There
were several cases of gastric and typhus fever,
but none of yellow fever.

Leprosy in the Orient. — In the Academy of
Medicine, Paris, M. Zambaco recently stated that
the question of the contagiousness of leprosy,
though admitted by manj-, was not yet settled
in his own mind. He had not discovered an ex-
ample of contagion either in Turkey or in the
other oriental countries that he had visited. Until
he is better informed he will remain an anti-con-
tagionist, for he believes that if leprosy is conta-
gious at all it is onh' very exceptionallj' so.

Cholera is prevalent at Pekin, China, and
nearly all the foreign residents have fled to the
mountains.

Overcrowding of the Professions in Ger-
M.\NY. — Prof Lexis of Berlin has been writing a
pamphlet on the undue increase in all the learned
professions. He says there are twice as many
students as can hope to make a living by the pro-
fessions which they are preparing to enter.

The French law gives a physician's claim
against the estate of a deceased patient prece-
dence.

Another Elixir of Youth. — The British
Medical Journal says that it is stated by a Pesth
newspaper that Dr. Szikszay, a Hungarian phy-
sician, has been making experiments in the State
Prison at Engelsfeld by injecting a liquid, the
composition of which is not revealed, into aged
persons. The results are said to be remarkable.
The strength of the " subjects " was tested with
a dynamometer before and after the injections. In
the case of a man aged 75 years the strength was
found to be increa.sed after the .seventh injection
from 14 to 19 kilograms, and after the thirteenth
to 35 kilograms. Experiments on men and wo-
men of different ages showed, as might be ex-
pected, marked individual differences. We may
take the liberty of suggesting to Dr. Szikszay
that he should communicate the details of his
experiments to the Imperial and Royal Society
of Physicians of Vienna, and then publish them
in full in some medical journal. The after re-
sults, if any, should also be made known.

1 889-1

TOPICS OF THE WEEK.

493

TOPICS OF THE WEEK.

STl"DY OF YELLOW FEVER.

Dr. George M. Sternberg, Major and Surgeon,
United States Army, has just returned from a six
months' staj' in Cuba, where he has been continuing his
researches with reference to the cause and prevention of
yellow fever.

He found in the hospitals a sufficient number of cases,
and in the course of the summer made thirty autopsies.
He has brought with him specimens in alcohol and cul-
tures of microbes with which he will continue his inves-
tigations during the winter at the Johns Hopkins Univer-
sity. At the end of this time he hopes to present a general
report of his investigations to President Harrison.

" My researches up to the present," said Dr. Stern-
berg, "have not led to a positive demonstration of the
specific cause of the disease. But I have isolated a con-
siderable number of pathogenic bacilli — disease-produc-
ing germs — from the intestines of yellow fever cases, and
have strong hopes that one or more of these may prove
to be the specific germ. I have confirmed my previous
conclusions as to the absence of specific microbe organ-
ism in the blood and tissues of the patient, and have
failed to find in any of my cases the germ which Dr.
Freire of Brazil has claimed to be the cause of the dis-
ease. For this reason I have given my attention entirelj'
to the bacilli of the alimentary canal. As none of the
lower animals are subject to yellow fever, and inocula-
tion will therefore be impossible, it will be extremely
difficult to arrive at a positive demonstration. It will,
moreover, be necessary to make extensive comparative
researches to ascertain the character of the bacterial flora
in the intestines in other diseases. I have isolated a long
list of unknown and undescribed bacteria found in the
digestive system of yellow fever patients. But I have
vet to prove that some of these are uniformly constant
in this disease and are not found in others. For instance,
in all ray researches I have never found the comma ba-
cillus of Koch, now generally believed to be the cause of
cholera."

phex.^cetin.

In a paper prepared by Dr. B. Fr.\nk Humphreys,
of Texas, upon "The Uses and Abuses of the New Anti-
pvretics," he quotes the clinical experiences of various
observers in connection with the uses of this new rem-
edy', as follows :

Dr. G. Kobler, assistant at the medical clinic of Prof,
von Bamberger, at Vienna, under whose direction he ex-
perimented, was the first to observe the effects of phe-
nacetin as an antipyretic remedy. Fifty cases with high
temperature came under his observation. Dr. Kobler
makes the following remarks with reference to the prop-
erties of this new antipyretic :

Uz) A specific influence on the course of the disease
itself was never observed.

(Ai Phenacetin in every case was borne well without
any toxic or even disagreeable effects.

yc) The reduction of temperature is, as a rule, pretty

rapid, while the subsequent rise is comparatively much
slower. Large single doses of phenacetin have a decid-
edly more energetic effect than small doses frequently
repeated.

(d) There was never anj- cyanosis or collapse, such as
is not infrequently seen during the administration of
some other antipj'retics. Even in the ten cases of pneu-
monia treated with phenacetin there was no deleterious
action on the heart, which we often meet with in the
course of this disease.

Summarizing his experience, Dr. Kobler comes to the
following conclusions :

1. Phenacetin is a verj- efficacious antipyretic.

2. It has no disagreeable or deleterious effects, such as
cj-anosis or collapse.

3. It produces decided euphoria.

4. It is best administered in single doses of from 8 to
12 grs., instead of smaller ones given every hour or two.

5. The reduction of temperature after such a dose is
from 3.6° to 4.5° F.

Dr. Hugo Hoppe, of Berlin, under the direction of
Prof. Albert Fraenkel and Dr. Paul Guttman, medical
director of the City Hospital at Moabit, has collected
notes of twenty cases affected with maladies in which
there was pyrexia, nine of whom had typhoid fever. Dr.
Hoppe's paper is a carefully written thesis, verj- elab-
orate and minute in clinical notes, taken with reference
to the therapeutic action of phenacetin. He arrives at
very similar conclusions to his predecessor. Dr. Kobler ;
and although neither of these clinicians obser\-ed any-
untoward effects of the drug, even in doses of from 15 to
50 grs.. Dr. Paul Guttman afterwards informed Dr.
Hoppe that he had observed a severe chill in a child dur-
ing the subsequent rise of temperature after the exhibi-
tion of phenacetin, without stating, however, the quan-
tity administered or age of patient. Now, it is alleged
that in Kobler's fifty and Hoppe's twenty cases there
were no rigors observed upon the subsequent rise of
temperature. A reasonable inference, therefore, would
be that in Dr. Guttman's single case the child had prob-
ably received a dose which "transcended the exclama-
tion point," or that it may have been a single exception
to the action of the medicine as a rule.

Professor Giuseppe Cattani, physician to the Grand
Hospital at Milan, has tried phenacetin in more than
fifty different cases, mostly febrile diseases, and his re-
ports are almost exclusively favorable. One of the
many forms of disease in which he has used phenacetin
with advantage is rheumatic endocarditis, in which, he
says, it acts like a tonic by rendering the heart's action
steady, even where a valvular lesion has been establish-
ed, as, for instance, in mitral incompetency. Prof. Cat-
tani, like Prof Dujardin Keaunielz, thinks that in its
analgesic property, phenacetin outrivals its predecessors.
Dr. Gaiffe has found phenacetin of considerable benefit
in nervous polyuria. He says the heart and pulse are
never influenced by this drug. Drs. Cesari and Burani
confirm most of the antecedent observations of others
with reference to the action of phenacetin. Drs. Mis-
rachi and Rifat contribute a clinical study of phenacetin,
in which they also recommend the drug as an effective

494

TOPICS OF THE WEEK.

[October 5,

antihyperthermic and antinervine remedy. In children's
practice thev advise it to be rubbed up in some sugar,
which, they say, totally disguises any taste or smell.

Prof. Rumpf, of Bonn, saj-s that this drug, as now pro-
duced by the manufacturers, is almost chemically pure
phenacetiu, and that it has no disagreeable action what-
ever, if given in doses not exceeding 45 grains daih-. In
doses of 15 grains daily, he says, it is absolutely harm-
less, and that there are no nausea and vomiting, no cya-
nosis and syncope, and no untoward symptoms in pa-
tients with high temperature.

The dose administered b\- Prof Rumpf was 15 grains,
by which the temperature was reduced 3.6° to 5.4° F.
within from two to four hours. In a case of pleurisy, for
instance, the temperature fell from 104° to 99.2° F., and
on the next day from 103° to 99° F. within four hours.
Havin<^ found that 15 grains of phenacetiu would in
some cases cause the temperature to fall below the nor-
mal, Prof Rumpf advises that the dose given in febrile
maladies should never be larger than S grains ; but,
strange as it may seem, even when given in doses of 45
grains, it is alleged that the drug never caused any nau-
sea, vomiting, chilliness, cyanosis, or eruption of the
skin ; onlj' profuse perspiration was observed in some
cases.

Encouraged by the favorable results obtained by
Hoppe, Heusner, and Dujardin-Beaumetz, with the ad-
ministration in cases of hemicrania and other forms of
neuralgia. Prof Rumpf tried the drug, with regard to its
analgesic property in a great number of cases, with uni-
formly satisfactory results, the dose in such cases being
15 grains. The effects of the medicament were observed
in many cases within thirty or forty minutes after its ad-
ministration, in other cases not until an hour or two had
elapsed.

From a considerable clinical experience with this new-
candidate for favor. Prof. Rumpf arrives at the following
conclusions with regard to its therapeutic properties :

1. Phenacetin is an antipyretic of reliable action and
certain efifects, from all untoward and disagreeable sym-
toms.

2. Phenacetiu is to be recommended as an antineu-
ralgic in 15-grain doses, viz.:

(a) In all cases of vaso-motor neuroses.

(6) In locomotor ataxia against the lancinating pains,
and in cases of chronic neuritis against neuralgia.

(c) In various cases of neuralgia, to sooth the pain at
least.

Prof Mueller, at the meeting of the Verein fiir In-
nere Medizin, at Berlin, July 2, 1S8S, in a discussion with
regard to the merits of phenacetiu, confirmed the ob-
servations of the authors detailed herein, and further
added that in daily doses of 75 grains or less its exhibi-
tion is never followed by cyanosis and methaemoglobinu-
ria. This statement if found true by other observers,
will prove to be a strong argument in favor of the claim
that the drug is comparatively safe in large doses, and
innocuous in medicinal doses.

Some distinguished English physicians have ex-
pressed a favorable opinion of phenacetin, corroborating
the observations of the writers already mentioned.

Prof. Dujardin-Beaumetz says : "Phenacetin is a rival
ofautipyrin and antifebrin ; in a word, it is an antipy-
retic and a nervous sedative. It is not unlikely that it is
more active thau either of the two agents just
named. . . .

"I have tried it in doses of 5 grains, given in wafers,
and I must say that I have observed — as others have done
before — a considerable reduction of temperature in tuber-
culous, feverish patients, and in those suffering from
typhoid fever. This reduction, which amounted to 5.4°
F. in some cases, is remarkably persistent, although the
dose is comparatively small ; it lasts from eight to ten
hours. On the duration of the disease itself the new
remedy has no influence, just as with the other antipy-
retics.

"Phenacetin is also a strong analgesic, more power-
ful in its action, perhaps, than either autipyrin or anti-
fibrin. And it acts very rapidly, in spite of its insolu-
bility ; in the gastric juice, about twenty minutes after
its administration, its eflFects may already be observed.

"I will state in addition that phenacetin does not pro-
duce c\'anosis, like antifibrin, and that in contradistinc-
tion to the latter, its presence in the urine may be de-
tected ; ferric perchloride will turn red, and cupric sul-
phate will turn green, if added to urine containing phe-
nacetin."

Prof R. Lepine, of Lyons, in a paper on typhoid
fever, also expresses satisfaction with the effects of this
new medicament. He sa\s, however, that after daily
doses of 90 grains there is some headache and some cya-
nosis ; but in doses of 45 grains he says it does not affect
the heart, and produces neither cyanosis nor any other
untoward symptom, except, perhaps, some sweating. He
gives it in 8-grain wafers, of these six to eight a day.
From the foregoing it is to be inferred that the drug, in
very large doses, or perhaps if long-continued in smaller
doses, may produce blood changes not very unlike the
effects of antifebrin. — Therapeutic Gazette. — The Prac-
titioner.

ILEMORRHAGE FROM THE LARYNX.

In a paper read by Dr. William Porter, of St. Louis,
at the eleventh annual meeting of the .\merican Laryug-
ological .\ssociation upon this subject, he presents the
following conclusions :

1. Laryngeal haemorrhage may occur from simple
local conditions.

2. Unless associated with other and more positive
symptoms, it is not indicative of pulmonary lesion.

3. It is possible, through the passing of blood from
the larynx into the lungs, that pulmonary disease may
be incited.

4. Care should be taken to distinguish between pul-
monary and laryngeal luemorrhages, not only for the
sake of more exact treatment, but especially because of
the more favorable prognosis that may be given in many
cases of the latter condition. — New York Medical Jour-
nal.

A NEW hospital has been erected in Denver, Colo., at
a cost of ;f30,ooo.

1889.]

PRACTICAIv NOTES.

495

PRACTICAL NOTES.

MILK SUGAR AS A DIURETIC.

Prof. See has recently presented the result of
his study of the diuretic action of milk sugar,
which he considers the most reliable of all diu-
retics. In diseases of the heart and stomach, and
also in renal or cardiac affections accompanied
by dropsy, its diuretic qualities render it very
servaceable. Milk in these cases, as is well
known, is of great value, not only on account of
its diuretic properties, but also because it is so
complete a food. Three or four quarts of milk a
da3' may be used with advantage, but the propor-
tion of sugar in milk is rather too small. Prof
See has discovered, by experimenting successive-
ly with the different constituents of milk, that
lactose is the active agent. The action of the
other constituents of the milk, such as the water
and the salts, is inconsiderable, the chloride of
sodium adds nothing, and the salts of potassium
very little, to the polyuria induced b^' the sugar
of milk.

This sugar is found in all kinds of milk, is
crystalline, and quite soluble in water. About
three ounces of it dissolved in two quarts of
water, with complete suppression of everj' other
liquid, as soup, tea, wine, mineral water, etc,
will afford marked diuresis in all cardiac troubles,
no matter what the lesion may be, though the
results are less constant in arterio-sclerosis.

In twenty-five cases abundant diuresis resulted;
at least eighty ounces of urine were passed,
usual!}' one hundred or more, in the twenty -four
or forty-eight hours subsequent to beginning the
treatment. As soon as the treatment was stopped
the amount of urine fell off to what it had been
before the administration of the diuretic. Prof.
See, therefore, considers lactose to be not only
the most efficient diuretic, but also the least
harmful. If milk is used and two quarts only
are taken, diuresis follows ; if four quarts of milk,
containing six and one half ounces of sugar of
milk, marked glycosuria is produced ; at the
same time there is considerable excretion of urea,
indicating a destruction of the albuminates.
With the sugar alone these disadvantages may
be avoided, for three and a quarter ounces of milk
sugar in water will .set up a copious diuresis,
such as we cannot be sure of having from even
four or five quarts of milk.

The polyuria resulting from this treatment sur-
passes that from all other methods ; the amount
of urine rises rapidly to two, two and one-half,
usually to three or three and one- half quarts, and
even to four or four and one-half quarts on the
third daJ^ After this it remains at that point,
or drops to two and one-half quarts for some days.
After a few days the same treatment may be em-
ploj'ed to repeat the diuresis.

It is fair to say that this action of lactose may
be relied upon in cases of cardiac dropsy, but in
those of renal origin its effects are slight. In car-
diac disease it never fails unless the kidneys are
diseased and the amount of albumin is consider-
able. When the amount of albumin is small the
result is favorable, from which it ma}' perhaps be
inferred that there is present only a simple ven-
ous congestion.

It is suggested that the diuresis may serve as
an indication of the condition of the kidneys.
Various conditions may affect the diuresis ; some-
times diarrhoea occurs, and this diminishes the
amount of urine, or the patient may have been
subject to profuse sweating, which would also
lessen the quantity of urine.

As a rule the remedy is well borne. It may
be prescribed for eight or ten days and then
omitted for a few daj'S and again renewed. If
the simple solution is not well tolerated, brandy
or peppermint may be added to it. All other
liquids should be reduced in amount or omitted
while this treatment is pursued.

This method presents great advantages over
many others, and the patient may partake of any
food, a meat diet, if the physician so desires.
Prof. See considers that the phj'siological action
of lactose is upon the kidneys, since it does not
exert any influence upon the circulation. He
classes it with caffein, as he believes that caffein
acts upon the kidneys only, and not through the
circulation, as do digitalis and strophanthus.

Lactose is regarded as superior to caffein, as
it does not affect the brain and nervous system.
— Z,' Union Medicale, American Journal of the
Medical Sciences.

EPILEPSY TREATED BY AMYL NITRITE.

Having read a few weeks ago in this journal
Dr. Woods' treatment of epilepsy, and being
called to a ver}' severe fit in a young man who
has been an epileptic from birth, and whose mind
has been so impaired that, though 21 years old,
he is unable to read, write, or dress himself, I de-
termined to try amyl nitrite. After inhalation of
one capsule, the convulsion ceased, and in about
twenty minutes the patient was himself again,
the insensibility which always followed the fits
being almost nullified. Since then the drug has
been tried four times, and each time with success;
if administered at the commencement of the fit,
the latter was aborted, and the insensibility almost
completely prevented. This patient is in the habit
of having, on an average, a fit daily ; and fre-
quently a succession of fits — status epilepticus.
He has been a patient for years at the Epileptic
Hospital, Queen Square, and has been taking bro-
mides daily, but apparently with no effect, I hope
soon to be able to give an account of the action of
nitro-glycerin tablets, which he is at present tak-

496

PRACTICAL NOTES.

[October 5,

ing, in the hope that they will render the fits less I
frequent.

I believe that hitherto the amyl nitrite has been
used onlj' in the status epilepticus, but it appears
to me to be also useful in severe single fits. The
rationale of its action has not, I think, been worked
out, but obviously would seem to be due to its di-
lating influence on the cerebral arteries contracted
during the convulsions. — ^J. P. Parkinson, M.B.,
in the British Med. Journal.

THE DRINK QUESTION IN FRANCE.

The recent Anti-Alcohol Congress in Paris
showed that the dram shops of Paris have risen
since 1880 from 24,000 to 29,900. In thirty j'ears
the consumption of alcohol has been trebled, and
as much as 36,000,000 galls, have been manufac-
tured out of potatoes for the French market. This
shows an average yearly consumption of over 12
quarts per adult man. The consumption of al-
cohol doubled between 1875 and 1885. The Con-
gress voted a resolution that inebriates should be
treated as mad, and that prison hospitals should
be created for them. It was also resolved that
the Governments of the world should be asked to
impose a prohibitive duty on alcohol, and exempt
from duty tea, coffee, and other ingredients for
temperance drinks.

voted upon and carried almost unanimously: "It
is necessary to carry out, by all possible means,
including indemnification of those interested, the
general application of the principles of seizure
and total destruction of all meat coming from tu-
berculous animals, whatever may be the gravity
of specific lesions found in those animals. ' ' Chau-
veau, President of the Congress, suggested that
simple instructions should be printed and widely
distributed throughout the cities and towns and
in the country, explaining the danger of drink-
ing tuberculous milk and eating tuberculous
meat, and the waj's of rendering the meat inert.
Though much has yet to be learned on this vital
question, enough proof has already been adduced
to warrant the adoption of active measures towards
the extermination of tuberculous cattle. Is not
the Government called upon to deal with tuber-
culosis as it does with pleuro-pneumonia ? — Mon-
treal Medical Joiimal.

THE MILK OF TUBERCULOUS COWS.

At the Congress on Tuberculosis held in Paris
in Jul}', 1888, it was unanimously conceded that
the milk of tuberculous cows was dangerous for
use. Some held that it was only so when the
udder was affected with tubercular disease ; but
as it is impossible for milkers and dairymen al-
ways to diagnose this, they unanimously recom-
mended that all milk should be boiled. There
was some difference of opinion as to the use of]
meat of tuberculous cows. Dr. Trocart held that
if the disease is localized the flesh does not con-
tain any bacilli. Dr. Arlving contended that in
his experience virulent bacilli existed in the mus-
cles of tubercularized animals in one-fifth of the
ca.ses. He desired to see tuberculosis inscribed
among the infectious diseases, and thought the
flesh of tuberculous animals should be prohibited
as food till means were found to render it harm-
less. He suggested the creation of a permanent
committee to carrj' out, in cities and towns, the
realization of a complete sanitar\' organization.
It was learned that in Paris, Brussels, Constanti-
nople and other large cities the meat is con-
demned if the disea.se is generalized and the cat-
tle emaciated. After a lengthened discussion,
which brought out a great many interesting facts
in relation to the etiology of tuberculosis and its
communicability, the following resolution was

TYPHOID FEVER — ANTIPYRIN RASH.

In the case of a girl of 25 years suffering from
severe typhoid fever, with the temperature for
several nights at 105°, antifebrin was given with-
out marked effect, and subsequently antipyrin.
The latter reduced the temperature for a time,
but after two doses had been taken a rash broke
out on the face and neck. It did not resemble
urticaria or measles. The forehead became of a
pale red color, like the skin of a newborn baby,
and there was slight puflBness of the lids. On the
neck the pale red patches were somewhat discrete.
By next morning all the rash had disappeared.
Antipyretics were abandoned, when, after two
days, the temperature fell to 102° and 101°, and
the S3'mptoms improved. The action of antipyrin
in producing rashes seems to be very common,
though so far I have seen but these two cases.
The journals contain manj' such records. The
rashes are described as measly, erythematous, or
urticarious. — Montreal Hosp. Rep., Montreal
Med. Journal.

INGESTION OF ASCITIC LIQUID.

Probably the most remarkable potation on rec-
ord is that of an inmate of the hospital at Ober-
nay, France, who, after being tapped for the fifty-
third time, took advantage of an opportunity to
drink oft" about eight ounces of the product of his
own peritoneum, and with apparent relish. But
what is more and stranger, his dropsy has not
recurred within the year that has elapsed since
he took the beverage, the oedema has been re-
duced, and he has been enabled to resume his
employment. Dr. Duhamel is responsible for
this narration in the (iazetle Medicate de Stras-
bourg.

1889.]

SOCIETY PROCEEDINGS.

499

SOCIETY PROCEEDINGS.

Association of American PliTsicians.

Fourth Atinual Meeting, held m the Army Medical

Museum a}id Library, IVashingioti, D. C,

September 18, ig ajid 20, i88g.

[^Concluded from p. 46$.)

Dr. D. W. Prentiss, of Washington, reported

A REMARKABLE CASE OF SLOW PULSE EXTENDING
OVER A PERIOD OF NEARLY TWO YEARS.

G. W. P., white male, carpenter, aet. 54 years.
Has alwaj's been healthy ; the only illness he re-
members is neuralgia of stomach fourteen years
ago. The only injury ever received was a fall a
distance of 15 feet and striking on his feet, when
19 years old. Ten years ago a brick fell upon his
head, cutting the scalp but causing no serious in-
jurj'. Never had any form of venereal disease.
Always temperate in the use of alcohol but not in
the use of tobacco. He has been under the ob-
ser\-ation of the writer for sixteen years, but had
never been attended professionall}' until present
illness.

December 13, 1887, after working some time in
a malarial locality, he began to have weak spells,
and several times fainted on lifting heavy weights.
Examination showed no well-defined disease. No
fever, mind clear, pulse 36 Urine normal. No
organic disease of heart discovered, the systole
was full and strong, diastole greatly prolonged.
Between December 13, 1S87, and Januarj- 20,
1888, the pulse ranged from 22 to 76. During
this time there were frequent attacks of syncope.
During one fainting attack he fell down stairs.
At another time fell out of a chair, remaining un-
conscious about a minute. After Januarj' 20,
his pulse had reached 76, he had no more faint-
ing spells. In March he resumed work. Octo-
ber 2, 1S88, he had a relapse with the same sj'mp-
toms as in previous attack. From this date to
April 15, 1889, the pulse ranged from 15 to 44
per minute. The fainting attacks continued
throughout this time, occasionally verj- severe. He
improved to a certain extent, but about August
29 he began to have a return of the old symp-
toms. During the fainting spells the pulse fell
to 12 or 15°. Between August 5 and September
18, the pulse ranged between 12 and 38° per min-
ute, and between August 10 and August 15, it
did not rise above 14° per minute. The temper-
ature during this time was between 94.5° and 97°.
The patient improved somewhat after August 15
and September 18 was well enough to present
himself for examination before the Association.

The "spells" referred to, were described. They
came on without warning, often without appar-
ent cause, sometimes often exhaustive. He faints,

losing consciousness. They last from a few sec-
onds to half an hour. Breathing gasping and
slow. Face and hands, first pale, then dark and
purplish. There is no pain. He has great con-
fidence in the bromide of ammonium, which he
thinks controls the attacks. The treatment of
the case from the first has been rest in bed, tonics,
stimulants, electricity and bromide of ammonium
together with supporting diet. The tonics used
were strj'chnia, opium and iron with belladonna.
Digitalis was tried but made him worse. Nitro-
glycerine seemed to help for five doses, but later
caused distress. Convallaria and strophanthus
were tried with like result. The drug which ap-
peared to give the most relief was bromide of
ammonium, given in doses of i gram (15 grains)
three times a daj', and extra doses when parox-
j-sms threatened.

The most interesting question in this case turns
upon the pathology. What is the cause of the re-
tarded action of the heart ? The causes which
may produce slow pulse may be classified as fol-
lows :

1. Disease or injur>' of the nerve centers, pro-
ducing either irritation of the pneumogastric or
paralysis of the sympathetic (acceleration) nerves
of the heart.

2. Disease or injury of the pneumogastric
nerve increasing its irritabilitj-.

3. Disease or injurj' of the symphathetic
nerves of the heart — paralyzing them.

4. Disease of the cardiac ganglia by which
the influence of the pneumogastric preponder-
ates.

5. Disease of the heart muscle (degeneration)
whereby it fails to respond to the normal stim-
ulus.

6. Action of poisons, as of lead or tobacco,
either on nerve endings or nerv^e centers.

In this case it is difiBcult to saj' to which of
these divisions it belongs. There are no symp-
toms to indicate any form of disease of the nerv'e
centers. There is no evidence of disease of the
nerves themselves, nor has anj- organic disea.se of
the heart been discovered. There is left only the
action of certain poisons, and the question arises
whether or not in some obscure way the condi-
tions maj' not be due to tobacco poisoning from
excessive smoking. Another possibilitj' is ma-
larial poisoning. The attacks first appeared
while he was working in a malarial district, and
in the summer of 1888 he had intermittent fever.
These considerations make it probable that there
is paralysis of the accelerator nerves and not an
irritation of the vagus. The symptoms are due
solelj- to defective circulation.

In man}' of the cases collected in connection
with this report, the pathological appearances
were a result of the slow pulse rather than a
cause.

Abstracts were given of 55 cases of slow pulse

5O0

SOCIETY PROCEEDINGS.

[October 5,

of which the following is a brief analj-sis as to
causes : i. Fracture or dislocation of cervical ver-
tebrae, 9 cases. 2. Disease of brain, 9 cases. 3.
Cerebral syphilis, 2 cases. 4. Sunstroke, i case.
5. Ossification of aorta valves and coronary ar-
teries, 2 cases, 6. Starvation, exhaustion, loss
of sleep, convalescense, 3 cases. 7. Epilepsy and
epileptoid disease, 9 cases. 8. Heart disease, 6
cases. 9. Lead poisoning, poisoning bj- salt fish,
pernicious fever, 3 cases. 10. Nervous shock,
cholera morbus, 2 cases and 11, not stated, 9
cases.

Thursday — Morning Session.

Dr. Frederick P. Henry, of Philadelphia,
read a paper ou the

RELATION BETWEEN CHLOROSIS, SIMPLE .A.N.E-
MIA AND PERNICIOUS AN.EMIA.

The discussion of the relation between chloro-
sis, simple anaemia, pernicious anaemia, etc., may
be divided into three heads : i. Are they separate
diseases ? 2. Are they of kindred nature ? 3.
Are they different stages of one affection ? Per-
nicious antemia is first considered, because the
determination of its status is of fundamental im-
portance. It is admitted by all that the clinical
features of this disease are common to a number
of affections, especially cancer and atrophy of
gastric glands ; but those who argue most for-
cibly in favor of its independent nature exclude
from the categorv' of pernicious anaemia all cases
in which an anatomical lesion of any organ is
found. This appears to me unscientific, for an
independent disease is one which rests upon a
constant anatomical basis or is invariably pro-
duced by the same specific agent. Hunter has
endeavored to establish pernicious anaemia as an
independent disease by the demonstration of an
excess of iron in the liver in cases of that affec-
tion. He regards this as the essential anatomical
feature of pernicious anaemia. The work of Hun-
ter is of great value, and certainly demonstrates
the existence of an excessive haemolysis in that
disease. In my opinion, however, this excessive
haemolysis is a consequence of defective haemo-
genesis, for certain facts show the red corpuscles
of pernicious anaemia to be abnormally weak and
perishable. Chlorosis is universall}' admitted to
be due to defective haemogenesis, and, therefore,
I regard it and pernicious anaemia as closely re-
lated affections. Transitions from the one affec-
tion to the other have also been observed bj' my-
self and others.

Conclusions: (i) That pernicious anaemia is a
process, not a disease ; (2) that it is closely related
to chlorosis ; (3) that it may be the terminal
stage of other diseases, and especially of cancer
of the stomach and atrophy of the gastric
glands.

Leucocythsemia and Hodgkin's disease, in that

they are alwaj's associated with lesions of the
blood-making organs — spleen, lymph glands,
bone marrow, etc. — are independent diseases, or
rather, different stages of the same disease, for
several cases are recorded in which an undoubted
transition from one to the other has been ob-
served.

Dr. F. Forcheimer, of Cincinnati, read a
paper on

the relations of AN.EMIA to CHLOROSIS.

He referred to the confusion which existed in
regard to the definition of the two diseases. Im-
mermann says that we are justified in stating that
anaemia is that condition in which there is a dim-
inution of red corpuscles as well as of the albu-
mens of the plasma in the blood (hypalbumi-
nosis). Striimpell considers that "the essential
element in anaemia is therefore a diminution in
the number of red corpuscles or so-called oligo-
cythaemia," and states further that " oligocythae-
mia is not invariably accompanied by a diminution
in the amount of serum albumen (by which means
plasma-hypalbuminosis)." Going on it is found
that anaemia or oligaemia vera reallj- means a di-
minution of the whole quantity of the blood, and
that this condition can be divided into hydraemia,
oligocy thaemia, oligaemia sivea and oligaemia hyp-
albuminosa. We have three representative defi-
nitions ; the one broad and general, including a
diminution of any one or all of the constituents
of the blood ; a second, in which hypalbuminosis
and oligocy thaemia are the principal if not the
only factors; and a third which makes oligocythae-
mia alone the characteristic feature. From a purely
practical standpoint the latter seems the best.

The same confusion in regard to definition is
met with in a consideration of chlorosis. Duncan
(1867) was, however, probably the first to make
the distinctive feature, oligochromaemia, charac-
teristic for chlorosis —that is, in chlorosis we find
the individual red corpuscle deficient in haemo-
globin. Unfortunately for this definition the term
chlorosis is to be looked upon as an essentially
clinical one : it is not going too far to state that
by far the great majority of reported cases of
chlorosis are not chlorosis at all. Another diffi-
culty is that both oligocythaemia and oligochro-
maemia may occur in the same individual, so that
the term chloranaemia is justified by observation
of existing conditions. It is more than probable
that anaemia is a forerunner of chlorosis in a great
many instances, and possibly a number of cases
occur in which there is a combination of both
conditions.

Almost any cau.se put down for anaemia will
hold good for chlorosis. Sex, age, a peculiar
composition of the blood and certain vascular
anomalies are held to be especially characteristic
for chlorosis. The two latter are the only ones
to be found in chlorosis. The process of sexual

1889.

SOCIETY PROCEEDINGS.

501

development is looked to as the time of most
common occurrence of chlorosis. This age also
produces a great number of cases of anaemia, but
children and old people are subject to anaemia
and practically excluded from chlorosis. The
greatest number of cases occur between the ages
of 15 and 25 years, decidedly after the time of
first menstruation. Furthermore, an anaemic con-
stitution is a strong predisposing cause for chlo-
rosis.

The clinical characteristic of chlorosis lies in
the peculiar changes in the blood. In anaemia
the red corpuscles as well as the albumens of the
plasma are reduced in quantity, and frequently
there is production of a greater number of smaller
corpuscles (microcytes). As a result of the re-
duction of the number of red corpuscles the haem-
oglobin is correspondingly reduced in quantity.
In pure chlorosis the number of red corpuscles is
not diminished and a tendency to the production
of larger red corpuscles (megalocytes) is espe-
cially well marked. These changes are, however,
not sufficiently characteristic to establish a diag-
nosis. It is also found that the proportion of
haemoglobin in each corpuscle is diminished. It
has been said that in anaemia there is always hyp-
albuminosis, while in chlorosis this is absent, but
this has not yet been positively proven.

One respect in which chlorosis is said to differ
materially if not absolutely from anaemia consists
in the pathological changes, first described by
Virchow. These are narrowing of the lumen of
the aorta and larger arteries as well as thinning
of their walls. The heart is sometimes small,
sometimes hypertrophied. This view would per-
mit us to state that chlorosis is always congenital,
in some cases latent for years, while anaemia in
most cases is acquired. Many objections have
been urged against this view.

The relation of the symptoms of anaemia to
chlorosis depends upon the conditions of the blood
and the anatomical substrata. Given a case of
anaemia in which there is onl}- a reduction of
haemoglobin as a result of oligocythaemia and a
case of chlorosis in which there is a reduction of
haemoglobin as a result of oligochromaemia, and
metabolism in both these cases will be approxi-
mately the same ; but if in anaemia we have oli-
gocythaemia as well as hypalbuminosis, which is
said to coexist in the majority of cases, the meta-
bolism must be different from that of a pure case
of oligocythaemia. As a result of a reduction of
haemoglobin there is simply reduction in the pro-
cess of oxidation ; at the same time the waste
products are carried off and sufficient albuminous
food is carried to the tissues by the plasma of the
blood, which is unchanged. Hypalbuminosis and
oligocythaemia produce an entirely different re-
sult. We have the same factor, suboxidation,
but we have in addition deficiency of supply. In
mild cases of anaemia, there is produced a loss of

weight ; in severe cases, the condition called ma-
rasmus. In chlorosis very little if any loss of
weight occurs ; very frequently the opposite con-
dition is brought about by too great suppl}^ and
by the presence of too much CO.^, preventing de-
composition of fats. When anaemia is associated
with chlorosis, we have a very unfortunate com-
bination, especially if there is a great amount of
hj'palbuminosis.

Unless we believe that the anatomical lesions
of Virchow belong to chlorosis, there exists no
difference between the symptoms of chlorosis and
anaemia.

The therapeutic relations of the two diseases
must be considered. While the indiscriminate use
of iron in anaemia must be deprecated, yet upon
the whole iron is just as much looked upon as a
specific in anaemia as in chlorosis. Where in anae-
mia we try to remove the cause and institute
causal treatment, we are satisfied in chlorosis
with removing the symptom which is the essen-
tial of the disease. It has been repeatedly demon-
strated that the removal of this essential symptom
is followed temporarily by complete recovery.
Whereas, in anaemia, treatment is followed by
complete recovery or complete failure, iron in
chlorosis will always result in amelioration, even
if the tendenc)' to relapse cannot be removed.
There are few cases of chlorosis, even those with
the lesions of Virchow, that are not benefited by
the administration of iron in sufficient quantity.
In a great many cases of anaemia, the use of iron
would be followed by negative or by bad results.

Dr. Willi.\m Osler, of Baltimore, took issue
with Dr. Henry in regard to chlorosis. He held
that chlorosis is absolutely distinct from per-
nicious anaemia, for the following reasons: i.
The sex ; he had never seen chlorosis in the
male. 2, The pathological conditions. He re-
garded thus the hyperplasia of the heart and
great vessels as a specific anatomical distinction
of a certain number of cases. 3. The character
of the blood. He considered the diminution of
the percentage of haemoglobin a distinctive fea-
ture of chlorosis. 4. Curability, Although in
chlorosis there is a tendency to relapse, each
given attack can be cured if sufficiently large
doses of iron are employed.

Dr. Francis P. Kinnicutt, of New York,
agreed as to the lack of relation between chlorosis
and pernicious anaemia. He had never seen true
chlorosis in the male. All his cases of pernicious
anaemia, on the other hand, with one or two ex-
ceptions, had occurred in males. He agreed with
Dr. Henry in regard to the relationship between
Hodgkin's disease and true leukaemia.

Dr. W. W.Johnston, of Washington, thought
that a study of certain anaemias which are met
with in women will throw light upon the asso-
ciation of anaemia with diseases of the intestinal
glands and gastric tubules. The explanation of

502

SOCIETY PROCEEDINGS.

[October 5,

the chronic anaemias of parturition is probably
the continued pressure upon the intestinal tube,
causing a long starvation lasting nearh- a year.
This seems to produce an actual organic change
in the intestinal glands. Several illustrative
cases were cited.

Dr. William Pepper, of Philadelphia, agreed
with Dr. Osier in regard to the relation between
true anaemia and chlorosis and progressive per-
nicious anaemia, so called. He was not prepared
to admit the analogy between true chlorosis and
progressive pernicious anaemia. The conditions
of the blood are widely antagonistic in these two
affections. The clinical differences are also very
marked. In the present state of knowledge it is
probably wiser to consider essential anaemia as
an independent affection.

Dr. Frederick P. Henry, of Philadelphia,
thought that the definition of chlorosis given by
Dr. Osier could not be maintained ; that is, there
is always a diminution of haemoglobin, with a
nearly normal number of red corpuscles. The
arguments that he had advanced were based en-
tirely upon personal observations. While chlo-
rosis is readily relieved bj' treatment in the early
stages, yet, if it is neglected, the chlorosis may
become more intense and may present the appear-
ances of pernicious anaemia.

Dr. S. Weir Mitchell, of Philadelphia, read
a paper on

subjective false sensation of cold, consid-
ered AS A symptom.

The speaker had met with many cases where a
feeling of cold is complained of in members
which do not present any objective changes in
temperature. These may be placed in three
classes: i. Those due to a central cause. 2.
Those due to neuritis. 3. Those whose origin is
at present inexplicable or due to hysteria. A
number of cases exhibiting this symptom to an
extreme degree were reported. In the first case
a marked sensation of cold involving the left side
of the body followed an injury to the head.
Three or four cases were referred to coming in
the second class. The .sensation of cold involved
the posterior part of the legs, the back or but-
tocks. In all these cases there was either neuritis
at the time or it developed sub.sequentl)^ When
this symptom is noted neuritis may be expected.
Two cases belonging to the third group were de-
scribed. One was an elderly individual with no
signs of hy.steria : the other was a case of young
woman with marked hysterical symptoms.

Dr. G. M. Garland, of Boston, read a paper
on

gastric neurasthenia.

Three cases of vomitus nervo.sus were reported :

Case r. — Miss S. began at the age of 2 years to

have sudden attacks of vomiting. These recurred

at irregular intervals until the time of her death.

The attacks lasted twenty-four hours and it re-
quired a week for the child to recover her
strength. At the age of 20 she began to have
excessive muscular twitchings with the attacks.
Two years later she began to have severe head-
aches. These graduallj- merged into one steady
ache. January' 2, 1884, the author saw the pa-
tient suffering from intense headache and slight
twitching of arms and legs. Vomiting appeared
the next day, causing intense burning of the
throat from the intense!}' acid character of the
matter vomited. After four days she graduallj'
improved and entirely recovered. November 12,
18S4, the patient was again seized with head-
ache. November 15th vomiting and twitching
began. She gradually improved until December
2d, when all the symptoms returned and contin-
ued until her death, December 13th. Urine was
normal until a few days before death, when it
contained a trace of albumin, but no casts. At
the autopsy no marked organic change was found
in any part of the bodj-.

Case 2. — Miss S., 22 years old, first seen Sep-
tember 19, 1888. She was in bed with headache,
poor appetite, constipation and weakness. Pulse,
temperature and urine normal. Some nausea.
Vomiting appeared in a few daj's. She was fed
exclusively' by the rectum for three weeks, but
the vomiting persisted and there was severe burn-
ing along the entire oesophagus. At times the
urine was scant}', but never contained albumen.
She gradually improved, but is not as strong as
before her illness.

Ca5f J.— Miss D., aged 43 years, had been sub-
ject to bilious headaches. During the summer
of 1888 she had a severe attack of vomiting and
she was very ill for several weeks. During the
following September, as a result of anxiety, the
appetite left her and the nausea returned. She,
however, did not vomit.

Afternoon Session.

Dr. John H. Musser, of Philadelphia, read a
paper on

PRIMARY cancer OF THE GALL BLADDER

AND DUCTS.

The speaker, after describing two cases of this
affection that had come under his observation, re-
viewed the cases that had been reported and pre-
sented the following conclusions :

Primary cancer of the gall bladder is not so
rare as is generally believed. It occurs in the fe-
male nearly three times as often as in the male.
A large number (57 per cent.) of the ca.ses occur
under the age of 60. Gall stones are an e.Kciting
cause, especially in persons predisposed to the af-
fection. The organ is generally not much en-
larged save as the result of secondary processes.
Metastasis is not widespread. By continuity of
structure neighboring organs are involved. Ad-

1889.]

SOCIETY PROCEEDINGS.

503

hesions to adjacent organs with ulceration and
perforation are not uncommon. Pain, jaundice
and the presence of a tumor are the most common
phenomena. With them are associated anaemia,
cachexia, vomiting, constipation or diarrhoea and
ascites. Pain was present in 62 per cent, of the
cases, at first ill-defined, then becoming localized
to the right hypochondrium and lancinating in
character. Jaundice was present in 69 per cent.,
gradually increasing in degree. In some cases,
however, it was intermittent. Tumor was noted
in 63 per cent. The tumor was hard, firm, pain-
ful, and generally movable with respiration. The
progress of the disease is alwa5-s continuous.
Some extraordinary cases are reported in which
there was temporary^ cessation in the progress of
the disease. Death results from exhaustion ; fre-
quently from peritonitis. In some cases from
metastasis to other organs ; in some from biliary
obstruction. In eight cases death was due to
cholaemia. The duration of the disease is short,
the average being six and two-thirds months.
The progress is rapid after complete occlusion of
the biliarj- passages or evidence of inflammation
of the bilian,' passages has developed.

Dr. Henry Formad, of Philadelphia, read a
paper on The Anatomical and Physiological Rela-
tions of Lesions of the Heart and Kidneys. The
paper was based upon the post-mortem study of
300 ca.ses obser\'ed in public and private practice.

Dr. p. G. Robinson, of St. Louis, read a pa-
per on

THE CONTAGIUM OF DIPHTHERIA.

Diphtheria is an acute infectious disease, doubt-
less due to a living organism (microbe) the exact
identity of which cannot yet be regarded as settled.

Primarily a local affection, the system becomes
secondarily and generally infected through absorp-
tion of a poison generated at the primary and lo-
calized seat of inoculation.

The modes of infection are numerous, the con-
tagium being directly transferred by contact, in a
dr>' state through the air for limited distances, in
foul clothing, in polluted food and drink, milk
probably being a prolific source of infection.

The most difficult problem to solve is that which
relates to the conditions most favorable to the
growth and development of the germs and the
propagation of the disease.

While, strictly speaking, diphtheria can hardly
be called a filth disease, since it prevails often to
a verj' limited extent in those localities whose hy-
gienic surroundings are apparently the worst, yet
certain kinds of filthy- accumulations, as the ord-
ure of animals, notably the refuse from cowsheds
and dairies, seem to furnish the most favorable
conditions for the culture of this particular germ.

Until this problem can be solved and the life
history and habitat of the diphtheritic germ is
understood, no definite plan can be formulated

for the arrest of the contagium nor for the hopeful
treatment of the disease.

Friday Morning.

The following officers were elected : President,
Dr. S. C. Busey, Washington ; ist Vice-Presi-
dent, Dr. Wm. Pepper, Philadelphia ; 2nd Vice-
President, Dr. Henrys M. L^'man, Chicago; Recor-
der, Dr. I. Minis Hays, Philadelphia ; Secretarj',
Dr. Henrj' Hun, Albany ; Treasurer, Dr. W. W.
Johnston, Washington ; Member of Council, Dr.
G. Baumgarten, St. Louis ; Representative on
Executive Committee of Congress of American
Physicians and Surgeons, Dr. Wm. Pepper, Phil-
adelphia.

The following members were elected : Drs.
Wm. G. Thompson, Wm. H. Thomson, J. West
Roosevelt, New York ; Charles Carey, Charles
G. Stockton, BuflFalo ; Victor C. Vaughn, Hene-
age Gibbes, Ann Arbor ; Charles W. Purdy,
Chicago ; Starling Loving, Columbus, O. ; W.
H. Geddings, Aikens, S. C: Wm. C. Dabney,
Charlottesville, Va. ; B. F. Westbrook, Brook-
lyn, and Henry P. Walcott, Cambridge, Mass.

The date of the next meeting to be between
May 20 and June 15, 1890.

Dr. James J. Putnam, of Boston, read a paper
entitled

A SUPPLEMENTARY INQUIRY INTO THE FRE-
QUENCY WITH WHICH LEAD IS FOUND
IN THE URINE,

The paper embodied further researches as to
the frequency with which traces of lead are
found in the urine of persons in good health, or
not presenting the classical symptoms of lead
poisoning ; and discussed the propriety of en-
larging our clinical conception of that disease. A
table was shown in which the results of the pres-
ent investigation were combined with those re-
ported upon two years ago, which may be sum-
marized as follows : The urines of 68 persons,
either presenting no symptoms (healthj- medical
students) or only symptoms of specific or local
disease (phthisis, pleurisy, local injuries, etc.)
were found by Dr. A. M. Comey and Dr. C. R.
Worcester, to contain lead in the proportion of
about 17 per cent.; while those of another group
of 125 persons, presenting various symptoms of
disea.se, such as it was thought might possibly be
due in part to lead poisoning, contained lead in
the proportion of 50 per cent. The largest sub-
group of this latter class embraced 36 cases, not
strictly homogeneous, but made up of chronic or
sub-chronic affections of the .spinal cord and peri-
pheral nerves. One (typical) fatal case of this
sub-group was analyzed at some length, and the
results of the microscopic examination of the
spinal cord and nerves were reported upon. The
case was that of a carriage painter, who suffered for
some years with progressive anaemia and general
emaciation, and for the two years preceding his

504

SOCIETY PROCEEDINGS.

[October 5,

death with weakness, parassthesia and impair-
ment of sensibility with exaggerated tendon re-
flexes and extensor spasms, increasing finally to
complete paraplegia. Lead had been found in
the urine three times, but the patient had never
presented "a blue line," characteristic of paraly-
sis, encephalopathic sj'mptoms, or colic, though
the bowels had been obstinately constipated for
years. The morbid changes found after death,
besides the signs of general anaemia, were those
of combined antero-posterior and lateral sclerosis
of the cord, on which at the last, a subacute pro-
cess of diffuse destructive softening had engraft-
ed itself.

This latter process, which was characterized by
the presence of a dense infiltration of granule
cells and by a breaking down of the ner\'e tubes,
so as to form round or oval cavities, such as have
often been, described, extended throughout the
length of ihe cord, occupying the position of the
sclerosed system traits of the adjoining tissue.
The nerv'e roots were effected though to a less de-
gree than the cord ; the posterior much more
than the anterior. The acuter process was at its
height in the dorsal region. The graj' matter
was also affected, apparently in proportion to the
severity of the secondar}' acute change, /. c, most
severely in the dorsal region. The smaller ar-
teries were here and there thickened. The peri-
pheral nerves were degenerated, but only to a
moderate degree.

It was not assumed that these changes in the
cord were due to lead as a specific poison, though
at the same time the evidence is that such my-
elitic changes as lead does set up are diffuse in
character and not coordinated with the typical
peripheral nerve degeneration. It was, however,
thought more probable, in view of the circum-
stances under which such pathological processes
had been seen in other cases, that the lead acted,
if at all, by inducing a general and — through the
thickening of the vessels — a local anaemia, thus
intensifying the effects of other influences, of
which one might be an hereditarj- tendency.

Another case was cited to show that lead in
drinking water may cause outbreaks of acute in-
digestion in children,while other children exposed
to the same influence may be wholly unaffected.

A number of observations made on Bo-ston
drinking water by Dr. E. M. Greene were report-
ed, showing the frequency with which lead is
present and the length of time required to wholly
rid a pipe of its presence.

Dr. Harold C. Ernst, of Jamaica Plains,
Mass., read a paper entitled

HOW KAR MAY A COW BE TUBERCULOUS BEFORE

THE MILK BECOME.S DANGEROUS AS A

FOOD SUPPLY?

The ob.servations which he reported were made
at the instance of the Massachusetts Society for

the Promotion of Agriculture. The surround-
ings of the animals used were prepared in the
most careful manner. One hundred and fourteen
samples of milk were examined for the bacillus.
These were obtained from thirt)'-six cows suffer-
ing with tuberculosis of some organ other than
the udder. Seventeen samples were found to
contain tubercle bacilli. These seventeen speci-
mens came from ten cows. The cream was found
to contain bacilli as often as the milk. The ba-
cilli were present with a fair degree of constancy.

Well animals were then inoculated with the
result of inducing the disease in 50 per cent, of
the cases treated. Feeding experiments were
also made with the result of inducing the disease
in a number of calves and young pigs. The fol-
lowing conclusions were presented : i, and em-
phaticall}', that milk from cows affected with
tuberculosis in any part of the body may contain
the virus of the disease. 2. That the virus is
present whether there is disease of the udder or
not. 3. That there is no ground for the assertion
that there must be a lesion of the udder before
the milk can contain the infection of tuberculosis.
4. That, on the contrary, the bacilli of tubercu-
losis are present and active in a verj' large pro-
portion of cases in the milk of cows affected with
tuberculosis, but with no discoverable lesion of
the udder.

Dr. E. L. Trude.\U, of Saranac Lake, read a
paper on

HOT .AIR INHALATIONS IN PULMONARY TUBER-
• CULOSIS.

The paper presented a brief clinical history' of
four cases treated during periods varying from
one to four months by Weigert's method. This
was considered as secondarj- and only as a basis
for the bacteriological stud}- which is left to an-
swer the claim of specificity made for the method.
The question to be answered is whether breath-
ing of hot air can prevent the growth of the
tubercle bacillus in the lungs of living individ-
uals. The clinical evidence obtained brings out
no positive proof in favor of the treatment. From
the bacteriological research the following notes
are made : In all the cases the bacillus which
was present before the treatment remained in the
sputum, and no effect was produced upon that
important element of the disease. The claim of
diminished virulence was tested by inoculations
made on rabbits before, during and after the
treatment. The sputum of one of the patients
who improved was found, fifteen weeks after the
uninterrupted daily breathing of hot air, to pro-
duce tuberculosis in the animals injected as
promptly, and to a similar extent, as that inject-
ed before the treatment had been instituted.

Conclusions: — i. The therapeutic value of hot
air inhalations in phthisis is doubtful. 2. The
evidence obtained by bacteriological study of the

1889.]

MISCELLANY.

505

cases recorded does not confirm the assumption
that inhalations of heated air can either prevent
the growth of the tubercle bacillus in the lungs
of living individuals, or diminish the virulence
of this microbe when it has gained access to them.

NECROLOGY.

Dr. Addinell Ile^vsou.

Dr. Addinell Hewson, of Philadelphia, a
member of the Association in 1855, died Septem-
ber II, in his 66th year. He was descended by
a medical line of ancestry, being the fourth in de-
scent from an eminent London surgeon. He was
carefully educated at home, and at Dublin, after
taking his medical degree at Jefferson College,
which was in 1850. He was eminent in surgery
as well as editorial and literary work. He was
appointed visiting surgeon to the Pennsylvania
hospital in 1861,

tria ; Dr. Franz Hellwig, the botanist attached
to the German New Guinea expedition, and Dr.
Wasseige, professor of midwifery in the Univer-
sity of Liege.

Ex-Surgeon General Joseph Beale.

Ex-SuRGEON General Joseph Beale, with
relative rank of Commodore U. S. N., died on
the 24th ult., at his residence in Philadelphia.
Dr. Beale was born December 30, 1814, and re-
ceived his classical and medical education in the
Universitj' of Pennsylvania, from which institu-
tion he graduated in 1836. He practiced his pro-
fession for one year, at the end of which period
he entered the United States navy as Assistant
Surgeon, and afterward rose to the position of
Surgeon General of the navy, to which he was
appointed in December, 1873. He was placed
on the retired list in 1876.

Dr. S. O. IIabei"slion.

Dr. S. O. Habershon, the well-known English
medical author, died in London, on the 22d ult.,
at the age of 64 years. His books on the dis-
eases of the abdomen, passed through several
editions, of which two appeared in this country.
He was .senior physician to Guy's hospital. He
was a philanthropist and prominent in religious
undertakings.

MISCELLANY.

Deaths of Eminent Foreign Medical Men.

The Lancet announces the death of the follow-
ing eminent foreign medical men : Dr. Jacobson,
professor of chemistrj^ in the University of Ros-
tock ; Dr. Anthon Geuter, professor of chemis-
trj' in the Universit}- of Jena ; Dr. Anton Nuhn,
honorary professor of anatomy in the University
of Heidelberg ; Dr. Josey Tieftrunk, of Prague,
formerly body phj-sician to the Emperor of Aus-

The -American Public Health Associ.\tion. — We
again call attention to the meeting of this Association,
which will convene at Brooklyn Institute, Washington
and Concord streets, Brooklyn, October 22, 23, 24, 25.
Hon. Alfred C. Chapin, Mayor, will deliver the Address
of Welcome on behalf of the city. That on behalf of
the medical profession will be delivered bj- Dr. Alexander
Hutchins. The topics to be considered are as follows:

1. The Causes and Prevention of Infant Mortality.

2. Railway Sanitation (heating, ventilation, water sup-
ply, water-closets, carrying of passengers with infectious
diseases).

3. Steam-ship Sanitation.

4. Methods of Scientific Cooking.

5. Yellow Fever (unprotected avenues, local protec-
tion, the proper procedure of local health authorities in
case of an outbreak of yellow fever).

6. The Prevention and Restriction of Tuberculosis in
Man.

7. Methods of Prevention of Diphtheria, with Results
of such Methods.

8. How far should Health .Authorities be Permitted to
Apply known Preventive Methods for the Control of
Diphtheria?

9. Compulsory Vaccination.

10. Sanitation of Asylums, Jails and other Eleemosy-
nary Institutions.

The International Dental Congress.— Drs. E.
B. Ward and J. A. Swasey, delegates from Chicago to the
International Dental Congress at Paris, have returned,
and say it is a certainty that the meeting of the Con-
gress in 1S92 will be held in Chicago. A letter from
Mayor Cregier inviting the Congress to come to Chicago,
and one from Ferd Peck, tendering the auditorium hall,
were presented to the Congress and met a cordial recep-
tion, particularly from the French delegates. Dr. Ward
says the belief was quite general among the delegates
that the world's fair would be held in Chicago in 1892,
and they favored holding the International Dental Con-
gress here at the same time.

German Code of Ethics. — At the seventeenth Con-
gress of German physicians held recently at Brunswick,
the following resolutions were passed :

1. Everv kind of public laudation, whether it pro-
ceeds from the physician in question himself or from
others, and continued advertising in public papers are to
be reprobated.

2. The designation "specialist," for puffing purposes,
is to be reprobated.

3. The public offering of medical assistance gratis,
underbidding in concluding contracts in sick societies
and the like, offering advantages of any kind to a third
person in order to procure practice, are inadmissible.
The designations " klinik " and " poliklinik " (hospital)
belong exchisively to institutions which serve the pur-
pose of instruction in connection with universities.

4. The ordering and recommending of secret reme-
dies are inadmissible.

5. .A.nv attempt of any kind on the part of a physi-
cian to intrude upon the practice of another is dishonor-
able, especially in the case of one who has acted as sub-
stitute or in consultation. A practitioner must by no
means undertake the treatment of a case without the ex-

5o6

MISCELLANY.

[October 5, 1889.

press consent of the previous physician. A specialist
called in for a definite part of the treatment must strictly
confine himself to that.

6. No physician is at liberty to make disparaging re-
marks to others about another physician.

Tri-St.\te Medical Associ.\tion. — The following
papers have been promised for the meeting of the Tri-
State Medical Association :

"Demonstrations with the Microscope," Prof. James
A. Reeves, Chattanooga. "Stricture," Prof. Daniel H.
Howell, .Atlanta, Ga. " A Case of Typhoid Fe%er with
Subnormal Temperature and Subnormal Pulse," Dr. A.
S. Wiltse, Kismet, Tenn. " A Plea for the Medical Edu-
cation of Females," Dr. Chas. P. Gordon, Dalton, Ga.
" Choleo Cystotomy, with a Case," Dr. E. E. Kerr, Chat-
tanooga. Report of a Case, Dr. Wm. T. Blackford,
Graysville, Ga. " Physiolog}' of the Heart and its
Valves," Dr. W. L. Gahagan, Chattanooga. "Relation
of the Specialist to the General Practitioner," Dr. F. W.
Skillern, Pikeville, Tenn. "Some Points in the Diag-
nosis of Skin Diseases," Prof. E. A. Cobleigh, Chatta-
nooga. " Imaginary Foreign Bodies in the Throat," Dr.
Max Thorner, Cincinnati, O. "Antiseptic Midwifery,"
Prof. F. \V. McRae, Atlanta, Ga. Other papers of inter-
est will be presented.

Prof. Robert Battey, of Rome, Ga., has promised to be
present.

This meeting will be held in response to the following
call issued by a number of societies in Alabama, Georgia
and Tennessee ;

" The members of the medical profession in Alabama,
Georgia and Tennessee are requested to meet in Chatta-
nooga on the third Tuesday in October, for the purpose
of forming a Tri-State Medical Association. All will be
admitted to the meeting of the Association, but the
membership will be restricted to graduates of regular
medical colleges in good standing."

A Constitution will be adopted at this meeting which
will regulate all matters pertaining to the society. The
meeting will be called to order at lo a.m. Tuesday, Oct.
15th, at the Chamber of Commerce. The sessions will
continue two days.

Frank Trester Smith, M.D.,

Secretary of Committee.

Is Leprosy Hereditary ? — Ortmann (Archiv f.
Derm, und Syph.) gives a concise abstract of a paper by
Dr. .\mauer Hansen, in which the author gives the result
of an interesting investigation. He went to America to
visit the lepers who had emigrated from Nonvay, and
examined in the States of Wisconsin, Minnesota and Da-
kota lepers who had originally left Norway and their de-
scendants born in .America. He arrived at the interest-
ing result that of i6o lepers who had emigrated to Amer-
ica, the offspring had remained free to the third genera-
tion. This result shows emphatically that leprosy is not
a hereditary disease. The fact that, of the r6o emigrants,
only sixteen or seventeen are still alive without any new
case having sprung up does not, in his view, show that
leprosy is not contagious. The different mode of life in
the new country does not afford the same opportunity of
contagion that is given by the peculiar conditions of life
in Norwav.

LETTERS RECEIVED.
Dr. Dudley P. Allen, Cleveland, O.; Dr. Geo. E. Fell,
Buffalo, N. Y.; Dr. Perry H. Millard, St. Paul, Minn.;
Druggists' Directory, Boston; Dr. I. W. M. Gartury,
Stockton, Cal.; Ketteridge & Morau. .\nn Arbor, Mich.;
Dr. Edward F. Wells, Shelby vilU'. Ind.; Dr. H. C. Jones,
Maroa, 111.; Dr. John M. West, Philadelphia; Woman's
Medical College, Dr. C. H. Knight, New York; Dr. J. W.
Selman, Greenfield, Ind.; Dr. O. E. Abel, Winchester,
Ind.; Dr. M. H. Fletcher, Cincinnati, C; W. P. Clearv,
New York; Reed & Carnrick, New York; Dr. J. H. Bry-

an, Washington; Dr. M. G. Kolb, Cleveland, O.; Dr. G
B. French, Cedar Rapids, la.; Dr. F. A. Weir, Jesup, la.
Dr. E. A. Holmes, North St. Paul, Minn.; Dr. C. A. Free
man, Chicago; Dr. Robert T. Morris, New York; Cin
cinnati Polyclinic, Cincinnati, O.; Dr. J. A. Larrabee
Louisville, Ky.; S. H. Parvin's Sons, Cincinnati, O.; Bat
tie & Co., St. Louis, Mo.; Dr. A. K. Harrison, Columbus
Tex.; Dr. Arthur B. Coffin, Boston; Dr. J. H. Davisson
Los Angeles, Cal.; Dr. A. L. Hummel, Philadelphia; Dr
Wm. B. Atkinson, Philadelphia: Dr. Chas, C. Browning
Adrian, 111.; Dr. Richard J. Dunglison, Philadelphia; Dr
H. D. NicoU, New York; The Bancroft Co., San Francis
CO, Cal.; Hammond Typewriter Co., New York; Dr. Johi

A. Robison, Chicago; J. Walter Thompson, New York
Alban\' Medical College, Albany, N. Y. ; Belle\'ue Hospi
tal Medical College, New York; Surgeon-General Johi

B. Hamilton, Washington; Geo. P. Rowell & Co., Nev
York; Dr. E. R. Palmer, Louisville, Ky.; Dr. E. G
Cochran, Chihuahua, Mexico; Dr. E. von Denhoff, Lou
isville, Ky.; Dr. F. Koeller, Pittsburgh, Pa.; Dr. A. E
Prince, Jacksonville, 111.; Niagara Universitv, Buffalo
N. Y.; Dr. C. C. Hunt, Dixon, ill.; College of Physician:
and Surgeons, Chicago; J. H. Chambers & Co.. St. Louis
Mo.; J. H. Bates, New York; Prof Dr. H. Dor, Lyons
France; Dr. A. Hanson, Paulina, la.; Miss N. J. New-
comer, Indianapolis, Ind.; Dr. Jesse Hawes, Greelv, Col.
Dr. John M. West, Philadelphia; Dr. Chas. T. Disen
Minneapolis, Minn.; Dr. A. H. Hunt, Wooster, O.; Wan
Bros., Jacksonville, 111.; Dr. Ed. A. Pennock, Chartram
Pa.; Thos. Leeming & Co., New York; Dr. A. Vande
Veer, Albany, N. Y. ; Dr. Frank Trester Smith, Chatta
nooga, Tenn.; Miner & Elberg, Indianapolis, Ind.; Dau
chv & Co., New York; Dr. C. F. FoUey, Breckenridge
Minn.; Dr. C. L. Ford, Ann Arbor, Mich.; Dr. Thos. \v
Kav, Scran ton, Pa.

Official List of Changes in the Stations and Duties oj

Officers Serving in the Medical Department. U. S
Army, from September ji, iSSg, to September 2y
iSSg.

Bg direction of the acting Secretary of War, Major Geo
M. Sternberg, Surgeon, having completed the dutie
assigned him in War Department order dated Februar
4. 1889, S. O. 30, February 5, .^.. G. O., is reassigned ti
dutv as attending surgeon and examiner of recruits a
Baltimore, Md. Par. 12, S. O. 218, A. G. O., Septem
ber 19, i88q.

By direction of the Secretary of War, the station of Ma
jor Leonard Y. Loring, Surgeon, is changed from Ft
Mojave, Ariz. Ter., to Ft. Wingate, N. M., and he wil
report for duty at the latter accordingly. Par. 7, S. 0
219, A. G. O., September 20, iS8q.

By direction of the Secretary of War, Capt. Henry G
Burton, Asst. Surgeon, will report in person, on th
expiration of his present sick leave of absence, to th
commanding officer, David's Island, New York for terc
porary duty at that station, and by letter to the Supei
intendent recruiting ser\-ice. Par. 3, S. O. 223, A. G
0., Washington, September 25, 18S9.

Official List of Changes in the Medical Corps 0/ the U. i

Navy for the Week Ending September sS, i8Sg.
Medical Director A. C. Gorgas, detached from examinin

board and to hospital, Philadelphia, Pa.
Medical Director W. T. Hord, detached from hospita'

Philadelphia, Pa., and wait orders.
Medical Inspector E. S. Bogert, detached from Newpoi

Navy Yard and to examining board.
Surgeon D. McMurtrie, detached from V. S. S. " Vei

mont" and to Navy Yard, New York.
Surgeon H. J. Babin, ordered to the recei\'ing ship " Vei

mont."
P. A. Surgeon C. H. H. Hall, resigned from the naval sei

vice, to take effect November i, 1890, and resignatio

so accepted.

THE

Journal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.

PUBLISHED WEEKLY.

Vol.. XIII.

CHICAGO, OCTOBER 12, 1889.

No. 15.

ORIGINAL ARTICLES.

THE MANAGEMENT OF INFANTS UNDER

A YEAR OLD, HYGIENIC, DIETETIC

AND MEDICINAL.

Read in the Section of Diseases of Children at the Fortieth An-
nual Meeting of the American Medical Association,
June, 1SS9,

BY r. B. GRERNLEY, M.D.,

OF WEST POINT, KY.

When we consider the great mortality of early
childhood, compared to other periods of life, it
induces inquiry on the part of sanitarians and
clinicians as well as philantropists to endeavor to
ascertain why it is so. In this country the death-
rate of infants under one year is 60 per cent of
all who die under five years.' This is a very
astounding fact and greatly calculated to arouse
the sympathy and interest of all good men.

We know that this great mortality cannot be
due altogether to natural or unavoidable causes,
and therefore it behooves all workers in the med-
ical profession as well as philanthropists to investi-
gate the cau.ses and, to the best of their ability,
mitigate as much as possible such a dire calamity.

The question may arise in the minds of some,
why is it that the young of the inferior animals
are not subject, to some extent, to disease and
death, like our infants? Can it be that they take
better care of their young ; that they have better
ventilation ; that the mammifera afford a better
milk supply ; that they better protect them from
violence ? Is civilization one of the factors detri-
mental to infant life ? Can it be that we, more
than the brute creation, violate the laws of health
and cleanliness to such an extent as to procreate
weakly and diseased offspring?

In discussing the subject before us I shall very
cursorily speak of ( I) the mortality, (2) the hy-
giene of infancy, ( 3 ) the proper food for infants,
and (4) allude to some of the diseases incidental
to that period of life. There can be but little
doubt that a large proportion of infantile mortal-
ity is due to improper food, or, more correctly
speaking, the want of proper food and unsanitarj^
surroundings. A very large percentage of the
mortality of infants during the first year occurs

' vital statistics, U. S. census 1880.

during the first month and greatly diminishes as
age advances.

In France, out of 1,000,000 births over 29,000
die the first week, 22,000 the second week, and
22,000 in the sixteen days following, showing a
mortality during the first month of 10.36. The
annual rate of mortality among infants aged one
month and under one year does not exceed 1 14.6
per 1,000, whereas among infants from birth to
one year of age it is equal to 165.6.- In a supple-
ment to the twenty-fifth report of the Registrar-
General of England, 1838 to 1854, we find a
table of annual rate of mortality, per cent., at
each month under one year of age. During the
first month 57 per cent, die ; second month, 21.80
per cent.; third month, 15.70 per cent., and so
on, rapidly decreasing as age increases. To
those unfamiliar with such statistics this would
seem astounding.

These statistics should remind us that there are
causes producing such terrible mortality aside from
disease. No doubt many children die in the first
month from congenital causes due to disease of
their parents ; and, on the other hand, many die
from neglect, starvation and exposure, and some
from infanticide, while many die from the effects
of improper food. Now, after considering the
great mortality of infancy during the first year,
the question is strongly presented to us, what
can we do as sanitarians, philanthropists and med-
ical men to modif}' or curtail it? Can we do any-
thing? The solution to these questions consists
mainly in endeavoring to ascertain the causes
underlying such a terrible death rate, and, to the
best of our abilities, remove them.

We have already intimated that, to a great ex-
tent, improper food was a prominent factor in
this respect, as well as exposure, neglect, starva-
tion and infanticide. If we visit localities of the
poor in large cities, where squalor, filth and deg-
redation prevail over everything else in the way
of cleanliness and good morals, we can to some
extent account for the excessive death-rate of in-
fants recorded in most of our large cities.

Now, what can be done to ameliorate the con-
dition of the indigent poor who crowd the alleys
and cellars of our cities ? We are familiar, to a
great extent, with the cause of a great deal of

- British Medical Journal, June 12, 1875.

5o8

THE MANAGEMENT OF INFANTS.

[October 12,

poverty existing in such localities. I allude to the question arises, was there not an element in

the excessive use of alcoholic liquors. This is
one cause we cannot remove outside of legislative
enactments ; for as long as politicians rule, spirit-
uous liquors will be for sale, no difference what
the consequences may be. But from a sanitary
point of view a good deal might be accomplished
in such localities. It should be the duty of the
sanitary ofiBcers of cities to superintend the reno-
vating and disinfecting of such unhealthy prem-
ises, and see that ventilation and cleanliness as

this law lacking, as far as it respects stamping
out the disease? It should have been fuller in
its provisions. Every woman found with the
disease should have been put in a hospital for
the treatment of syphilis.

It was the licensing part of the law that the
religious part of the population complained of,
which could have been left out. There is but
little doubt that inspection comes the nearest of
anj- means we possess, added to confinement in

far as possible are secured to the families of the hospital until well, that promises to stamp out

the disease or greatly limit its present extent.
It maj- be said, in this regard, that many places

poor.
As

to the effects of inebriation, we have but

little hope of amelioration ; but when it is found j of a private character would be overlooked, but
that children are starving, neglected or abused in j by strict .surveillance of proper officers all such

any way, they should be taken from their parents
and placed in charitable institutions provided for
their benefit. This part of the work of saving
children wodld mainly fall to the lot of philanthro-
pists. It has been said bj- some good people that
it would be as well for mankind if the children
of inebriates were all to die, so that we might
soon be rid of drunkenness. This idea is ex-
pressed on the hypothesis that drunkenness is
hereditary' from parent to child. Regarding this
as being true, of which there is little doubt, the
proposition would not destroy the habit, as, un-
fortunately, many young men and boys acquire
it from force of association and imitation. The
idea may have originated from the theon,- of
scientists that it would be in accordance with the
law of survival of the fittest.

There is another cause in force which destroys
the lives of many infants. I allude to syphilis.
We have no idea of the great mortalits- resulting

houses of resort would finally be discovered. It
is impossib e to ignore the existence of such an
evil. We have had it among us for centuries,
and if it is the result of super-civilization, so
much the worse for humanity. I think it must
be evident to the minds of all obser\'ers that if
syphilis and alcoholism could be eliminated from
the worll, the death-rate of the race would be
wonderfully abridged ; and if by any means pos-
sible such a Utopian condition of the world could
be brought about, the millenium would be near
at hand and humanit}- would rise up as one man
and pronounce the authors of such results the
great benefactors of their race.

As for the filthy condition of the streets, as be-
fore remarked, where the poorer classes congre-
gate, as well as the unventilated tenement houses
are concerned, much could be done bj- the proper
surveillance of the health officers. It must be
patent to the obser\'ation, at least of all medical

from this cause unless we examine the' register of I men, that it is in such localities where epidemic

hospitals for infants. Most all children inherit-
ing this disease die before they are a year old,
and a large majority perish during the first two
months. Now, can we do anything to diminish
this mortuarj' record?

As a large majority of these' children are born
in cities, something, perhaps, might be done in
the way of stamping out the disease. Several
years ago the plan of licensing and inspection
was tried in St. Louis, and it was said by Dr.
Bernard, who was supervisor of inspection, that
during its existence it curtailed the disease about
40 per cent. But the law was short-lived, as it
was so repugnant to the minds of the religious
element of the population that they soon rebelled
against it. and it was aboli.shed. They seemed

diseases find their greatest number of victims.
The construction of tenement houses, as it re-
gards drainage and ventilation, should be under
the supervision of a health officer. All such
things as these can be regulated by municipal
authority. The women living in such unhealthy
localities cannot be in good health them.selves,
and, consequently, their offspring will be affected
thereby ; and in many instances the infants, to
start on, are independent of hereditary diseases,
anaemic, or possessed with very feeble constitu-
tions, added to these impoverished milk and un-
sanitary surroundings. These are common causes
of mortality among infants. In such places as
these we find overwork and the want of proper
nourishing food on the part of the mother as the

to be actuated by the principle that, although it causes of bad health and death among infants

while in higher life, among fashionable women,
other causes militate against infantile health and
life. Here we find imprudence in dress, inactive
life, late hours and irregular habits, producing
impaired appetite and digestion, and, con.sequent-
ly, a poorly nourished embryo. And after birth
the little impoverished waif, on account of the

may be under.stood that moral di.sea.se exists
among us, we must not acknowledge it openly.
The St. Louis law was that every hou.se of ill-
repute was granted a license, and, on inspection,
every inmate who was not diseased was granted
a certificate of health, and those who were found
to be diseased were refused a certificate. Now

i889.]

THE MANAGEMENT OF INFANTS.

509

fashionable tenets of the mother, is greatly neg-
lected, perhaps committed to the care of a care-
less and incompetent nurse : and if the little thing
dies it is recorded in the mortuar}' list as having
died of inanition, when really it was from neglect
and starvation.

Can anything be done that will v.'ork a favor-
able change in this particular? It is feared the
world will be compelled to wait an indefinite
time, at least until common sense and proper ma-
ternal instinct resume, to some extent, their an-
cient domain. Fortunately these unnatural hab-
its and lack of philo-progenitiveness are confined,
comparatively speaking, to but a small portion
of our population. In order to make a compari-
son between the offspring of such parents and
that of those who observe regular habits, take
due amount of exercise and observe the proper
maternal care of their infants, we have only to
note the contrjst presented' between the two
classes of children. If we go into the countrj-
we commonly see not only large families of chil-
dren, but stout and healthy ones. Here their
mothers, as a rule, observe the various means to
preserve health, and furnish a healthy supply of
nourishment to their oflFspring. Could not the
profession who have charge of the fashionable
portion of humanity as their clientage exert a
salutarj' influence over them in this particular?

It is said by a late writer in this regard, that
"it is a common thing to find in fashionable
families but few children, hardly ever more than
two to four at the highest, manj' having only
one and a poodle dog, and some onh' the poodle."
If thej- have been unfortunate enough to give
birth to many children, death has claimed a ma-
jorit}- of them through neglect, if not disease.

As the mortality of infants during the first
month of life is sd great, it behooves us to have j
special supervision over them. As far as possible
a healthy, ventilated room should be chosen for
the lying-in woman, the temperature of which
should be kept equable at about 80° F. When
the child is born it should be kept, if possible, in
a temperature of 90° or 95° until it is washed and
dressed, and then placed in bed alongside its
mother. Manj- infants have perished from the
effects of exposure between birth and being
dressed. As soon as convenient the child should
be allowed the breast, whether there is milk pres-
ent or not, so that it may learn to nurse. Of
course, if the breast contains no milk, which is
common until the second da}-, the child must be
fed on fresh cow's milk. After the .secretion of
milk is e.stablished the infant should be allowed
the brea.st everj- four or five hours, or oftener if
necessary. The mother should avoid taking any
drugs in sufficient quantity to affect the child
deleteriously. The position of the child should
be changed frequently, not allowing it to remain
in one position more than a few hours at a time,

say when it nurses or is fed. This is essential
on account of the bones of the head not being
[ sufficiently compact to support the gravity of the
brain so as to pre.serve its proper shape. Many
children, from inattention in this particular, have
misshapen heads. When children are born in
cold or changeable weather they should wear
caps. Neglect in this regard frequently event-
uates in cold in the head, producing discharges
from the nose and ears, which not infrequently
becomes chronic. An infant should not be
j washed all over in cold weather oftener than once
a week, and then always in a temperature not
less than 80° or 85° and with warm water. Care
should always be observed that the flexions of
the joints and the folds of skin around the neck
are dusted daily with some finely prepared pow-
der to prevent chafing, the finely prepared chalk
being as good as any. An infant should not be
taken out in cold weather unless well protected
with heavy, warm clothing and well wrapped up.
Young children are very easily impressed with
cold from exposure, and on that account more
liable to inflammations of the chest, brain, etc.,
than older children. vSpecial supervision should
be exercised over them in this particular. Close
attention should be exercised over the digestive
apparatus of infants, and particularly so in their
early life, when deprived of the mother's milk.
As a rule, a child under its mother's care, when
she is in good health, needs but little outside at-
tention ; but when it is necessary to feed it on
artificial food it is liable to indigestion, flatulencj-,
colic, etc., which, if not corrected, will soon pros-
trate it. This is more particularly so in hot
weather. This condition, in many instances, is
due to the use of milk undergoing fermentation,
and to neglect in properly cleansing the nursing
bottle, etc. In warm weather it would be better
to obtain fresh milk from the cow three times a
day, and every time a bottle is used it should be
thoronghlj' cleansed and rin,sed with a warm .so-
lution of common soda and allowed to remain in
the sunshine until needed for further use. A
young infant fed on cow's milk should have the
bottle everj- three or four hours, so that it will
not, by becoming verj' hungry-, take too much at
a time and therebj' engender indigestion and
colic by over-distension of the stomach.

It is a question among the best men in the pro-
fession whether or not cow's milk should be di-
luted. A majority of those writing on the sub-
ject recommend dilution from one-fourth to three-
fourths, according to the age of the child. As
far as m}- observation extends, 1 prefer to use the
milk undiluted. When we dilute cow's milk to
one-fourth it requires a large quantit\' of it to
furnish a due amount of nourishment, which, if
the child takes enough, so distends the stomach
as to produce colic, and if kept up sufiicientlj^-
long we will have disordered digestion, diarrhoea

5IO

THE MANAGEMENT OF INFANTS.

[October 12,

and colic, due to over-distension of the organ.
And, on the other hand, if a sufficient amount is
not taken to produce over-distension of the organ,
gradual starvation will ensue.

When I promised our worthy Chairman to
write this paper I consulted my friend Prof.
Howe, scientist of the Louisville Polytechnic So-
ciety, in regard to milk, etc., as food for infants,
the reagents necessary for digestion, etc. He
kindly furnished me the following notes :

First. — The food which nature has provided
for the infant is presumably the best. This con-
sists essentially of

1. Casein — the nitrogenous food, flesh-former.

2. Sugar ) the carbonaceous foods, heat and

3. Fat I force producers.

4. Salts — bone former.

5. Water.

Second. ^—\m all foods prepared for infants the
latter ingredients are present in sufficient quan-
tity, and play not a small part either in starving
the infant or impairing its power of digestion.

Third. — Casein. The casein of woman's milk
is characterized by not forming a solid curd when
acidified. This, among the mammalia, is said to
be true only of the milk of woman and the mare.
Other milks form more or less tough coagulum
when acidified, and hence the infant's stomach
at once assumes a condition in which the feeble
digestive fluids of the infant fail to act upon them.
On the other hand the casein of the milk of
woman or the mare in the infant's stomach is so
finely divided that it is digestible. This is a
plausible reason why infants have been found to
thrive better upon mare's milk than upon that of
cows (carried out on a large scale in Paris), even
though the proportion of its ingredients is not
that of woman's milk. It has been attempted to
obviate this difficulty of coagulation by diluting
cow's milk (ineffectual), or by adding various
farinaceous materials which are in themselves in-
digestible by the infant, as mentioned later.

This difficulty may be obviated by partiall}^ di-
gesting cow's milk (peptonizing, a process which
requires some considerable care), or by malting,
both of which seem to render the casein of cow's
milk digestible by the infant.

Fourth. — Sugar. Nature has provided for the
child an animal sugar — lactose, or milk sugar,
which is distinguished from all vegetable sugars
by yielding, upon fermentation, lactic acid, an
acid which in itself plays an important part in
digestion. Milk sugar cannot safely be substi-
tuted in an infant's food by any vegetable sugar,
such as cane or grape .sugar, both of which are
very readily fermentable and produce alcohol and
ascetic acid.

Fifth. — Much less can the sugar be substituted
by starch in any of its forms, nor can any form
of starch be safely used in an infant's food, as is
most commonly done in most so-called infants'

foods. Nature has prepared animal food for the
infant ; no vegetable food can be a substitute.

As regards starch, the infant's saliva contains
no ptyalin, which is important for its digestion,
and in many cases at least the various starch
preparations will pass through the infant's diges-
tive canal in a wholly undigested condition, and
the infant, eating heartily, may be huugn,- all
the time and finalh' star\-e to death.

We are frequentlj- asked by parents if it is not
better to feed infants on other food besides breast
milk. The answer should be infallibly no, unless
the mother gives an insufficient supply. It is
shown by Dr. Whitehead's tables that the chil-
dren fed on breast milk exclusively resulted in
perfect development in 67 per cent., medium de-
velopment in 23 per cent., and bad development
in 14 percent.; whereas in children fed partly on
breast milk and partly on other food there was
good development in only 52 percent., medium
in 19, and bad in 39 per cent,; and lasth", as op-
posed to these results, where hand feeding was
used entirely, there was good development in 10
per cent., medium in 26, and bad development in
64 per cent.

If an infant is so unfortunate as to be deprived
of its natural food, either on account of the heart-
lessness of its mother or some accidental cause, it
should be committed to the care of a competent,
careful nurse. In selecting a nurse it is essential
that one of good moral character should be
chosen, and, if a wet-nurse, that she is perfectly
healthy. Even if one of this character is selected
she and the child should be under the supervision
of the medical attendant at least once a week for
several months, in order to know that the child
is well supplied, that it digests its food, and that
it is well taken care of.

I believe more infants die from neglect, expos-
ure and want of proper food than from actual dis-
ease, aside from heredity. Then, if these matters
could be properly super\-ised, there would be a
great saving of infantile life. Manj' times, if the
nurse is of a vicious and reckless disposition and
the child becomes fretful from indigestion, hun-
ger or pain, it is dosed with some opiate prepara-
tion, or perhaps alcoholic beverage, in order to
quiet it and thereby secure time for her own bene-
fit. Habits of this kind practiced on infants are
very injurious to health, tending very greatly to
impair the digestive functions and vitiate the
secretions, to say nothing of ultimate injurious
effects that may result.

I have always thought that a mother in good
or ordinary health, who, for the sake of enjoying
fashionable life or for any other selfish motive,
would commit her child to the tender mercies of a
wet-nur,se, or, in fact, any other, is destitute of
that natural instinct which pertains even to all
inferior animals, and that she, in .so doing, not
onlj' commits a sin against true motherhood, but

1889.]

THE MANAGEMENT OF INFANTS.

5"

is gruilty of possible, unintentional infanticide.
Children under a year old, as a rule, when fed
on breast milk, need but little medication, unless
affected by contagious diseases peculiar to them.
To be sure, in cities, during the hot season, we
may have some bowel affections which are, appar-
ently, unavoidable. It would be well, in ex-
tremely hot weather, to take delicate, and espec-
ially bottle-fed, children to the country, where a
change of air would do more good than medicine.
But on account of want of means a large majorit}-
of city children are deprived of the advantage of
such a change. It is under circumstances of this
kind, particularly in unsanitary localities, that
hot weather diseases run up such long mortality
lists. This character of children's ailments make
up a large ratio of the death-rate in cities during
the hot months. I have thought that, through
charitable organizations, aided by municipal au-
thority, homes for indigent children might be
constructed, where they could be cared for during
the summer months and thereby save the lives of
thousands who otherwise die from neglect, the
want of proper nourishment and from unsanitary
surroundings. Much good could be accomplished
during extreme hot weather in such buildings by
the use of large fans in the various rooms, kept
in motion. The difference between hot air in
motion and in a state of rest becomes very palpa-
ble when we go from a close room into the open
air. where there is a breeze. Although the. tem-
perature is the same, warm air in motion produces
a cooling and an invigorating effect. How grate-
ful it is even to be fanned in the face when one is
almost overcome with heat. Large fans could be
easily and cheaply constructed and worked at an
inconsiderable expense. Netting, something in
the form of hammocks, could also be arranged in
the rooms to sen'e in the place of beds for the
children, which would allow the animal heat to
escape much more readilv than from ordinan,'
beds. The netting should be so arranged as to
be as nearly horizontal as possible. This would
be a very eligible and beneficial arrangement,
more particularly in cases of disease accompanied
with very high temperature.

Infants, as before remarked, under ordinary
circumstances need but little medicine, and that
of a mild character. It has been a habit with
me for years to u.se the mo.st simple means in
children under a year old. Colic and disordered
bowels due to indigestion are the main troubles
we are called upon to treat during the first
months of infant life. If the child is fretful and
restless, with tympany of the stomach, a little
ginger or mint tea, sweetened, will in a majority
of cases afford relief Should there be much
pain, add a few drops of paregoric. When this
is due to indigestion, a little lactopeptine and
bismuth sub. nit. might be given with advantage
after each nursing.

In cases of diarrhoea accompanied with acidity
of the discharges, which is generally evidenced
by the smell as well as a foamy appearance, the
first thing to do is to correct the acidity. For
this purpose a little sublimated or prepared chalk
is about as good as anything. This alone will
frequently correct the condition of the bowels ;
but should an astringent be needed, a little syrup
made of the fluid extract of cranesbill is as ef-
fective and simple as anything we can use ; but
do not attempt to arrest diarrhcea due to acidity
and fermentation by the use of astringents alone.
Many times, after the acidity has been corrected,
the diarrhoea can be arrested bj' minute doses of
castor oil, say a drop or two given every fifteen
minutes until it passes the alimentary canal.
The same thing may be accomplished bj- very
minute doses of calomel, say ^V- of a grain every
half hour until its eifects are obser\'ed in the dis-
charges.

In an attack of cholera infantum the child
should, if in the city, be removed to the countrj^
or some place where it can have pure air and
healthy surroundings. More, as a rule, can be
done b}' sanitary means than by medicine. If
the diarrhoea is accompanied bj- acid vomiting,
administer fresh milk and lime water in small
doses frequently repeated, and as soon as the
vomiting has ceased exhibit minute portions of
calomel or hyd. cum creta frequently repeated
until the character of the discharges is changed
and become more consistent and less frequent. I
have also had good luck in the use of subnitrate
of bismuth and Dover's powder in the treatment
of cholera infantum. Food should be withheld
from the infant during the existence of the acute
symptoms. Should the case be protracted after
the acute stage has subsided, it would be well to
use cretaceous preparations with astringents, such
as acetate of lead, cranesbill, kino, etc.

In chronic constipation of young babies harsh
purgatives must be avoided, as well as hydro-
gogues. I have had good results from .syrup of
figs, cascara sagrada, rhubarb, etc.; but if the
child is debilitated combine some muscular tonic,
as tinct. nux vom., columbo, etc.

In the various contagious diseases of children
isolation is an important element in their manage-
ment.

In writing this paper it was not intended to
claim any superiority over my confreres in the
management of infantile life, or with the expecta-
tion of presenting anything new in the way of
treatment, but more particularly to impress them
with the necessity of a closer supervision over
; young children, more especially during the first
months. If, by our attention and advice to par-
ents, we can tide a child over the first 3'ear, its
prospects to live ten years are increased 50 per
j cent. It therefore behooves the medical man, as
1 well as parents and nurses, to exercise careful

512

PURIFICATION OF DRINKING WATER.

[October 12,

supen'ision over their health during that period.
If each one of us could, by increased watchful-
ness, save even one additional life annually over
what we have accomplished in the past, it would
add greatly to the population of our country-.

Dr. Sears, of Texas, said that the life of a
child depends very much upon the care it receives
during the first months of its existence. There
was great ignorance among the people generally
as to the quantity of food a child should have,
its nature, and the time and manner of feeding.
Infants were, as a rule, too frequently nursed.

Dr. Whitney, of Rhode Island, thought the
author had overstated the prevalence of s)-philis
in children — for New England, at least. He
would especialh' call attention to straining as a
cause of infantile hernia. He had never seen a
case of true congenital hernia. The condition at
birth is simply /a ivrad/t.' to the production of her-
nia and for its production.

Dk. Willi.\m Perrv Watson, of New Jersej',
took exception to the advice given by the author
of the paper in regard to wearing a cap. He di-
rects mothers to keep the heads and necks of their
infants bare, and bj' this means inures the chil-
dren to temperature changes. As a result he
has very few cases of nasal and pharyngeal ca-
tarrh among his practice.

Dr. Latimer, of Maryland, said that for arti-
ficial feeding there was no testimony defending
anything but cow's milk. The doctor called at-
tention to the differences between cow's and hu-
man milk, and said that Dr. Meig's method of
preparation was to be highly commended.
Nothing had been said in the paper about steril-
ized milk. The mother's milk was taken by the
infant directly from the breast and was practi-
cally sterile, no opportunity being given in its
passage from the mammary gland to the child's
stomach for infection with the spores of decompo-
sition microbes. During the hot months the in-
fection of milk with decomposition microbes was
a most important factor in the production of in-
fantile diarrhcea, and the sterilization of the food
was a necessary prophylactic measure.

THE PURIFICATION OF DRINKING
WATER FOR CITIES.

^fti(/ tn the Section of State Medicine, at the Fortieth Annttal Infect,
iiiii of the American Medical Association, June, i88g.

BY CHARLES V. CHAPIN, M.D.,

OF PROVIDENCE. R. \.

The importance of the purification of public
water supplies was impre-ssed upon the writer with
special emphasis b)- the brief epidemic of typhoitl
fever which occurred in Providence last fall. At
that time there occurred in the space of two weeks
about 250 cases and forty-seven deaths. The

cause of the outbreak was the contamination of
the river which furnishes our water supply, by
the stools of typhoid fever patients. That simi-
lar occurrences are by no means rare is well known,
and probablj- instances of the kind have come
under the personal observation of very many of
the gentlemen here present.

The impurities which are liable to be found in
the public water supplies of cities are varied.
There may be coloring matter from swamps and
bogs or other sources which renders the water
disagreeable to the sight. The water may be
muddy from the presence of claj- or earth. It
may contain infusoria or algse which, of them-
selves or by their death and decomposition, ma}'
render the water exceedinglj' unpleasant both to
smell and taste. The water maj- also contain
larger organisms, such as the eggs of worms,
parasitic or otherwise, molluscs or fish, particu-
larly eels. Lastly, the water may contain the
active virus of disease. While the other impuri-
ties in water which have been mentioned ma}'
often be sufficient to demand active measures for
their removal, it is the actual pathogenic proper-
ties of water which are of peculiar interest to
medical men. The disease which far more often
than any other has been traced to water is typhoid
fever. Medical literature is full of instances where
epidemics of greater or less severitj' have been un-
questionably traced to a public water supply.
Cholera is another disease which has often been
I distributed by thesame agency. Besides these two
i in which the facts are beyond dispute there is
I some evidence to show that dysentery, diarrhojal
diseases and malaria may occasionally gain access
to the human system through the medium of
drinking-water. Now, it has been determined
that typhoid fever, cholera and malaria are caused
by minute living organisms, and it is most likely
that the other diseases mentioned are caused by
similar organisms. Hence if we desire to deprive
water of its pathogenic properties, and that is the
problem which I now wish to consider, we must
determine how the.se organisms can be removed or
kept out of our public water supplies. It is true
that these organisms doubtless acton the body by
means of the .soluble chemical products of their
vital activity. But such substances can never
exist in any potable water in quantity sufficient
to do harm, so that if we can remove the organ-
isms theuLselves we can rest a.ssured that the prob-
lem will have been solved.

There are three points at which contamination
may be dealt with :

The first is at the source, be it river, lake,
spring or well. Every gentleman here will agree
with me that no municipality should spare any
expense or neglect any legal expedient whereby
dangerous contamination of the source of its
water supply may be avoided. In many instan-
ces, by suitable means of control the water may

1889.]

PURIFICATION OF DRINKING WATER

513

thus be kept substantially pure. But in other
cases, when the source is in a thickly settled re-
gion, this is practicalh' impossible, and fatal con-
tamination is at any time liable to occur. This
is well illustrated in the Providence epidemic re-
fen'ed to. Our source of supply is a river flowing
through manufacturing villages. At the point
where the infection took place the owners of the
mill tenements had provided water-tight vaults
at a suitable distance from the river, and frequent
inspections were made by the Board of Public
Works to see that they were kept in repair. But
when typhoid fever occurred in these houses the
tenants, instead of using the vaults, threw the
stools on to the bank of the stream, whence thej^
were washed into the water by the heavy rains.

A second point at which the water supply may
be purified is at the point of consumption. To
accomplish the removal of the germs of disease
as well as of other suspended particles, domestic
filters have been used. Sometimes they remove
the dirt, sometimes they do not. In any e\-ent
they do not remove the living bacteria. The ex-
periments of Dr. Swarts, of Providence, show
that with one exception the domestic filters of-
fered to the public in this country are worse than
useless because, instead of removing microbes
from the water, they rather ser%'e as incubators to
increase their number. The only filter which he
found could be relied on to furnish germ-proof
water was the Pasteur, but its cost puts it beyond
the reach of all but the wealthy. Boiling water
of course destroys all organisms, but it will never
be resorted to by the majority of consumers.

Lastly, we must consider the treatment of the
whole supply centrally by the municipalit}-. A
large amount of experimental work has been done
in relation to the removal of microorganisms by
filtration through sand or other media, one of the
pioneers in this direction being Prof. Pumpelly of
this city. Such work has also been done b}' Hesse
and Piecke in Germany and by Frankland in Eng-
land. But the most recent and elaborate, and
particularly interesting from a bacteriological
point of view, is the work in filtration which is
now being done by the State Board of Health of
Massachusetts, These latter experiments are per-
formed chiefly with sewage, but the results at-
tained throw much light on the filtration of pota-
ble waters.

The conclusions which have been arrived at are
that for continuous filtration on a large scale fine,
sharp sand is the best material. The finer the
sand the better is the removal of organisms and
other suspended matter accomplished, but the slow-
er is the filtration. A rate of from i to 2 gal. per sq.
ft. per hour has been found to be the most avail-
able for practical work. The thickness of the sand
makes some difference, but not as much as might
be expected, for the upper layers exert by far the
greatest influence in removing the organisms. ,

Strange as it ma}- seem, fresh sand is not as effec-
tual as that which has been in use some time, and
sterilized sand has the least value of any. This
is explained on the supposition that the grains of
sand when in use soon become encrusted with or-
ganic matter which serves to entangle bacteria
and other solid particles. The heating during
sterilization destroys this. It is certainly possible
by means of sand filtration to remove all bacteria
from water. In one of the filters tested bj' the
Massachusetts State Board of Health the organ-
isms in the applied sewage were reduced b}- filtra-
tion from over a million to less than a score, and
sometimes none at all were found. In fact, it was
demonstrated that the few organisms discovered in
the effluent were only such as inhabited the effluent
pipe. When enormous numbers of known forms
were poured on to the top of the filter none at all
could be discovered in the effluent by repeated
tests. The depth of sand in this filter is 5 feet
and the rate of filtration is ver\' slow, i gal. per
sq. ft. per twenty-four hours. While this filter
purifies the sewage so that it can be and is used
for drinking purposes, it is far too slow for actual
practice.

Passing from this experimental work we will
now briefl}- con.sider some of the filters which are
in use for supplying drinking-water to towns.

Of filters on a large scale for potable water those
at Berlin were the first whose workings were
investigated from a bacteriological standpoint.
Ever since 1S84 regular weekl}^ chemical and bi-
ological analyses have been made of the water
both immediately before and after filtration and as
delivered at the house taps. These experiments,
conducted at the Imperial Bureau of Health, fur-
nish the most complete and valuable data concern-
ing the action of this class of filters. Berlin draws
its water from two sources, the rivers Spree and
Havel. The former is much polluted and con-
tains a large number of microbes, sometimes as
many as 100,000 per cc. The Havel supply has
a smaller number. The water from both sources
is passed through sand filters. The total area of
the.se filters is about 67,000 gm., or nearly twenty
acres. They consist of ma.sonry basins containing
successive layers of stone, gravel and sand, the
essential portion being the upper layer, which is
of fine sharp sand and is about 22 inches in thick-
ne.ss. The manner of using the filter is of par-
ticular interest, for it is upon this that its value
has been found to depend. It is first slowly filled
from below with filtered water so as to drive out
the air. Unfiltered water is then admitted from
above until it is i m. in depth above the surface
of the sand. It is then allowed to stand until the
suspended matter is precipitated upon the surface
of the sand in the form of a delicate film. This
is an essential feature, for it is this superficial
layer of sediment which gives the apparatus its
value as a filter. The effluent valves are now

514

PURIFICATION OF DRINKING WATER.

[October 12,

slowly opened and filtration begins. The rate of
filtration is at the maximum about 3 cm. per
twenty- four hours through each gm. of surface,
or a little less than i gal. per hour per sq. ft. The
amount, however, rapidly becomes less, and it be-
comes necessarj' to clean the filters everj' four to
ten days according to the amount of impurities in
the water. The cleansing is done by drawing off
the water and removing by means of flat shovels
a very thin layer from the upper surface of the
filter, for it has been found that the impurities do
not penetrate more than a few millimetres. The
chemical analysis shows that by this filtration all
of the free ammonia, verj- small in amount, and a
large percentage of the oxidizable material (oxid-
izable bj- potassic permanganate), and a consider-
able amount of the volatile residue is removed.

As regards the removal of bacteria, the weekly
examinations of the unfiltered Spree water for the
j-ear ending June, 1886, gave the average number
of organisms per cc. as 11,278, while in the water
immediately after leaving the filter bed there were
but ijq. The unfiltered Havel water contained
2,628 and the filtered 97. In the former case
about 98.5 per cent, and in the latter about 96
per cent, of the microbes were removed. The
larger organisms, the algae and infusoria, are
completely removed. It is said, however, that
the spores of these algce do to some extent pass '
through the filter, so that if the water is stored in
reservoirs after filtration algse sometimes develop
there in great quantity. That not only good con-
struction but great care in the management of this
class of filters is necessarj- is illustrated by the fact
that Currier found that an American filter con-
structed on the Berlin plan allowed more than
half the organisms to pass through simply be-
cause it was not properly cared for. [

For many }'ears the various water companies !
supplying the city of London have employed
sand filtration to improve the quality of the water
furnished by them. Their filter beds are con-
structed on substantially the same principle as
the Berlin beds, and consist of a laj'er of fine sand
supported on coarser sand and gravel. The thick-
ness of this sand varies from 2 ' _. to 4/j' feet. The
rate of filtration is from 1.5 to 2 gal. per hour per
sq. ft., which is considerablj- more rapid than in
the Berlin filters, though the thickness of the sand
is greater. These filters are cleaned at varying
intervals depending on the amount of .sediment in
the water, the usual time being once in two or
three weeks. The action of the.se filters in remov- ,
ing microbes from the water was investigated by
Percy F. Frankland, who found thaf the average
number of organisms removed from the water was
97.7 per cent, for the Thames companies and 95.7
per cent, for the Lea companies. In some in.stan- f
ces, however, as many as 99.4 per cent, were re-
moved. The number of organisms in the unfil-
tered Thames water varied from 4,800 to 45,000, !

and in the Lea water from 2,900 to 39,000. In
one instance the filter of the New River Co. re-
duced the organisms from 20,600 to 74. It is es-
timated by practical hydraulic engineers that in
this couutrj- the cost of filter beds of this charac-
ter would be $25,000 per million gal. of supply,
and that the running expenses and interest on
plant would bring up the cost of filtering to $10
or $11 per million gallons of water filtered.

Of late 3-ears a number of patented filters have
been put on the market b}' American makers and
are now in use in many manufactories and in con-
junction with several town supplies. In this
form of apparatus the water is filtered under a
considerable pressure, 40 lbs. or more, and the
rate is very rapid and the filters themselves oc-
cup5^ a very much smaller amount of space than
do the European gravity filters.

The Hyatt filter consists substantially' of a cir-
cular wrought iron tank containing as a filtering
material about 4? J ft. of moderately fine sharj:) sand,
with about 18 in. of coke (locomotive cinders) on
top. This latter is for the purpose of catching the
suspended organic matter and preventing its chok-
ing the sand. The water passes through the fil-
ter under pressure. The resistance of the filter is
about 3 lbs.; that is, it decreases the pressure of
the water passing through it to that extent. At
proper intervals, usually once even.- twentj--four
hours, the filter is cleansed by sending a reversed
flow of filtered water up through it, violently
agitating it and washing out all the precipitated
material that has been removed from the water.
The washing takes saj' ten minutes, and the filter
is then read}- for use. There is said to be practi-
cally no loss of filtering material and it never
needs renewal. The rate of filtration is about
125 gal. per sq. ft. per hour. An essential part
of the claim of the owners of this filter and of the
others which resemble it, is the employment of
continuous coagulation with the process of filtra-
tion. This coagulation is accomplished by adding
to the water before it enters the filter, by means
of a suitable contrivance, a small proportion of
alum or sulphate of alumina. The amount is
easily regulated and the persons in charge of the
filters allow a sufficient amount to enter to en.sure
an effluent which is satisfactory on gro.ss examin-
ation. The actual amount used in the filters of
this company is said to varj' from ^V to i gr. per
gal., the average being yV, gr. An important ques-
tion is what becomes of this alum ? Prof. Chand-
, ler states that he took samples of the water of the
Raritan River before and after filtration by the
Hyatt filter, which is in use at the Somerville
waterworks. He found alum present in the un-
filtered water in about the amount in which the
operators of the filter claimed they were adding
it — ' .i gr. per gal. The water after filtration he
found "did not contain a trace of alum." Other
analvsts have obtained the same results. It is

1889.]

PURIFICATION OF DRINKING WATER.

515

claimed b}- the makers of these filters that the
alum all unites with the organic matter in solu-
tion in the water and, forming a part of the co-
agulum, is removed with it. Whether this is true
in all instances I am not prepared to say, enough
experiments under varj-ing circumstances have
not as yet been made to determine it with certain-
ty. We can be sure, however, on general princi-
ples, that a considerable amount of alum must be
decomposed and removed in this way if there is
much organic matter in the water, and the alum
would not be added unless this organic matter
were present. In the localities where this process
is in use there is no complaint of any taste of alum
in the water, nor any complaint that I have heard
of from medical men that the added alum cau.s<=s
any digestive troubles. And we should hardly
expect that it would, for even i gr. in a gallon is
an extremeh' small amount, and much less than
this is the usual quantity employed and a large
part of this must be removed in the precipitate.
On studying alum baking powders Prof Mallet
found that 20 gr. of alumina hydrate were required
to affect digestion unpleasantly, and it is hardly to I
be supposed that the amount derived from even yi
gr. taken in twenty-four hours in divided doses
would produce any bad results. And }? gr. is as
much as would ever be taken by one person even \
if it all passed through the filter. It seems highly j
improbable, then, that the addition of alum to ;
potable water to produce coagulation preparatory •
to filtration can produce any injurious consequen-
ces on the consumers.

The National filter is another filter of this class
which has come into quite general use, and which
differs from the Hyatt in what are apparently mi-
nor points. The makers of this filter recommend 1
that w^hen it is used to furnish a town supply a |
pump be used to add the alum solution, thus en-
suring a more certain regulation of the amount
than can be obtained b)- the regulation which de-
pends on a supposed constant rate of solution.

The waterworks in this city have recently put I
in a filter which will be described to you by Dr.
Rankin, and which seems to differ from the Hyatt
only that it is open to the air and filters under a
head of a few feet onlj-, and is so verj- much
larger that the rate of filtration is hardly one-fifth
as great as in the Hyatt and National filters.
These points of difi^erence seem to be in favor of
the Newport filter, and why it does not give better .
results I cannot say. The owners, however, do
not claim that it is yet in proper working order,
and have certain changes to make which they ex-
pect W'ill improve it.

There are several other makers of this class of
filters, but the Hyatt and National are the best
known and seem to be good types of the principle
of coagulation and continuous filtration under
pressure.

For the purpose of examining the Hyatt filter

in person I recently visited Long Branch, where
a 2,000,000 gal. plant was established a year ago.
I found the plant in operation as described, and it
had given great satisfaction to the users of the
water ever since it had been put in. At the time
of my visit the unfiltered water was of a dark
yellowish brown color and had considerable or-
ganic matter in suspension. It w^as surface water
from swamps and shallow ponds. The effluent
was perfectly clear and colorless. The pumps were
lifting at the rate of about i, 800,000 gal. per twen-
ty-four hours, and the engineer was adding about
180 lbs. of alum during the same time. This
W'ould be a little less than fV gr. per gal. The
filters had been cleaned in the morning and I
made a biological examination of the water in
the afternoon. Three gelatin culture tests were
made on the spot at intervals of half an hour.
After a growth of thirty-six hours, at which time
the liquefying cultures began to run together, the
results were as follows :

I St Test.

Unfiltered 258

Filtered 5

2nd Test. 3rd Test.
298 248

2 3

The only other biological test that I know of,
of this filter, was a single one of Prof. Formad
at Allegheny Citj^ in which about two-thirds of
the organisms were removed.

None of the National filters for town use have
been accessible to me, but the makers of the
filter suggested that a satisfactory test could be
made at the Valle)' worsted mills. Providence, or
at the bleachery at Canton, Mass. In the former
place I found the alum was not used, and the
filter was made to work under much greater pres-
sure than was intended. It furnished water clear
enough for manufacturing purposes, but scarcely
half the microorganisms were removed. At Can-
ton the alum was in use, and too much so, for it
was stated by the engineer that he thought that
I }'2 grains per gallon was added to the water.
What the amount reallj' was I do not know, but it
could be readilj^ tasted in the effluent. Five tests
gave an average of 86 per cent, of the organisms
removed. Dr. Currier tested one of these filters
at Brooklyn, and found that ' it removed a much
larger per cent. , and in one instance the effluent
was entirely sterile. He also failed to detect any
alum in the water.

The Newport filter I found had no appreciable
effect in removing the bacteria from the water,
and you have probably noticed that it leaves
much of the other suspended matter. But as I
am informed by Dr. Rankin, the amount of alum
added is so small, and it is so largely removed by
the filter that it can exert no injurious effect upon
the water.

There seems to be then little doubt that both

the sand filters in use in Europe and certain of

I the coagulating filters made in this country can

5i6

EVISCERATION.

[October 12,

be relied upou to remove from goto 100 per cent,
of the organisms contained in the water.

They cannot be relied upon to render infected
water absolutely safe. But we know that the
smaller the number of pathogenic organisms
which a person receives the less liable is he to be
affected by them. If nine-tenths of the organisms
can be removed, I believe it is not far from the
truth to assume that nine-tenths of the danger
will be removed.

The cost of the European system is, as has been
stated, $10 per 1,000,000 gallons. The cost of
the coagulating sj'stem is not more than half that.
It is al.so, when properly constructed, much
easier to manage. Its onlj' disadvantage is in the
addition of a foreign substance as a coagulent,
and I am inclined to believe that further investi-
gation will show that no danger is to be appre-
hended on that score.

Aeration has been spoken of and used as a
means of purifying water, but it can onlj' accom-
plish this to a verj^ limited degree. There is no
reason to believe that aeration has any influence
on the growth of bacteria, and recent investiga-
tions have shown that its power of oxidation is
very slight indeed. It is true that aeration is
sometimes vers- useful in removing the smell or
taste of water, but it accomplishes this by vola-
tilizing or driving out the offensive substances,
rather than actually oxidizing them in situ. At
least this is the view now generally adopted by
the best chemists.

There is another means of improving the water
supply, at least, so far as bacteria are concerned,
and that is by allowing it to stand in storage
reservoirs. The experiments of Wolihiigel,
Bolton, Frankland, and others, have demonstrat-
ed that pathogenic organisms, such as cholera,
typhoid and anthrax bacilli and various pus-
forming organisms soon die in ordinarj' river or
■well water, the typhoid bacillus living onh' about
two weeks. Certain harmless aquatic forms do,
however, live and propagate, but observations
show that most of the bacteria found in our town
supplies rapidly perish. This was found to be
true at Berlin, and Prof Sedgwick determined it
for Boston. In Prov.idence we have two reservoirs,
both in constant use. One holding ten days' sup-
ply, the other three months. Bi-monthly analysis
for a year showed as the average number of organ-
isms in the river 354, in the ten days' reservoir
223, in the three months' reservoir 42. Storage
reservoirs may, however, develop algae which,
besides rendering the water unpleasant to the
taste and smell by their death, furnish pabulum
for the bacteria. But the growth of the algae can
be prevented bj' covering the reservoirs, and it is
not to be apprehended in every case.

In order to purify water then,

I . The source must be made as pure as pos-
sible.

2. Storage reservoirs should be built.

3. The water should be filtered by the mu-
nicipality.

4. The consumer must boil the water if any
danger is suspected to exist ; but it is not likely
to if the first three conditions are complied with.

Dr. Smart took exception to the suggested
idea that if nine-tenths of the bacteria are re-
moved by filtration the danger is proportionately
lessened. He said it was all verj' proper to filter
water if the water was made purer by the filtra-
tion, and it was a good thing to have experimen-
ters determine for us in such cases the extent of
the purification that was effected ; but he sug-
gested that certain experiments had been per-
formed to which no reference had been made by
the author of the paper just read. Biological ex-
periments, in which the organism had been cul-
tivated, not on gelatine plates, but in the human
system. The paper had a special reference to
typhoid fever, and we all know of the propaga-
tion of typhoid by waters, well waters which had
been filtered through the soil until they had lost
all trace of their organic matter, and became ap-
parently so pure that the chemical analysists
were obliged to confess their inability in certain
cases to .say whether a water was wholesome, al-
though it seemed to be pure. On account of this
consideration he objected to placing any reliance
on filtration where the contention was against
typhoid fever. Water which has not been con-
taminated should be; obtained from a community
rather than permit its lives to be wasted by a
fever germ which cannot be removed by filtra-
tion. Non -contaminated water should be procured,
no matter what the financial consideration.

EVISCERATION.

Read in the Section of Ophthalmology, at the Fortieth Annual Meet-
ing of the American Medical Association, June, r$3o.

BY A. E. PRINCE, M.D.,

or JACKSONVILLE. ILL.

It will be five years in September since Prof.
Alf Graefe, of Halle, delivered his address before
the Society of Naturalists and Physicians at Madge-
burg in which he described the operation of exen-
teration or evisceration, and asserted the advanta-
ges that it possessed (except in malignant diseases)
over enucleation, viz.: that the danger of menin-
gitis was avoided, and that a superior stump was
thereby obtained. Besides the denial of these
claims, by some it has been objected that the
greater degree of pain, and increased amount of
inflammatory reaction, together with the pro-
longed period of healing, were decided disadvan-
tages to be taken into account.

It is not my purpose in this paper to review the
arguments of the author regarding the advantages
of the method ; but first, to offer a consideration

1889.]

EVISCERATION.

517

relating to the chief objection, that of the conse-
quent pain ; and second, to mention an obsen'a-
tion which raaj' prove of value in securing a fur-
ther improvement in the character of the stump.

PAIN.

All the published accounts of the operation
which have come to my notice agree in the ac-
knowledgment, that the severity of the pain and
the duration of the healing is materially greater
after evisceration than is the case following enu-
cleation. Mj' observation in the first five cases
was a corroboration of these statements. The
swelling was intense and the pain for several days
was very great. Local application failed to af-
ford relief, and morphia was required. At this
period in my experience, stimulated by this dis-
couraging feature, an effort was made to de-
termine the cause of the pain. The anatomical
fact that the long ciliary nerves lie in exposed
grooves along the concave surface of the sclera,
leading forward to the ciliar}' region, led at once
to the hypothesis that the cause of the pain was
the tension, pressure and inflammatory irritation
to which these nerves were subjected.

To test the truth of this hj'pothesis the entire
concave surface of the sclera was cauterized with
pure carbolic acid immediately following eviscer-
ation in a case of extremely painful panophthal-
mitis con.sequent upon an incision, the suffering
attending which had been intense for several days.

The result surpassed all expectations. The
pain ceased with the operation. The degree of
swelling was small and the patient was discharged
in five days. Since this operation the number of
Lviscerations has been about twenty-five. The
results have not been uniformly so brilliant.
Sometimes the conjunctiva has become cedema-
tous and been forced out through the palpebral
aperture, but in no case, in which the cauteriza
tion has been efiicient, has there been the type of
pain which was remarked previous to the cauter-
izing treatment.

It is believed that the use of the acid in this
connection is indicated

1. On account of its quality as an antiseptic.

2. Because it is an anaesthetic.

3. Because it is believed to close the apertures
in the sclera, and thus prevent the escape into the
orbit or sheath of the nerve, of any microorgan-
isms which should escape the action of the acid.

4. Because the sensory nerves thus treated can-
not respond in sensations of pain to the subse-
quent irritation and tension to which they are
liable to be subjected.

STUMP.

The second question raised by critics is that of
the nature of the stump.

That the question is one which deserves atten-
tion will not be denied. The inadequacy of the
stump following enucleation needs onl3' to be

mentioned. Dr. Mules, of Manchester, England,
struck a responsive .sentiment when he published
his observation on the use of the glass vitreous
in 1884.

The general feeling was that it would be a great
step forward in cosmetic surgery if his method
could stand the test of experience.

From the little that has since been said of it I
am led to infer that the practice, which was at
first so extensively resorted to in Manchester, has
not met with extended favor. My experience in
the use of the artificial vitreous in six cases was
at first very encouraging, but later equally dis-
couraging.

While the balls were at the commencement re-
tained kindly and the patient seemed overjoyed
at the excellence of the stump, this joy was con-
verted later into grief in five cases of the six by
the absorption of the line of union and the escape
of the glass ball. Though my experience in at-
tempting to secure the permanent retention of
artificial vitreous is to be regarded as a failure,
yet there was an element of instruction in it which
I offer for your consideration. It was noticed in
some of these cases that even though the glass
ball was retained but a few days, it left upon its
escape a distended sclerotic, infiltrated with form-
ative material which prevented the usual collapse,
and enclosed a cavity which gradually filled with
granulations and finally resulted in a stump which
was fuller and more mobile than that following
enucleation. Following the lead of this inquiry
I was led from theoretical considerations, after
cauterizing with carbolic acid, to pack the cavity
of the eviscerated globe -with pulverised iodoform.
The method which has been employed is to dry
out the globe and, after pouring from a paper fun-
nel into the cavity of the globe as much of the
powder as it will contain, to tamp it with cotton
on a cotton holder, making room for more of the
iodoform, which also is to be lightly packed into
the cavity. If p.acked too tightly the escape of
the serum is impeded, and in that event, either
forced to infiltrate into the orbit or extrude the
plug of iodoform. Pursuing this process it has
been observed in more than a dozen cases that the
sclera remains partly distended by the iodoform,
which may remain in position for sev-eral days or
even weeks, in some cases.

In one case of recent injury in which I eviscer-
ated, cauterized and packed with iodoform, on the
following day no pain had been experienced and
exceptionally no swelling had resulted. The pa-
tient was to notify me if he had any trouble. On
the fifth day my a.ssistant called and found that
he had removed the bandage and taken a trip into
the country. He subsequently objected to having
the bandage reapplied, and was digging wells in
another week. In his case a small plug of iodo-
form remained for three weeks and was finally
crowded out by the encroaching granulations.

5i8

WOUND DRESSING.

[October 12,

An excellent stump possessing good excursion
was the result. After three months, considerable
shrinkage has occurred, but there is still a fair
degree of prominence and good motion. In no
case in which iodoform has been packed into the
sclerotic cavity has there been the least suppura-
tion, which, to my mind, establishes the position
of iodoform as an antiseptic, when it can be re-
tained in contact with moist organized tissue, in
the presence of which iodine is probably liberated.

The conclusion drawn from my experience is
that, though the subsequent shrinkage is more
than we would wish, yet, the resulting stump is
sufSciently better than that following enucleation
to lead me to prefer it in all cases, except in those
of suspected malignanc}', and those in which the
fellow eye is deeply situated in the orbit.

Dr. Prince also exhibited a book for registering
cases in which the ruling is so arranged that, by
glancing at the page, it is possible to see immedi-
ately the number of cases of a given disease re-
corded.

Dr. Jackson stated that Dr. Williams, of Bos-
ton, was the first to record a case of evisceration.
Dr. Williams was thereupon asked to speak on the
subject.

Dr. Williajis regarded the pain ensuing at'ter
evisceration of the globe as diflFering from the
ciliary neuralgia previously felt, in having such a
character as might be due to cedema and conges-
tion of the conjunctiva and the orbital cellular
tissue. He had been in the habit of evacuating
completely the contents of the scleral cavity in
cases of phlegmonous inflammation of the globe,
and then — as also in excision of anterior portions
of the globe in cases of anterior staphyloma or
hydrophthalmia — of bringing the edges of sclera
together with sutures. A verj- good stump, some-
times with little diminution in size of the globe,
is thus obtained, which parti}- fills the orbital
cavity and affords good support to an artificial eye.

WHAT DRESSING SHALL LIE NEXT
THE WOUND?

/ieati in the Section of Surt^ery and Anatomy, at the Fortieth Annua!
Meeting of the American Afcitical Association, June, lS8^..

BY ROBERT T. MORRIS, M.D.,

OF NEW YORK.

The combination of vaseline or oil spread upon
any textile fal>ric represents the worst type of
surgical dressiiig, because the unguent mingles
with exuded lymph and retards organization of
the latter ; because the textile fabric entangles
new epithelium cells and connective tissue cells ;
and because the moist condition of such dressing
favors the development of troublesome micrococci.
(Lint and cotton are even worse than textile
fabrics.)

The cerates spread upon textile fabrics are one
point better, because new epithelium cells are not
entangled in the mass, but such dresssings must
not be employed nowadays.

Balsams spread upon textile fabrics or upon
lint or oakum have a very limited field of useful-
ness. The dressing composed of the above men-
tioned elements is fairl)- antiseptic, but it does
not avoid the danger of entanglement of new epi-
thelium and connective tissue cells in a wound
which is undergoing repair.

There are onlj- two types of the perfect dress-
ing. An idoform covering for small exposed
wounds represents one of these. Iodoform forms
a thin, firm coagulum with lymph, and this is
not readilj- destroj'ed by microorganisms. More-
over, even when a limited number of microbes are
at work, the iodoform neutralizes the poisonous
ptomaines which they produce, and thus removes
an element of disturbance.

The other perfect dressing is the one which is
required for the great majority of wounds, and it
is composed of the following elements and for the
following reasons. Let me saj* by way of preface
that the surgeon is supposed to be familiar with
the scientific antiseptic methods of to-day.

Immediately next the wound we must have a
strip of the Lister protective oiled silk, which is
furnished by all manufacturers of antiseptic sup-
plies nowadays. New epithelium and connective
tissue cells shoot along under this material with-
out interruption, and it is the onh- material with
which I am familiar that will prove wholly satis-
factory. Gutta-percha tissue is absolutely water-
proof and the wound beneath it looks sodden.
Spun glass does not avoid the danger of entangle-
ment of new repair cells; but the Lister's protect-
ive oiled silk allows of a sufficient transudation of
moisture from the wound, so that the tissues be-
neath this dressing are not kept abnormally moist,
and it presents a regularsmooth surface to the dress-
ings applied. Without the Lister's protective, it is
almost impossible to obtain repair in a wound by
the new method of clot replacement — but with
the protective, after the employment of actual an-
tiseptic methods of work, it is an easy matter to
obtain repair in quite large open wounds in a very
short time bj- the method of clot replacement.

Again, in skin grafting, the Lister's protective
will make even pressure upon all parts of the
wound, and when the dressing is changed we
avoid tearing off the thin hyaline borders of new
epithelium that have started in on their mission
of repair. It ni^kes a vast diflference whether we
apply a dressing in which this pretty new epithe-
lium becomes entangled, or one under which the
epithelium is allowed to attend strictly to its own
affairs.

If we wish to apply the permanent dressing to
a large suppurating surface and to stop suppura-
tion it is difficult to accomplish our ends without

1889.]

TREATMENT OR GONORRHCEA.

519

the alliance of the Lister's protective antiseptical-
ly prepared.

We must first destroj- all of the pus and all of
the microorganisms by pouring peroxide of hy-
drogen upon the suppurating surface. As soon
as the peroxide stops foaming we know that the
granulating surface is chemicallj' pure. The strip
of Lister protective, just large enough to cover
the granulating surface, is then applied, and over
it a bulky dressing of absorbent gauze or cotton.
This dressing may remain in place untouched for
several weeks if necessary, and it is possible to
apply the dressing in such a way that not another
drop of pus will be formed beneath it.

FORCED RESPIRATION.

Deli-:'ered in the Section of Piaclice of Medicine, Materia Medica and

Physiology, at the Fortieth Annual Meeting of the American

Medical Association, June, jSSq.

BY GEO. E. FELL: M.D., F.R.M.S.,

OF ItUFFALO, N. V.

Forced respiration is an advance upon artificial
respiration. It will save human life where the
latter will fail. This is now a clearl)^ demonstra-
ted fact, the cases treated b}- the author proving
this conclusively. Four lives have been saved in
America by the author and one in Vienna later by
Prof Dr. Boehm, of the Vienna General Hospital.
In the first case 20 grs. of morphia were taken.
After all known methods of resuscitation had been
used, forced respiration was used for two and one-
half hours and the life of the patient saved.

The second case took place in Vienna, Austria.
In the third case 2 ozs. of tr. opii had been taken,
all retained, and after artificial respiration had
failed, forced respiration continued from 4 .\.M.
until 6:30 P.M., or fourteen and one-half hours,
succeeded.

Fourth case. Tr. opii .^ij taken, anterior jugu-
jar vein and trachea cut with razor, and a large
amount of blood lost. Forced respiration pro-
duced; patient became conscious in four hours. [
Forced respiration kept up until 4 a.m., when!
.sviij of a salt solution of ':; per cent, was injected
into left basilic vein by transfusion method. After
twenty-one and one-half hours the patient first
breathed freely for himself In half an hour he
requested that forced respiration be renewed for
him, this was repeated and the patient made a
good recovery.

The fifth case took place in a man 80 years
of age who had taken .y tr. opii. Forced respi-
ration kept up for some twelve hours failed to
produce recovery. |

Sixth case. Child 18 days of age had been i
given by mistake of a physician i gr. of morphia,
which was retained with all its serious effects five
hours before respiration per tracheotomy was in-
stituted. After about four hours' time it failed
through heart failure to keep up life.

Seventh case. Morphia in large but unknown
quantity taken. Operation undertaken after pulse
at wrist was lost, pupils dilated, and auscultation
failed to detect heart action; blood on tracheotomy
venous. Forced respiration produced return of
pulse at both wrists and clear action of heart on
auscultation. Blood became arterial. Within
about an hour it stopped beating.

Eighth case. Tr. opii ,5ij taken. Patient cj--
anosed, heart action weak, respirations about i
per minute, dilatation of asphj-xia taking place.
Forced respiration for about eleven hours saved
the patient. This last case occurred within this
week.

The apparatus is simple, practical, can be used
by any intelligent physician, and consists of a
bellows to supply a stead)- column of air which
passes through an air heating apparatus. The
operation maj- be carried on in the open air. The
apparatus connects with an air valve which con-
trols the ingress of air to the lungs and is con-
nected bj- an elastic tube with a tracheotomj'
tube which is placed in neck and trachea of pa-
tient.

The movements of bellows are utilized to con-
trol time of inspiration and expiration. The au-
thor believes that the operation should be used in
cases where indicated, now that it has been demon-
strated to be of value in saving human life.

THE PRINCIPLES THAT SHOULD GUIDE
US IN THE RATIONAL TREAT-
MENT OF GONORRHCEA.

Read before the .Mississippi l^allev Medical Association, September,
iSSg.

BY BR.A.NSFORD LEWIS, M.D.,

OF ST. LOUIS

If we were to reckon progress in medicine by
stages, we could select no more apt a term for
designating the present one than that of the
Stage of Bacteriology. Bacteriology has as-
sumed such an important role in all that relates
to medicine or surger}-, that our attention is
drawn to it in the consideration of almost every
subject in medical or surgical science. And yet,
dropping from this lofty plane of thought, which
tempts us into the field of glittering generalities,
and limiting ourselves to the more practical ques-
tion at hand, let us inquire, what has this all-ab-
sorbing and comprehensive study and knowledge
of bacteriology done for assistance in the treat-
ment of gonorrhoea ? Has the hope of aborting,
of quelling, of exterminating the disease by a
treatment based on the discover^', study and ac-
quaintance with the life historj' of that sturdy
villain, the gonococcus, been realized ? Have
the methods of treatment thus brought into
vogue accomplished the great wonders expected
of them ? Have they accomplished anj-thing

520

TREATMENT OF GONORRHCEA.

[October 12,

more than the palliation, to a considerable extent,
of the severity of the disease, of shortening,
somewhat, the duration of its several stages, and
of doing awa}^ with the old and barbarous forms
of astringent, caustic and stimulating injections ?
I believe that all those who have tried this or that
new antiseptic, this or that "infallible germicide,"
—not simph- on two or three isolated cases, in
which beautiful results may have been attained,
and which, by the way, were in all probability
not gonorrhcea ; I sa}', that all those who have
tried such new antiseptic plans of treatment in a
number of cases are doubtless convinced that
none are infallible ; that all are subject to various
influences, deleterious or favorable, that were met
with in treating after the older, prudent methods.

Many beautiful and touching theories have
been constructed to explain how the gonococcous
would quail with fear when, in his revels, he should
detect from afar the fumes of death- dealing iodo-
form, brought into action b5' means of this or that
preparation ; or how he would shrink with hor-
ror at the prospect of being literally boiled alive
by hot injections ; or washed out into the cold,
cold world by the relentless flood of a prolonged
irrigation ; or of being crushed in spirit, body and
soul bj' the continuous presence of a medicated
gelatine bougie ; or dried up into an Egyptian
mummy of a coccus in the arid soil of a mildlj'
astringent, antiseptic, non-irritating, magic heal-
ing, absorbent powder ! But experience with
these agents would seem to indicate that the
usual rule of the breeding of contempt by fami-
liarity is not broken in this instance. Nay, more.
That the festive gonococcus after a time appears
to become sufficiently acclimated to enjoy his
surroundings, for a while, at least.

And this, notwithstanding the fact that anti-
septics do kill gonococci, and with great certainty
and facility — when they are in culture- fluids.
But why not, when they are in the urethra, as
well ? For this reason : The gonococcus in pre-
paring himself for the conflict does not foolishly
remain where his foes can get at him with these
various medicaments ; he makes his landing and
starts immediately for the woods, so to speak. He
pushes on, b3- proliferation, between the epithe-
lial cells, breaking through their connecting sub-
stance andfinally en.sconces himself belowitsdeep-
est layers, along on the basement membrane, and
even sometimes within and between the interlacing
fibres of this structure. Here he proliferates and
disseminates to his heart's content.

This has all been repeatedly and absolutely
proved by eminent investigators. Bumm has
watched the invasion of the conjunctival tissues
by the hordes of gonococci ; has .seen them pen-
etrate to the connective tissue layer, and has
noted the strong obstruction ofiered by this tissue
to their further progress. Not only this, but he
has .seen that the effect of astringents applied

over the epithelial surface serves onlj' to con-
stringe and harden this covering, which then, in-
deed, forms a secure protection against the ab-
sorption or leaking through of any germicide or
antiseptic which, embodied in the injection or
whatnot, has been applied to the mucous surface.
Moreover, he has seen that the elimination of the
cocci contained in this meshwork of cells and
fibres is brought about, not bj' the penetration of
the germicides into the tissues, there to attack
the organisms in their strongholds, as has been
thought by some, but it is accomplished bv a pro-
cess of proliferation of the connective tissue
fibres into which gonococci are unable to pene-
trate, as intimated above. In the stage of im-
provement, these fibres, incited b}^ the irritation
present, increase in number, push forward, driv-
ing before them the microbes towards the surface
of the membrane, from which they are washed by
the outgoing urine, or killed by the germicides.
When a sufficiently strong connective tissue bul-
wark has been constructed, new epithelial cells
begin to dot the denuded surface here and there.
The cocci have bj' this time lost much of their
vitality and are unable to break them down with
the ease shown at the first onslaught. The con-
ditions for resisting their inroads, too, are then
more perfect. They lie simply along the surface
or among the superficial cells.

So that the final process of cure depends not al-
together on the extermination of the few remain-
ing gonococci, but also, and perhaps even more
especially, on the closing of the tissues against
their further invasion by the development of firm
layers of this protecting barrier. And the inflam-
mation then persisting may be interpreted as de-
noting the chronic irritation remaining after the
severe disorganization wrought by the previous
disease

It is for these various reasons then, that in the
earlier stages, when the gonococci themselves are
doing the damage, the eSicacj' of antiseptics,
germicides, astringents, etc., is limited to the po-
sition which they now occupy.

In order to overcome these impediments and
give access of the medicines to the ambushed
cocci, an enthusiastic Frenchman has recently
suggested that the epithelial coat of the mucous
membrane be scraped off by a brush-swab, on the
plan commonly used in cleaning a pistol barrel ;
after which the urethra is to be douched with a
powerful antiseptic .solution. This method is
original and ought to prove efTective — in produc-
ing a stricture, if nothing else. It is certainl}'
more energetic than any I should care to under-
take.

I would therefore submit, that efforts at abort-
ing or killing gonorrhcva with strong medicines,
antiseptic or otherwise, not only do not attain the
desired end, but are ill-advised and liable to be
followed by unfortunate sequela; or complications.

1889.]

TREATMENT OF GONORRHCEA.

521

Consequently, treatment should be based on a
plan having for its object the idea of carrying the
disease through its various stages, as authors used
to say, into, cito et jucunde: allowing the patient
to experience as little discomfort, pain and an-
noyance as possible, mollifying the inflammatory
reaction and destroying, devitalizing and dis-
couraging the gonocococci as much as our rather
restricted powers will admit of ; and hastening
the healing process with all possible speed.

To accomplish these ends, having used various
forms and modes of treatment, I have concluded
that the one offering, with the general run of
cases, the most advantages with the fewest objec-
tions, is that of giving in the first stage of the
affection, simply alkaline diluents and sedatives
internally, making use of such adjuvants as dip-
ping the penis in hot water, etc., and in the
second and third stages, giving injections of
lanolin, medicated with an absolutely unirritat-
ing antiseptic, to which may be added in the third
stage a mildly astringent and stimulating anti-
septic.

As a means of introducing the
ointment, I have been using, dur-
ing the last six or seven months,
this hard rubber applicator,
which I present for your inspec-
tion. As you see, it consists of
a catheter-like stem, perforated
at its end, which is inserted into
the urethra to the desired depth;
a box to contain the ointment,
and a piston which is screwed
into the box, driving the oint-
ment before it into the stem and
thence through the perforations
into the urethra. When properly
performed, an injection given
with this instrument causes ab-
solutely no pain or' discomfort
for the patient. But sometimes
a sudden movement on his part
will jog the stem against some
tender spot and evoke an imme-
diate and earnest protest. To
obviate this and to leave nothing
undone that could in any way
assist in avoiding irritation of
any kind, I have had some vul-
canized, soft rubber stems con-
structed, which answer the pur-
pose very well. The square
shape of the second ("modified")
box is of advantage in affording
a surer hold on it. The stem
need not be inserted as deep as
its length will permit ; the flex-
ibility of the lanolin and elasticity of -the urethral
walls assure the spreading of the ointment over
the inflamed area.

^£li^

As to my reasons for preferring lanolin to other
vehicles, I would say, that with reference to the
other vehicles, water, the most common, is itself,
in its purest state, irritating, and unless it con-
tain some local anaesthetic, will cause pain ; pow-
ders or tablets, though dr>- and absorbent when
first deposited, soon become moist and cake up,
losing the properties for which they were chosen.
Gelatine bougies give pain at every movement of
the body until they are liquefied ; mucilages or
emulsions present no advantages which are not
possessed to a greater degree by lanolin, and — a
point of great importance — all of them are lack-
ing in "staying" qualities; with the first passage
of urine, out they go, and in order to make their
effect continuous, they must be renewed several
times a day, entailing frequent repetition of the
trouble, pain, etc., experienced each time.

Lanolin presents none of these disadvantages ;
it is wholly unirritating — is even soothing to in-
flamed tissues. When introduced pure, even
without any pacifying sedatives, it invariably
causes a feeling of relief and comfort to the pa-
tient who has been constantly reininded of his ail-
ment by the teasing, harrassing sensation incident
to all cases of gonorrhoea. As one patient re-
marked, the ease afforded allowed him to forget
all about it for hours at a time, whereas, before
he began to receive the treatment, it was never
out of his mind while he was awake. I believe
that the principal reason for this is, that it keeps
the inflamed surfaces apart, preventing their con-
tinuous friction and auto-irritation. Actual pain
in the urethra is also mollified by it.

The oiliness of lanolin assures its adhesion to
the canal walls, even in spite of the flushing of
the urethra by the stream of urine. It may be
noticed floating on the urine of the second or
third passage after the application. It is evident
that in this respect, too, it surpasses all of the ex-
cipients named. An authority tells us that lan-
lin possessed antiseptic properties of no mean
order.

I shall not take up more time in detailing its
many advantages, which are almost self-evident.

As to the medicament employed, any remedy
given in solution may be prescribed with equal
propriety in lanolin. Of the various drugs which
I have used, I sum up my impressions as follows:
Bichloride of mercury, even in minute quantities
is too painful or irritating, and frequently causes
an increase in pus-formation ; carbolic acid is also
irritating, but not painful ; iodoform might be
used were it less perniciously active in its odorif-
erousness. The zinc preparations are applicable
to the later stages, in which they give material
assistance towards shortening the wind-up. Re-
sorcin would be a most admirable remedy were it
not a most aggravatingly unstable drug. If ad-
ministered after it has degenerated, it will not- be
long ere the operator has cause to regret his ef-

522

MEDICAL PROGRESS.

[October 12,

forts in the waj^ of economy. Boric acid directly
following the increasing stage of the affection,
seems to fulfil every indication ; it is an antisep-
tic, a germicide, and yet has absolutely no irritat-
ing effect upon the inflamed membrane. It is
capable of killing the gonococci that it reaches,
and of preventing attacks from other microbes
which give rise to the .secondary, or mixed, in-
fection of Bumm. And, by the way, the contin-
uous presence of medicated lanolin forms a vigi-
lant guard against this complication.

Agreeing then with the dictum of all authori-
ties of the present day, that gonorrhoea is a spe-
cific disease which cannot be aborted after it is
once fairlj^ started, I conclude that

1. Our treatment should not have for its ob-
ject the futile idea of jugulating the disease in its
early but established stages.

2. The endeavor to control its severity, to
lighten in ever}' possible waj' all of its disagree-
able features, to shorten its course and to ward
off complications, should be our guiding prin-
ciples.

3. No local agent does its share in fulfilling
these indications more perfectl}- then does lanolin,
medicated after the manner suggested.

1006 Olive Street.

MEDICAL PROGRESS.

A Contribution to the Histology of the
Cerebrum. — (By Prof. C. L. Herrick, Univer-
sity of Cincinnati.) The striking results of re-
cent investigations upon the physiology of vari-
ous parts of the hemispheres, conflicting as they
are, have given a fresh impetus to the study of
the minute structure of the cortex. The interest
manifested upon the subject is so wide-spread
that the following notes are offered in advance of
the paper in the preparation of which thej^ were
made.

In spite of the astonishing advance made dur-
ing the last ten years in the knowledge of the
anatomy of the brain, there remain a large num-
ber of questions of primary importance upon
which nothing is known, or the testimony is so
contradictory as to have v-alue only as a stimu-
lant to further investigation. Indeed, the most
important question of all in this connection seems
to have fared the worst.

The primary and permanent gain of experi-
mental work has been the demonstration of the
topographical distinctness of various motor and
sensory areas in the cortex. The latest critical
studies of Luciani and Seppilli leave no doubt
that, however difficult or impossible it may l)e to
.sharply outline such areas, there are distinct
parts of the cortex chiefly occupied with special
senses and special groups of muscles.

If the occipital lobe be chiefly concerned with
the function of sight and its intellectual concomi-
tants, and the region about the crucial sulcus
more particularh' with the origin of voluntan,-
motions of extremities, what more natural than
to expect these areas to afford quite different his-
tological elements to the microscope? Bevan
Lewis has demonstrated that such a difference
actually exists, and with masterly skill has point-
ed out and illustrated the characters of the motor
areas. His figures of the cortex of the limbic
lobe and region of the crucial sulcus are certainly
beautiful, and amply reward the patience of the
author. The last papers of this writer which
reach us do not, however, indicate that the dis-
tinction between motor and sensory areas, bears
any correspondence to the facts of ph^-siology ;
that is, although the presence of large ganglionic
cells in motor areas and their absence elsewhere
is important, it does not afford a clear idea of the
direction which the stimuli pursue in being trans-
formed from sensory to motor phases. To saj'
the motor areas possess a five-layered cortex and
the sensory a six-layered is an advance, inasmuch
as we are able to distinguish microscopically the
two sorts of areas and concentrate attention more
closely upon the intimate structure ; yet we can-
not discover why a five-layered mass of cells
serves the motor function better than a six-lami-
nated cortical area ; neither do we see any clue
to the problem as to the waj' in which these
areas affect each other. Moreover, the naming
and numbering of cortical layers is necessarily
arbitrary, and along the distinct boundaries it is
impossible to sharply distinguish motor from sen-
sors- cell-chains.

Luys has positively announced a very different
basis for distinguishing the sensory and motor
cells. Making no topographical distinctions, he
simply declares the smaller superficial cells of the
cortex sensors', and the deeper ganglion cells ( in-
cluding the "giant cells") motor in function,
somehow deriving the fibers passing to the former
from the thalamus, and sending the descending
processes of the latter to the corpus striatum.
This has seemed to impress most critics as some-
what mythical, and really the difficulties in the
way of demonstrating such minute connections
seem unlikely to yield to methods like those em-
ployed by our author.

The present writer, in the midst of a series of
investigations, undertaken in connection with
Prof. \V. G. Tight, of Denison University, upon
the anatomy of the brain of rodents and lower
mammals generally, has been led to believe that
the attentive study of the.se simpler brains affords
a solution of this most important problem of
cerebral histology. The work is but begun, yet
its results upon this point seem worthy of a pre-
liminary abstract.

The subject chosen was the ground-hog, .-in-

1889.]

MEDICAL PROGRESS.

523

iomys monax, while the brains of rabbits, opos-
sums and raccoons served for comparison. The
functions of the cortex were investigated b)' elec-
trical stimulation and extirpation. In this way
the motor centers for the fore and hind legs, the
muscles of the face and neck and the sensory
areas were accurately diagramed. A method
used by us for the first time ma}- be incidentally
mentioned as worthy of more careful employment.
As the electrodes were removed from the brain a
small pasteboard or wooden peg bearing a num-
ber was inserted, and the reaction produced at
this point was carefulh' recorded upon a diagram
of the surface of the hemisphere with the corre-
sponding number attached. After the removal
of the brain these tags served to check the accu-
racy of the diagram and a careful drawing was
made, including the areas experimented on.

The brains were placed in chromacetic solution
twenty-four hours and then in alcohol, and con-
tinuous series of sections in various directions
mounted in balsam. Several hundred such sec-
tions were prepared and studied by the method
of geometric reconstruction from camera drawings
and mea,surements.

To briefly summarize the facts elicited upon
this point, it may first be stated that over the en-
tire recognized motor area and along the limbic
lobe, or region along the median fissure, a well-
defined type of structure can be observed, while
the remainder of the cortex contains an entirely
different set of cells. In the motor 'area the cor-
tex resembles that described bj' Bevan Lewis in
the sheep and pig, though the minor subdivisions
are less distinct. The outer neuroglia layer is fol-
lowed b3- a zone of small pyramidal cells with a
strong axial process derived from the superficial
layer and fine anastamosing fibrils from the lower
and blunt extremity. Below this is an indistinct
layer of fusiform cells, which connect below with
the "giant" or ganglion cells, which are not
only more than twice as large as the other mem-
bers of the series, but are nested or clustered and
have peculiarities of form readily distinguishing
them. The axial process is strong and may be;
traced upward a considerable distance. The nu-
merous inferior processes of these giant cells con-
nect with multipolar, parametric, or irregular
cells lying upon or imbedded in the white fiber
zone. Occasional anastamosing of cells of the
same level can be detected, but the connection
seems generally to be between cells of different
orders.

Now directing our attention to the cortex in
portions known to lie within the sensorj^ area, we
find an entirelj- different t\-pe of cell arrangement.
In general, the sensorj', or, preferably (not to
prejudice their function), centripedal, cells receive
the stain less readily and are only visible in good
preparations ; but distinctions based on receptiv-
ity to stain are untrustworthj-. The cells of the

upper zone, lying next the neuroglia layer, are
nearly of the same size as those of the correspond-
ing zone of motor areas, but are more nearly
globular, possess a larger nucleus, and, in partic-
ular, receive their axillary process from belozi'.
Cells of this sort occupy the entire thickness of
the cortex to the depth of the giant cells, the
onlj' variation obsen-ed being an increase of size
downward. Corresponding to the giant cells of
motor areas are large pyramidal cells, each with
a slender downward projection terminating in an
axillary process, while the upper blunt extremity
gives off numbers of fine fibrils. Thus the con-
trast is complete, the course of the chains of cells
being completely reversed, and we seem warrant-
ed in assuming that there is a similar variation
I in the direction of the stimuli traversing these
chains.

We hasten to explain that this varietj- of cell
which is termed centripetal is by no means limit-
ed to circumscribed areas exclusive of all centri-
fugal or motor chains. On the contrarj% there
are numerous centrifugal cells scattered in groups
within the area chiefly affected by the centripetal
variety, and, per contra, the centripetal variety is
sparsely scattered among the undoubted centrifu-
gal elements of the motor area. Nevertheless, in
tho.se areas ascertained by electrical stimulation
and extirpation to be sensory the centripetal vari-
ety greatly preponderates, and in the optic centre
quite excludes the other, while in the motor cen-
tres the other type occupies the prominent role.
To carefully test this point, sections taken through
an isolated motor area surrounded by a zone indif-
ferent to the electrode were sought. Such an op-
portunity is afforded hy the centre to the sphinc-
ters of the face, which can easily be located in
rodents. This spot lies well back of the centre
for the hind leg, and near the median line.
The existence of a sensory centre for the orbicii-
laris palpebrarum was postulated by Munk as the
result of extirpation. (This area lies in what
Munk would call the "independent sensory re-
gion of the eye," not seeming to recognize that
there existed a true motor area for the sphincter.
This latter fact appears demonstrated bj- our very
definite results. The" zone is very small and ac-
curately defined, but its stimulation, even with a
feeble current, induced violent and long contrac-
tion, not only of the orb. palpebrarum, but appa-
rently o{ orb. oris. Cf. Munk: " Ueber die Func-
tionen der Grosshionrinde," Vierte Mittheilung,
p. 64.) Tran,sverse .sections passing through this
i centre bring out the distinction between the motor
I and sensory areas. In that region shown to govern
j the sphincter the centrifugal cells are abundant,
I but laterally bej^ond its limits the centripetal
predominate.

] Upon the posterior aspect of the occipital lobe

motor cells are numerous, as along the limbic lobe.

, Near the gyrus fornicatus the centripetal tj'pe pre-

524

MEDICAI, PROGRESS.

[October 12,

vails, and in the external part of that gyrus, but
internally groups of peculiar multipolar cells
traverse the cortex in all directions, requiring
further study and affording evidence of the ex-
tensive disturbance due to the fold producing the
amnion's horn.

One familiar with the recent literature of this
subject will note that the facts here adduced cor-
respond closely with the conclusions of the most
careful experimental observers. Meynert quotes
with approval Munk's conclusion "distributing
sensory areas over quite the whole of the cortical
surface, and therefore terming the region from the
occipital lobe to near the frontal margin the ' sen-
sory sphere ' of the brain."

It is strange, however, that such distinctions as
are here claimed should not have been previously
noted, and this naturally will cast doubt upon
these statements, which, however, can be amply
supported bj' camera drawings or actual sections.
The greater avidity with which the centrifugal
cells take the stain explains why imperfect prep-
arations demonstrate one class onlj', and the wide
distribution of the motor type maj- have prevented
an}- serious search for another structural modifi-
cation.

It may be left for subsequent examination to
decide what becomes of Meynert's theory that
" in order to explain volition it is only necessary
to postulate sensations of innervation, and tactile
and pressure sensations are thought to be a means
of regulating the excitation of sensations of in-
nervation " (Meynert, " Ps3-chiatry," p. 145).
But if we can demonstrate in the cortex afferent
and efferent projection systems, and distinguish
the cells occupied with p.sycho- motor and psycho-
sensor3' processes, certainly a great step is taken
toward an intelligible construction of cerebral
mechanics.

The Dry Method of Wound Treatment. —
In an address delivered to the German Congress
of Surgeons Dr. Iv.\nderer, of Leipzig, advocated
what he calls the dry method of wound treat-
ment, consisting of the use of pieces of dry asep-
tic gauze in place of moist sponges and irrigating
fluids in surgical operations. Pieces of this
gauze are also placed on any portion of the
wounded surface not under manipulation at any
time during the operation, for protection aud as
a haemostatic. No fluid whatsoever is permitted
to come in contact with the wound at any time.
He approximates the surfaces carefully by deep
and superficial stitches, but uses no drainage ;
neither does he leave the ends of the wound open.

He is .scrupulously careful in rendering the
surgeon's hands and those of his a.ssistants, the
instruments and the field of operations absolutely
aseptic, and keeping them .so throughout the
operation. He has had primary union in ninety
consecutive cases, including abdominal sections,

amputations of breasts, extirpations of tumors
and glands, castrations, hydrocele operations,
osteotomies, nerve-stretching, plastics, resections,
amputations, etc. The advantages claimed for
the method are : i. The patient is not exposed
to wet and cold. 2. The loss of blood is mini-
mal. 3. Absorption of antiseptics is not possi-
ble. 4. Time of operation is decreased. 5.
Rapid recover}', only one dressing being neces-,
sary, and that only if non- absorbable stitches are
used. 6. Great convenience, especially for coun-
try practice. 7. Saving of surgeon's hands. —
Laiigenbeck' s Arcliivc fiir Klinische Chin(rgit\
vol. 39, heft. I.

Inoculation of Carcinoma. — (Dr. Wehr.
Paper read before the Eighteenth German Con-
gress of Surgeons, published in Langcnbeck's Ar-
^ chive fur Klinische Chirurgie, vol. 39, heft i.)
Dr. Wehr made a series of experiments upon
twenty-six dogs by taking pieces of carcinoma of
the vagina or penis and inoculating them sub-
cutaneously through the shell of a trocar upon
healthy animals. In most ca,ses the nodules
failed to grow, or if they grew at first they be-
came atrophied later on ; but in one animal,
which was inoculated December 12, 18S7, the
tumors grew constantly until the animal died
June 16, 1888. The autopsy .showed the tissues
surrounding the points of inoculation infiltrated
with carcinomatous tissue, and the pelvis filled
with nodules, some of which exceeding the size
of a hen's ^^^. These tumors had occluded the
urethra, causing a rupture of the bladder by over-
distention, and this causing death from haem-
orrhage. There were also metastases in the
spleen and infected lymphatics in the chest.

Subnitrate of Bismuth in Erysipelas. —
M. Marc See has been using for several years
I a permanent antiseptic dressing of which .sub-
nitrate of bismuth is the essential element. Dur-
ing this time he has not seen the development of
a single case of erysipelas when the dressing was
used, although the surroundings of the patients
were often such as to favor its appearance. In
certain operations, where wounds are left which
are evidently not in an aseptic condition, he ab-
stains from the scrupulous use of antiseptic
douching, and relies upon the bismuth, with
which the wounds are filled, after which he ap-
plies a layer of hydrophile wadding. He has
also had reason to believe that bismuth is a very
useful application in cases of erysipelas already
developed. — La Semaine Med., Aug. 28, 1889.

Fraulina Scorbilis in Dysentery. — Dr.
Aphel employs the powder of fraulina scorbilis
in doses of seven grains every two or three hours.
It is indicated chiefly in adynamic forms of the
disease. — l.os Avisos Saiiitarios.

1889.]

EDITORIAL.

525

journal of the American Medical Association

PUBLISHED WEEKLY.

Subscription Price. Including Postage.

Per Annum, in Advance $5-oo

Single Copies 10 cents.

Subscription may begin at any time. The safest mode of remit-
tance is by bank check or postal money order, drawn to the order
of The Journal. "WTien neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
tetters.
Address

JOrrRNAL OF THE AMERICAN MEDICAL ASSOCIATION,
No. 68 Wabash Ave.,

Chicago, Illinois.
All members of the Association should send their Annual Dues
to the Treasurer, Richard J. Dunglison, M.D., Lock Box :27it, Phila
delphia. Pa.

London Office, 57 and 59 Ludgath Hill.
SATURDAY, OCTOBER 12, 1889.

THE PHYSIOLOGICAL RESISTANCE OF THE
PERITONEUM TO INFECTION.

In the past j-ear hardlj' a more interesting
series of experiments has been made in the inter-
est of surgical pathology than those of Rinne.'
Practically and clinically it has been demonstrat-
ed that the peritoneal cavity under certain un-
known circumstances has the power of taking
care of a vast amount of filth. It remained for
Rinne to harmonize observed clinical facts with a
priori deductions.

He found that large quantities of septic ma-
terial and pure cultures of pyogenic bacteria were
absorbed, although injected dailj- into the perito-
neal cavity of animals, provided that the perito-
neal surfaces were uninjured. The injections
produced only mild symptoms in direct propor-
tion to the quantity of septic material used, and
in no case was there more than a moderate rise
of temperature. The results were verj' different
when there were coincident defects in the perito-
neum, exposing the subperitoneal connective tis-
sue to infection. Then there invariablj- appeared
progressive suppurative peritonitis going out from
the infected connective tissue, which usuallj' ter-
minated fatally.

The practical import of these experiments can
hardly be over- estimated. Thej^ explain wh\'
the escape of pus into the peritoneal cavity from
the rupture of a pyosalpinx is not necessarily^
fatal if the tube is promptly extirpated, and the
wound and stump properly treated. They point
out that the incision is the point of greatest dan-

' F. Rinue, Langenbeck's .\rchiv. fiir klinische Chinirgie. 39
pp. 1-96.

ger in all abdominal operations, and they would
indicate that too much care can not be taken in
coaptating the peritoneal edges of the wound.
They explain why the removal of abdominal
tumors is so much more dangerous after adhe-
sions have taken place, because the resulting de-
nuded places offer less resistance to the invasion
of septic bacteria. They explain the success of
those operators who disregard the dictations of
scientific bacteriology, and also the recovery^ of
patients after abdominal section by horned ani-
mals. They teach us to consider cautiously the
evidence presented by the statistics of operators,
and await the demonstration of more exact
methods as to the import of their results. The}'
warn us that clinical evidence is inadequate to
overthrow the deductions of experimental physi-
ology and patholog^^ and that our time is pro-
vided with methods of precision which are yet
imperfectly improved. They beckon the ambi-
tious into fields of activitj- and thought far less
crowded, though more promising than the oper-
ating room and the dead house.

The resisting and absorptive power of the per-
itoneum is beji'Dnd that of anj- other serous cav-
ity. This is as we should expect. The perito-
neal surfaces are only a line distant from the most
filthy and prolific culture medium about the
body. It is connected with this seething and
turbulent mass by the most active absorbent
lymph channels. Doubtless it is frequently in-
vaded b}' septic bacteria from the intestinal con-
tents. From these frequent invasions an immu-
nity has been developed which has been perpet-
uated and transmitted bj' the working of the or-
dinarily recognized laws of evolution.

Again we are taught to consider the causes
which determine the localization of infection, as
more important than the quantity and qualitj- of
infective material. Doubtless traumatism is one
of the most important of these causes, but we
must not forget that the depression of the general
temperature of the body, the interference with
nutrition, and general malaise frequently ob-
served after operations, are factors which may
speak for the life or death of our patient. Not
only should the abdominal section be made with
the greatest attention to cleanliness, but the pe-
ritoneal edges must be accurately coaptated, the
operation must be done with the greatest celeritj'
and delicacy, and depressing influences of star-

526

HYPNOTISM IN THERAPEUTICS.

[October 12,

vation, over- medication, and deprivations ofj
every kind must be avoided if we would eliminate
all those causes which determine the localization i
of that infection, which is still the greatest danger
the operator has to meet.

HYPNOTISM IN THER.A.PEUTICS.

This seductive method of treatment is still on
the increase. Its exponents are for the most part
more enthusiastic than ever. The therapeutical
practice of hypnotism is no longer circumscribed
by the narrow confines of France. It has spread
throughout Continental Europe. Its progress has
not been staj'ed by that watery Gibraltar, the
English Channel, but sailing across has laid hold
upon the insular conser\'atism of Great Britain.
It has reached Germany, Sweden and Russia. It
has scaled the Alps from all sides and wellnigh
taken Switzerland by storm. It is more popular
in staid Holland than in France. America alone
has thus far escaped— but we expect it soon as
we do all widespread contagion. Let us see, then,
to what we may look forward. Hj'pnotism, not
long since wrested from the hands of charlatan-
ism, is held as a trophy by the medical profession.
What we know of it in this countr}^ is mainly
what we have learned of its employment bj' Char-
cot in the Salpetriere. At present, however, there
are in France two schools of hypnotism^that of
Nanc3% with Bernheim, Liebault and Liegois as
its principal champions, and that of Paris, where
its practice has been developed under the influ-
ence of Charcot. The former school is by far the
more radical, and its teachers claim the wider field
of applicability for the method.

Nearly thirty years ago Dr. Liebault began to
treat dispensary patients in Nancy by a system
which he elaborated and termed ' ' Treatment by
Suggestion." In 1866 he published a book in
which he gave a full description of his various
methods, together with a report of cases success-
fully treated. Nevertheless he remained for many
years a prophet without honor. In 1884 Prof.
Bernheim, of Nancy, although skeptically in-
clined, began an investigation of the subject with
the result of soon becoming a convert, and in
1884 he published his cla.ssical work, a second
edition of which has recently appeared in this
country, bearing the title, "Suggestive Thera-
peutics. A Treatise on the Nature and Uses of

Hypnotism." Hitherto the English language
has been practically without a literature on this
subject. To Liebault is due the credit of having
founded a school of practice which has found rep-
resentatives throughout Europe. The interest in
the entire subject, which has been gradually in-
creasing, and which has been fostered bj' discus-
sions in the medical societies of various European
cities, has finally culminated in a "Congress of
Hypnotism" held at Paris, where congresses of
all possible descriptions have been unprecedent-
edly numerous of late. At this Congress the
forces were marshalled under the leadership of
the aforesaid schools of practice. The Nancy
contingent, with its radical views, was well
equipped and ably generaled by Prof. Bernheim,
whose paper on the "Therapeutical Value of and
the means of Inducing Hypnotism " served as a
point of departure for a pretty lively dispute.

The principal differences between the two
schools may be briefly explained. In the first
place, the Nancy school believes that hypnotism
is a physiological condition ; the Paris school in-
sists that it is a neurosis. The Nan^y school
thinks that pretty much all the manifestations of
hypnotism are produced by suggestion and that
the hypnotic state is so produced. The Paris
school complains that hypnotism and suggestion
are two separate things, and that Prof Bernheim
is so absorbed in suggestion that he has lost sight
of hypnotism altogether.

These are some of the victories claimed by the
champion of Nancy : Nearly all the tedious and
rebellious cases of hysteria ; cases of nervous
anaesthesia, hyperaesthesia and ambh^opia almost
instantly relieved ; pains from lead poisoning,
neuralgia and rheumatism instantaneously or verj-
quickly subdued ; chronic rheumatic arthritis
cured ; pleurisy pains removed in one or several
sittings ; chorea quickh' cured or greatly short-
ened in its duration ; menstruation regulated,
checked or made to appear at a fixed date; spinal
disea.se ameliorated ; an obstinate case of vomit-
ing of long standing cured in two weeks ; a case
of cerebro-spinal sclerosis with palsj' and stagger-
ing relieved for a long period ; an old and most
obstinate case of migraine with insomnia cured
in three weeks, etc'.

Charcot, however, holds very different opinions.
Without wishing to deny that in cases of organic
disease of the nervous .system hypnotic suggestion

1889.]

EDITORIAL NOTES.

527

may, in certain cases, result in a degree of im-
provement, he is convinced that this occurs onl}^
by mere accident, and that, in such cases, the
methods of suggestion have no claim to be re-
garded as therapeutical measures. On the other
hand, in cases of hysteria in women and in indi-
viduals markedly susceptible to hypnotism in its
stage of somnambulism, good results may reason-
ably be expected. As for hysteria in men, one
must express one's self with greater reserve and
beware of insisting upon a method which is verj'
far from giving good results in all cases and may,
indeed, produce exactl}' opposite effects with very
disagreeable consequences. One should deal with
hypnotism as with all other therapeutical meas-
ures; it has its indications and its contra-indica-
tions, and if one fails to employ it in a judicious
manner the results are apt to be disastrous. Char-
cot's application of hypnotism has been confined to
neurotic patients, and even with them he seems
of late to be somewhat less enthusiastic than for-
merly.

It is, however, from the Nancy school that we
receive the most glowing accounts of cures by
hypnotism. As for the other side of the question,
we hear but little from the opponents of hypno-
tism in France, where, if the subject is mentioned
at all, it is spoken of in terms of praise.

In England a variet3' of opinion is expressed,
much of which is favorable to the method. In
connection with a paper read at the recent meet-
ing of the British Medical Society by Dr. Voisin,
of Paris, several English physicians reported suc-
cessful cases, while others admitted having re-
ceived a favorable impression by witnessing its
action in England and France. Dr. C. L. Tuckey
has also written an interesting brochure, entitled
" Psycho-Therapeutics," a large part of which is
taken up with an ingenious argument of induc-
tive reasoning with a view to explaining the phe-
nomena of hypnotism.

In Germany, although there is a growing in-
terest manifested in the subject, there is not
wanting an expression of wholesome caution and
distrust, as indicated by recent expressions from
writers of eminence, some of whom do not hesi-
tate to pronounce hypnotism a very dangerous
agent. Among those in Germany who are very
decidedly opposed to hypnotism may be men-
tioned Prof von Ziemssen, who, as the result of
a series of experiments conducted by his assist-

ants, has reached the conclusion that hj'pnotism
exerts little or no beneficial action even in cases
of slight functional disturbance, while it is posi-
tively injurious to many patients. He believes
that to employ the method as a therapeutical
measure in cases of slight functional disturbance
is like gunning for sparrows with cannon balls
for ammunition, while its repeated application is
apt to convert the milder forms of hj^sterical
manifestations into the o-rande /lysfen't' oiCha.Tcot:
in the severer forms of diseases it is a mere sub-
stitution of one form of mental disorder for an-
other, and is akin to curing one of the morphine
habit by giving him cocaine. He trusts that the
good sense of the medical profession in Germany
will restrain it from countenancing so dangerous
a procedure.

There can be no doubt that the elements of
faith and expectancy are prime factors in the so-
lution of this problem, just as thej- are in the
somewhat allied methods of faith cure, mind
cure, prayer cure, and, may we not add, in das-
sical homoeopathj^ as well. Expectancy of cure
in the mind of the patient is one of the most po-
tent allies of therapeutics, and one which the
physician ought never to disregard or underesti-
mate. As for hypnotism itself, it will be well
for all who are inclined to experiment with it to
remember the failures and dangers that have al-
ready been encountered, and not blindly trust the
voice of mere enthusiasm.

EDITORIAL NOTES.

HOME.

Chronic Invalidism. — An invalidism of un-
usual duration has appeared in the telegraphic
columns of the daily press, as follows: Miss Ann
Jones died recently at Jaybridge, Me., aged 87
years. She had been an invalid for seventy years
and had been confined to her bed for sixty years.
Her mind was clear to the last. We sometimes
hear our medical friends use the careless tautology
of "old chronic cases;" if it were permissible
ever to use that expression it would be in such a
case as this.

Preliminary Examination of Student.s. —
The Regents of the University of the State of
New York, through Professor Melvil Dewey,
their Secretary', have been taking steps toward
the carrying out of the law of 1889, which re-

528

EDITORIAL NOTES.

[October 12,

quires certain students of medicine to pass exam-
inations preparatorj' to entering upon their pro-
fessional studies.

Improvement of Jeffersox Medical Col-
lege.— The Jefferson Medical College and Hos-
pital at Philadelphia will soon add a building to
the group already located at Tenth and Sansom
streets, as the needs of the college and hospital
have increased to such an extent that the Board
of Trustees have found it necessary to have
another building.

Dr. R. a, Lancaster, of Gainsville, Fla., has
"been elected President of the Alachua County
Board of Health.

The Sanitary News says : ' ' The need of the
times now is the thorough dissemination of the
knowledge that sanitary science has made avail-
able for the promotion of the public health."

The Chicago Medical Library Associa-
tion, incorporated last month for the purpose of
securing and maintaining a library for the ad-
vancement of the medical and kindred sciences,
held its first regular meeting on Oct. 4, at the
Grand Pacific, at which the following were elected
officers : President, Dr. N. S. Davis ; Vice-Pres-
ident, Dr. Edward A. Lee ; Secretary, Dr. Bayard
Holmes ; Treasurer, Dr. E. Ingals. Dr. William
F. Smith was made a Director in place of Dr.
Mary H. Thompson.

A GOOD LAW, and one which should obtain in
everj' State in the Union, has been passed by the
iSTew York State Legislature. It reads : "Before
the Regents of the Universitj' of the State of New
York, or the Trustees of any Medical School or
College within this State, shall confer the degree
of Doctor of Medicine upon any person who has
not received a Baccalaureate Degree, in course
from a College or University duh' authorized to
confer the same, thej- shall require him to file with
che secretary or recording officer of their Universitj'
or College, a certificate showing that prior to en-
tering upon the prescribed three years' study of
medicine, he passed an examination conducted
under the authority and in accordance with the
rules of the Regents of the University' of the
State of New York, in arithmetic, grammar,
geography, orthography, American history, Eng-
lish composition, and the elements of natural
philosophy, and such certificate shall be signed

by the Secretary' of the Regents, and counter-
signed b}- the Principal or Commissioner con-
ducting the examination."

Huxley furnishes September with a reflection
having an R in it, addressed to those who have
recently resumed the consumption of bivalves :
"Very few persons, I suppose, imagine that when
this slippery morsel glides along the palate, they
are swallowing a piece of machinery far more
complicated than a watch."

FOREIGN.

Post-Gr.aduate Instruction in London. —
In a recent number of The Lancet appears the
announcement that an effort will be made this
year to inaugurate a post-graduate course at some
of the London hospitals, like the Moorfields Oph-
thalmic Hospital, at which there are no clinical
classes. The proposed course will be entirely
practical and for qualified practitioners only ; it
will cover three terms of eight weeks each, and
the fee will be ten guineas.

Depopulation of France. — The British Med-
ical Journal s^ys: "The movement of popula-
tion in France indicated h\ the summaries pub-
lished for 1888 in \.\ie Journal Officiel cannot be
read without regret. They are summed up pith-
ily bj' M. Georges Michet in a few words: Dim-
inution of marriages, augmentation of divorces,
decrease of legitimate births, increase of illegiti-
mate births, excess of deaths over births in fort}--
four departments. In 1888 onl}' 276,848 marri-
ages were celebrated, 6,360 less than in 1883 and
8,719 less than in the period 1847-1860. The
number of divorces was 4,708, or 1,072 more than
in 1887, and 1,758 more than in 1886. The num-
ber of births has considerablj- diminished. In
1888 there were only 882,639 births ; this is a
diminution of 16,749 births compared with 1887,
of 41,919 compared with 1886, of 42,000 with
1885, of 55,119 with 18S4. The proportion of
illegitimate births, which in 18S2 was 7.5 per
cent., is now 8.5 per cent. It is very unequally
distributed ; thus, in the Department of the Seine
it is 25 per cent., while in Brittany it is 2 per
cent. But for the afflux of illegitimate births,
the French population, says the official report,
\<'ould decrease. The excess of births over deaths
amongst the foreign residents in France is 1 1,000,
one-fourth of the total excess for the whole popu-
lation."

1889.]

TOPICS OF THE WEEK.

529

TOPICS OF THE WEEK.

MEDICAL SCHOOLS IN CANADA.

At the annual meeting of the Canadian Medical Asso-
ciation, held at Banff, N. W. T., August 12, 1SS9, the
president, Dr. H. P. Wright, in his annual address,
refers to Canadian Medical Schools as follows :

" Of our medical schools in Canada we have good rea-
son to feel proud. They are under the care and manage-
ment of thoughtful, hard-working and self-sacrificing
physicians and surgeons. In most instances the teachers
are necessarily active practitioners, for few in our rank,^
have private means, and the instructors' pecuuiarj' re-
wards are but pittances. As a country we do feel proud
of our schools, and, as a people, grateful to our teachers;
but, we know, that as institutions the\' are not yet perfect.
These imperfections are not faults controllable by the
teachers ; they are the silent appeals to the wealthy
and philanthropic. To quote from Dr. Alfred L. Loo-
mis in his magnificent address to the New York Academy
last year : "Why is it that men of wealth do not real-
ize their great opportunities for wise liberality in this
direction, liberalities which will not only shed lustre
upon themselves, but will mitigate the sum of human
misery as certainly, and in man}- ways far more effectual-
• ly, than our hospitals and charities for the sick and suf-
fering poor." He blames the profession for not having
tried to direct the stream of accumulated w-ealth in this
direction, for "next to religion, education is the corner-
stone of our civilization." Then, after alluding to the
noble gifts recenth* made to some of the medical colleges,
he is inspired by the hope that the stream of emotional
benevolence for the sick and suffering is being turned
into intellectual channels for educational needs. We
have not jet to complain of emotional benevolence, as
they have in the city of New Vork, where they have so
many hospitals and dispensaries that patients are at a
premium ; but we know that public attention has not
been sufficiently directed towards the endowment of
chairs in our educational institutions, for the provision
for scholarships to help on the needy and industrious
student, or for the establishment of a general fund for
the purpose of erecting and maintaining laboratories at
different points to further original investigation and re-
search. All these are necessarj- if we are to have a per-
fect system of medical education 'in order that those who
teach may, by personal and familiar contact, gain such
intimate knowledge of each student and firm control of
his mental processes ' as will enable them to become
teachers in the good old Anglo-Saxon sense — to be edu-
cators, and not simply instructors 'pouring out their
daily dole of wisdom into unreceptive ears.' "

Within the past j'ear several strong appeals have
been made through our medical press, in favor of more
practical instruction, and that every student may have
books in his possession giving a careful digest of the sub-
ject he is studying. The teacher's dut)-, in so far as the
method of imparting knowledge is concerned, is changed.
When books were scarce and biology was a nursling
twenty or twenty-five years ago, didactic teaching was a

necessitj' and note books were valued possessions. Now,
our teachers should be expert demonstrators, appealing
largely to the senses in the hospital wards and labora-
tories.— Montreal Medical Journal.

WAKEFULNESS IN NEURASTHENIA.

A wide range of opinion on the management of this
condition found expression at a recent meeting of the
Epidemiological Association. The use of drugs, with
the exception of sulphonal, perhaps, did not find nmch
; favor with the members. Some of them had found that
their patients of this class slept when they were at the
seaside, while others recommended the Colorado atmos-
phere. Some patients had been found to be able to sleep
at sea, but not on land. The weight of evidence seemed
to favor the resort to mountain air for patients who were
anaemic, with a presumption in favor of sea air for those
who were plethoric. Dr. Solly, of Colorado Springs, has
found that a large proportion of anaemic neurasthenics
find sleep on the mountain heights, but this cannot be
said of the entire class. It is not improbable that other
conditions besides those of climate enter into the account
where the patient travels from our Eastern cities to the
Rocky Mountains in pursuit of sleep. The jaded matron
leaves the worries of the household, and the business
man, broken down by the rush of daily cares, finds many
things changed besides the atmosphere among the far
Western altitudes. Still, as a rule, the climate gets all the
praise when an improvement takes place. Business men
from the East report a larger percentage of recoveries
than the matrons, however, probably because fewer of
their anxieties can follow them. Improvement in the
assimilation of food, it should not be forgotten, goes a
great way toward sleep production in those who are af-
fected with derangement of the nervous system; and this
is one of the frequent accompaniments of anv change of
scene and environment. Not that there is always any
marked increase of appetite or in the amount of food
taken, but there is an appropriation of the food by the
nervous centres, to their consequent strengthening. It
is often a prominent feature in neurasthenia that the food
may be taken in and digested fairly well, but stops short
somewhere in its distribution to the tissues and is largelv
wasted. Ordinarilj', when this waste ceases there is a
corresponding abatement of wakefulness and other neu-
rotic symptoms. — Xe-u< York Med. Journal.

THE FUNCTIONS OF THE CEREBELLUM.

Is the cerebellum an organ for the storage of cerebral
events which have become automatic ? Do we first of all
receive with the cerebral cortex and then practice with
the same brain-bark, and afterward relegate to the cere-
bellum, as to a limbo, those things of which we are so
tired of being conscious ? Are all performances of the
cerebral cortex conscious acts, and those of the cortex of
the cerebellum unconscious ? And so might questions,
more or less unanswerable, be postulated without end.
The functions of the little brain are scarcely known at
all ; even the dependence of the equilibrium on its exist-
ence may be called in question on the data supplied by

530

TOPICS OF THE WEEK.

[October 12,

pathology. It is perfect!}- certain that no obvious signs
of nervous disease need exist when the lateral lobes are
the seat of even extensive mischief. Some regard the
cerebellum as the terminal organ of all visceral sensa-
tion, and on this assumption it has been thought that
the curious perturbations in visceral epilepsy are to be
ascribed to perversions of the vitality of the gray matter
of the little brain. Anything is possible for the cerebel-
lum. The most gifted imagination might guess strange
things, yet pathology could perhaps find exact counter-
parts.— Lancet. — A'. }'. Med. Journal.

HOW THE LEPROSY BEG.\X IN H.WVAII.

The Hawaiian consul in London sends an interesting
sketch of the history of leprosy in Hawaii and the leper's
island of Molokai. The first known case of true lepra
(I cannot speak as to elephantiasis) occurred, he writes,
in the islands more than forty years ago.

It has been supposed to have been introduced by a
Chinese ; but this was never established ; and it ma\'
here be remarked that the ratio of leprosy among the
Chinese residents is less than that among the natives. In
twenty years the disease has attacked a large' proportion
of the Hawaiian population. In 1S65 as many of the
lepers as could be induced to go were taken to a beauti-
ful vallev in the island of Molokai, not to be called, as
was that of Rasselas, a "happy valley," but fertile and
eminently adapted to its purpose. Before it was the
ocean, and landward the plain was shut in completely by
a mountain range, in which were precipices 3,000 feet
hio-h. Doubtless at first some disorder and a want of or-
cranization existed. But the Hawaiian Board of Health
bean its work and improved matters. Pure water was
brought into the settlement from sources a mile distant
in abundant quantities, and was distributed by exits in
nine different situations

In the year 1S73 Mr. Ragsdale, a layman, gave an ex-
ample of self-sacrifice by volunteering to act as superin-
tendent to the leper asylum. He did efficient work there,
but did not live long. It is to be admitted that the hous-
ino- of the sufferers was for some lime bad and insuf-
ficient. Yet, in 1874, Mr. Widemann, President of the
Board, asserted that, " in a material point of view, the
people were better off in Molokai than most natives of
the islands, and also better, with few exceptions, than
thev ever were in their own homes. Parcels of land and
wooden houses had been bought for the increasing popu-
lation, and 6,000 feet of waterpipe had been laid." Next
the settlement was divided, and the two establishments
of Kalawao and Kalaupapa were placed at a consider-
able distance from each other. In 1S79 and 1S80 there
were in the former of these places S02 lepers, of which
458 were men and 344 were women. There has always
been an excess of cases among the males. The largest
number at any one time appears to have been 1,000. In
the year 1S74 the young Belgian priest Damien cast in
his lot with that sad society, and was appointed assistant
superintendent. The lepers cultivated plots of ground
and occupied themselves in such manual labor as Ihcy
were capable of.

The biennial grant of the government is f 100,000 for

Molokai and 135,000 for the establishment on the Island
Oahu. There is a resident surgeon at Molokai,

The present king and queen have shown great inter-
est in and sympathy with the lepers. Three vears ago
they paid a memorable visit to them, and a hymn writ-
ten for the occasion by the king was sung enthusiastic-
ally by the patients, I have understood that the resi-
dent medical ofiicer, Dr, Hoffman, is himself affected bj-
the disorder. I will add that the ratio of deaths in a year
is 58 per 1,000, and the disease runs its course after first
incubation in about eleven j'ears. I need hardly say
that all kinds of remedies are being tried on the suf-
ferers, and I must express my thanks to the English
government, who procured at my request from the gov-
ernment of India, a large quantity of Gurjun oil, which I
forwarded to Hawaii. It has been thought that this oil
is the most potent agent, if not for the cure, for the re-
straint and alleviation of leprosy.

A LEFT LUNG WITH AN .\CCES30RV LOBE.

Dr. Wm. a, Edw.\rds, of San Diego, reports a case
as follows : The lower lobe is of the usual size and for-
mation, but the upper lobe is sub-divided at about its mid-
dle into two distinct lobes ; the lower of these is remark-
able in that its so-called cardiac loblet is unduly devel-
oped, encroaching upon the cardiac triangle, and re-
moving the heart from the chest wall. The supernu-
merary lobe is formed altogether at the expense of the
upper, which is not at all decreased in size, but is simply
fissured throughoui its upper segment ; the increase iu
size is occasioned wholly by the prolongation of lung tis-
sue above referred to. The entire lung was functionally
active, and its histological character the same through-
out. In 18S5 Dr. Edwards reported the second case on
record of an accessory lobe of the right lung. Accessory
lobes of the left lung have been more frequently ob-
served.— Pacific Uledical Journal.

THE JOHNS HOPKINS UNIVERSITY.

President Gilm.^n has authorized the announcement
that there is no foundation for the rumor that the uni-
versity is in financial difficulties. The salaries of the
president and professors have not been cut, and several
new appointments have been made. While it is true
that the income from the Baltimore and Ohio Railroad
bonds has been cut off, yet there is an accumulated in-
come from former years, the receipts from tuition aver-
age 140,000, and f 108,000 is available as an emergency
fund during the coming three years. Within six months
the university has received 5300,000, and other gifts are
expected. The hospital funds are distinct from those of
the university, and are so invested that the income is an
assured one.

ST. JOHN'S GUILD.
The report of the past season's work by the St, John's
Guild, of New York, shows that over 30,000 children and
mothers were received on the lloating hospital, and 1,500
sick children and others were treated at the Cedar Grove
Seaside Hospital belonging to the Guild, The expenses
exceeded the receipts by ^3,000.

1889.]

PRACTICAL NOTES.

531

PRACTICAL NOTES.

I

AGARIC acid: a NEW DRUG FOR NIGHT SWEATING.

Some }-ears ago a substance derived from the
well-known Agaricus albiis was introduced as a
sweat-checkitig agent in phthisis (^Practitioner,
xxix, 321). It was looked upon as an alkaloid
body, and received the name of agaricine. This,
however, has now been found to be an impure sub
stance, and Professor Schmiedeberg has recently
extracted from it a triatonic dibasic acid, to which
the name of agaric acid has been applied. This
is a white, silky, crystalline substance, scarcely
soluble in cold, but readily so in boiling water.
Hofmeister has recently investigated its ph}'sio-
logical effects, and shown that its action is upon
the centres in the medulla, especially the vagus
and vaso motor. It possesses no mydriatic action;
on the contrary, instillation of the sodium salt of
the acid produces slight narrowing of the pupils,
probably from mechanical irritation. The influ-
ence of the substance on the secretion of sweat is
not a central one, but the result of an action on
the secretory structures. Klemperer has tried it
in very many cases of profuse sweating in Profes-
sor Leyden's wards. The dose given was usually
' 6 gr. in pill, administered in the evening about
6 o'clock. If the action was insufficient, as many
as five pills were given. In most cases the result
was very satisfactory, even in those cases where
atropin failed, and it was unaccompanied by any
unplea.sant symptoms. — Tlicrapeut. Monatshefte,
June, 1889; The Practitioner.

CARBOLIC ACID IX WHOOPING-COUGH.

Dr. Robert Lee wishes to emphasize the fact
that the proper mode of administering carbolic
acid in the treatment of whooping-cough is in the
form of vapor, and by inhalation ; and that the
onh' way of effectively doing this is bj' boiling a
solution of carbolic acid in water in the propor-
tion of I to 1.5 per cent. When such a solution
is boiled, the vapor is found to contain the acid
in the same proportion — a fact not generally
known. When used in the way referred to, car-
bolic acid is, in the opinion of Dr. Lee, the best
remedy for the relief of the cough and other lar-
yngeal sj-raptoms. — Brit. Med. Journal.

call}', as well as the symptoms of failure of the
heart and Cheyne-Stokes breathing that may be
produced by doses as small as j\^ gr. MM. Mag-
nan and Lefort have found excellent results in
five minutes from ^V gr. in acute mania. The
patient loses his morbid activity and grows silent;
then mydriasis and loss of power of accommoda-
tion come on, and he goes to sleep without fur-
ther inconvenience for five or six hours — a better
result than can be got from chloral or any other
drug of the sort. It can be used in delirium tre-
mens, in a child with severe local spasms, or' as
an injection of y^n gr- i" the case of an hj-sterical
woman with profuse sweating of hands and feet,
which it will check for several hours. M. Laborde
has found that, with perfectly pure hyoscin hydro-
chlorate, doses not more than a tenth part of what
MM. Magnan and Lefort had used were quite
sufficient. — Progres Med.

CLINIC-VL USES OF HYOSCINE.

MM, Magn.^n and Lefort have been making
some experiments with hyoscin prepared by La-
deuburg. This drug was first used in 1880, and
since then MM. Gle^- and Rondeau have shown
how it produces mydriasis and paresis in dogs,
and Dr. Mitchell Bruce (Practitioner, xxxvii,
321) has pointed out its calmative effects clini-

emmenagogues and pregnancy.

Dr. L- Atthill finds that, in his own experi-
ence, some of the so-called emmenagogues are
prai^tically devoid of special action upon the ute-
rus. For many years he has made a practice of
administering ergot to patients threatened with
abortion, hfemorrhage being present but uterine
action not having been excited. He finds that it
checks haemorrhage without exciting undue uter-
ine contraction, and accordingly he does not hes-
itate to give it to pregnant women if for any reason
it seems to be indicated. He has often adminis-
tered ergot before labor in cases where there is a
predisposition to post-partum haemorrhage. In
none of these cases has labor set in earlier than
was expected, while in two or three cases it
seemed to have been delayed. From personal
experience he believes that iron, quinine and
strychnine can be administered to pregnant wo-
men in ordinary doses with perfect safety. — Brit.
Med. Journal.

PEA REMOVED FROM AN E.\R AFTER IT HAD
BEEN THERE THIRTY -TWO YE.-VRS.

Dr. W. F. Wright, of Leavenworth, reports
the case of a woman, 40 years of age, from whose
ear he recently removed a pea which had been
there for thirty-two years. The patient herself
when a child, had introduced a pea in each ear,
one of which was removed at the time. She suf-
fered from vertigo nausea and loss of hearing in
the ear which contained the pea. Since the re-
moval of the pea hearing has been greatly im-
proved and the other symptoms have disappeared.

PREVENTION OF TYPHOID FEVER.

With reference to a circular recently i.ssued by
the Kentucky State Board of Health, in which
attention is called to the increasing prevalence of

532

PRACTICAL NOTES.

[October 12,

typhoid fever, and the advice given to boil all
suspected water before using it, or to guard
against contamination by using properlj- stored
cistern water, the iVew Orleans Medical and Snr-
gical Jour7ial takes occasion to point out the im-
munity from this disease enjoyed by the citizens
of New Orleans. The people of New Orleans
of course use cistern water, not from choice but
from necessity. The editor of the journal re-
ferred to says : "As typhoid fever is mainh- dis-
seminated by drinking water, we can feel confi-
dent that this horrible disease will never become
a fruitful cause of deaths here as long as we ad-
here to our good and much-abused method of
storing drinking water." It is not denied, how-
ever, that the water supply of New Orleans con-
tains much organic matter and myriads of algae.
Our present authority also claims that having
made a virtue 'of necessity in using open drains
instead of sewers, and thereby escaping from the
dangers of sewer gases within doors, New Or-
leans has at last awakened to the idea that "it is
as good a city (for a large city) to live in as any
in the Union, provided that the plainest laws of
hygeine be obeyed."

THE TIJIE DURING WHICH ALKALOIDS REMAIN
UNALTERED IN THE BODY.

This subject has been investigated by Polla-
CANI (Deutsche Med. Zeif.) who found that no
trace of digitaline or santonine could be discov-
ered after the lapse of four months, while atro-
pine, daturine and physostigmine could be de-
tected thirteen months after. Of codeine a trace
was still present after the latter interval. Mor-
phine and picrotoxine could be recognized after
twenty -seven months, aconitine and cicutine after
thirty-four months, and veratrine after thirty-
nine months. Curarine appeared unaltered after
twenty-eight months ; after thirty-nine months
the physiological test for this substance was in-
effectual, although the characteristic chemical re-
action could still be called forth. The author
concludes from these experiments that the vege-
table poisons are not so quickly destroyed by
bodily putrefaction as has been hitherto sup-
posed. — Dniggisls' Circular.

ANTIPYRIN.

7. In all cases of great debilit}- and exhaus-
tion, and in the later stages of long continued
fevers.

It is believed that the foregoing contra-indica-
tions with regard to the administration of anti-
pyrin and similar medicaments will receive the
approval of physicians generally, — Humphreys,
in The Practitioner.

ETHEREAL TINCTURE OF IRON IN CHRONIC NE-
PHRITIS.

Dr. Wyss, of Geneva speaks very highly of
the ethereal tincture of iron, or BestucheiTs tinc-
ture, as it is usualh' called on the continent, in
cases of chronic Bright' s disease. Five or ten
drops of this preparation in a glass of water were
given to a large number of patients from three to
six times daily, the result being that in more than
half of the cases the albumen entirely disappeared
from the urine, and the oedema and other symp-
toms were also cured.

RESORCIN IN ECZEMA,

Dr. Unna strongly recommends in the treat-
ment of seborrhoeal eczema an application of
linen cloths soaked in solution of resorcin. His
formula is resorcin and glycerine of each 10, al-
cohol 180, mixed and diluted with 4 parts of
water. In eczema with much secretion he ap-
plies a thin laj'er of cotton wadding soaked in
the solution, which is then covered with some
waterproof material, and kept in position with a
bandage.

The use of antipyrin is contra-indicated :

1. In all cases of cardiac weakness.

2. In diphtherial affections in which there is
evidence of myocarditic lesion.

3. After exhaustive haemorrhages.

4. During menstruation and dysmenorrhoea.

5. In catarrhal pneumonia generally, and in
lobar pneumonia when there is oedema of the
lungs — heart failure.

6. In the later stages of tuberculosis.

GURJUN OIL IN LEPROSY.

A systematic trial of the gurjun oil treatment,
from which Father Damien and several members
of his afflicted flock at Molokai are said to have
derived benefit, is now being made at the leper
hospital at Agra. Six tj-pical cases have been
selected, and the results are being closely
watched by the medical officers of the hospital.
Their report will be looked forward to with in-
terest.

THE GLYCERINE TAMPON IN THE VOMITING OF
PREGNANCY.

Dr, S. B. Kirkp.vtrick blistered the cer\-ix
in an obstinate case of vomiting in a pregnant
patient, and observing that the patient was not
relieved until the serum was formed and dis-
charged, conceived the idea of procuring a watery
discharge by the use of glycerine. He accord-
ingly inserted into the vagina a tampon saturated
with glycerine. The distressing symptom was
at once removed and, on its return at intervals,
was always relieved by the glycerine tampon. —
Te.xas Com. Kec.

1889.]

SOCIETY PROCEEDINGS.

SOCIETY PROCEEDINGS.

Medical Society of Virginia.

First Day — Tuesday, Sept. 3, 1889.

The twentieth annual session of the Medical
Society of A'irginia convened in Roanoke, Va., at
8 P.M. Tuesday, September 3, 1889, the Presi-
dent, Dr. E. W. Row, of Orange, Va., iu the
chair. The addre.ss of welcome was delivered b}-
Dr. A. Z. Koiner, chairman of the local commit-
tee of arrangements ; Dr. Thomas J. Moore, of
Richmond, Va., delivered the annual address,
selecting as his subject, Man and His Develop-
ment.

Second Day — Wednesday, Sept. 4.

Dr. John A. Wyeth, of New York, read a
paper on

THE STATUS OF COCAINE IN SURGERY.

After a note or two on the history of cocaine
as a surgical anaesthetic, in which he accords to
Dr. Karl Roller, of New York City, the credit
due for its introduction in eye surgery, and to
Dr. J. Leonard Corning, of New York City, the
credit for its practical application to other surgi-
cal purposes than anaesthesia for eye surgery, he
remarked first upon its dangers, due to idiosyn-
crasy, etc. Its dosage is uncertain, differing
widely not only in different individuals, but in
the same individual at different times. The gen-
eral rule should be to begin with the minimum
dose, gradually increasing it, alwaj's watching
the pulse, face, respiration and pupil. In small
doses it increases the number of respirations and j
is a cardiac stimulant ; in large doses it arrests
the heart in diastole and the action of the respi-
rator3- muscles. Cocaine is never applicable to
children under 10 or 12 years of age. In his
several hundred applications in adults, in all
parts of the body, he has several times observed
pallor of the face and fainting, but due, most
probably, to the patients being overcome bj^ the
sight of blood, etc. In some, however, it was
due to absorption of the drug. Exhilaration is
not an uncommon symptom, and in rare cases it
increases to boisterousness. In one instance con-
vulsive movements occurred, episthotonos being
rather well marked. In another case a convul-
sion occurred fourteen hours after a gradual in-
jection of 30 minims of a 4 per cent, solution of
cocaine (gr. jss). In many cases, when not ap-
plied about the eye, dilatation of the pupil oc-
curs, indicating absorption by the blood. For
hypodermic purposes he uses 20 grains of cocaine
and 3 grains of boracic acid, dissolved in an
ounce of distilled water — approximately a 4 per
cent, solution. A stronger aseptic solution is
equal parts of distilled water and saturated solu- 1

tion of salicylic acid. Always dissolve cocaine
in water free from lime.

Following these general considerations Dr.
Wyeth gave interesting specific directions for the
employment of cocaine in various operations of
minor surgery, including amputation of the fin-
gers, incision of felons, removal of finger nails
and tumors, and operations about the eye, mouth,
nose, urethra, anus, scrotum, etc.

Dr. Hunter McGuire, of Richmond, Va.,
said that he did not think that Dr. Wyeth had
dwelt sufficient!}- on the dangers of cocaine. He
had used this remarkable agent almost everj' day
for the past five years, but he had come very
near killing one or two patients with it — so un-
certain is its paralyzing effect in some cases,
which cases cannot be foretold until the danger
is recognized to be at hand. He had read that
Dr. Sims had injected a few minims of a 20 per
cent, solution of cocaine muriate into the male
urethra, and in twenty minutes his patient was
dead. Dr. McGuire said that he had cocainized
a great many children without observing the ver\'
serious effects referred to by Dr. Wyeth ; in fact
they seem to stand cocaine as the}' do chloroform
anaesthesia — very well. But there are objections
to cocaine. Undoubtedly it interferes with the
repair of wounds by the first intention. Another
thing — during the session of this society two
years ago, in Richmond, he heard a distinguished
authority in such matters, then a resident of New
York City, affirm that a cocaine habit, in the
sense in which the term habit is applied to the
whisky habit, the morphia habit, etc., could not
be established. But he is certain he has seen a
case or two of the cocaine habit in patients who
have come under his care.

Dr. Wyeth remarked, in repl}-, that he endorsed
everything that Dr. McGuire had said — in fact
the dangers of the indiscriminate use of cocaine
are very considerable. He did not mean to imply
the idea in his paper that the danger of cocaine,
when used with children, was in the drug itself,
but in the imperfect manner in which it is gener-
ally administered to them, because of their strug-
gling to resist its administration, and the peculiar
sensation, or loss of sensation, in the part which
frightens them.

MEDICAL reforms, WITH SPECIAL REFERENCE
TO THE PROFESSION OF VIRGINIA,

was the subject of the address by the President,
Dr. E. W. Row, of Orange, Va. He advocated
the establishment of a State General Hospital, to
be sustained by the State, just as are the asy-
lums; that matters of professional interest connect-
ed with the management of such an institution
should be placed under the control or direction of
the Medical Society of Virginia. In other words,
he thought that the medical affairs of the State
should be directed bv the medical men of the

534

SOCIETY PROCEEDINGS.

[October 12,

commonwealth, just as are the legal affairs by
the legal men, etc. The medical profession has
shown its ability to manage such matters as be-
long to it, as evidenced bj' the excellent work
done by the Medical Examining Board of Vir-
ginia— the creature of this societ}-. The insane
hospitals and like institutions should be more di-
rectly under the supervision of this society, so far
as the medical affairs connected with them are
concerned. It is the dutj- of this society at this
time to put itself to work to secure for the State
Board of Health an annual appropriation from
the State sufficient to pay all of its necessar}' ex-
penses, it appearing that the law establishing the
Board, some seventeen years ago, being alto-
gether satisfactory, with the exception that the
law ver}' foolishly concludes with some such pro-
viso as, "provided the said Board of Health shall
not be an expense upon the State."

The next order of business was the discussion
of the selected subject,

CROUPOUS PNEUMONIA.

The appointed leader, Dr. B. L. Winston, of
Hanover, Va., stated that he would confine his
remarks to uncomplicated cases of the disease.
The diagnosis is not difficult, although sometimes
the disease escapes detection unless resort is had
to the physical signs. Pain is probably never
present unless more or less pleurisj^ complicates
the pneumonia. Rusty colored sputa, though
pathognomonic when seen, does not by anj-
means occur in the majority of cases, according
to his experience ; and on this point he thinks
the text-books should be corrected. The causes
may be classed as either specific, exciting, or pre-
disposing. The view that pneumonia is due to
a specific organism does not meet with common
approval. Dr. Winston thinks that pneumonia
is not simply a local inflammation of the lung,
but that this is but an expression of a general
disease, and that the pneumonia deserves no
higher classification than the intestinal ulcers of
typhoid fever. Croupous pneumonia is not pro-
duced by extension of inflammation, but in such
cases lobular pneumonia is the result. It is not
produced by inhaling irritating gases, nor by
traumatism, nor bj- "cold," as are other inflam-
mations of the air pas.sages. It is a self-limited
disease and frequently occurs as an epidemic.
The common asthmatic tendency cannot be due
to the height of the fever, nor to cardiac weak-
ness, nor to the amount of lung consolidated (for
the amount invaded is often verj- small). It is,
at least, certain that the cardiac failure in no wa}-
corresponds with the severity of the other .symp-
toms. It seems to the speaker that the tendency
to heart failure, which is the most alarming
.symptom in uncomplicated ca.ses, is due to a
morbific agent acting on the nerve centres. But
the exact cause of croupous pneumonia is a sub-

ject for further investigation. The germ theory
may or may not be true. The predisposing causes
are age (under 60), the male sex, the negro race,
certain diseases, as t}'phoid fever, winter and
spring seasons, etc. The exciting causes are, in
general, such things as tend to lower the vital
powers, as exposure to inclement weather, insuf-
ficient clothing, neglecting the wearing of flannel
winter and spring, etc. It is more common south
than north, pneumonia being almost unknown in
the frigid zone. During the winter and spring
almost every article of food has the stamp of age
upon it, and it seems more probable that the
character of the food then taken, when the vital
powers are at their lowest, contribute most largelj'
to the development of the disease. As to treat-
ment, most everj' drug has been tried ; yet the
mortalit}- among adults is .second only to that
from consumption. Marayliona abstracts from
five to ten ounces of blood on the fourth or fifth
day, when the heart is on the eve of being over-
powered by the pneumonic toxic matter ; but Dr.
Winston thinks stronger evidence needed to jus-
tify resort to such bleeding on such occasions,
although there maj' be occasionally times when
.some venesection is useful. He also thinks large
blisters of doubtful propriety, although he has
seen blisters relieve pain. Calomel has no place
in the treatment of croupous pneumonia ; aconite
in the commencement, and quinine, given early
as an abortive, maj- be useful ; but he has gotten
the best results when he has given the least
medicine. Hot poultices, opium to relieve pain,
stimulants when needed, food, hygienic meas-
ures, and, above all, skillful nursing, will be all
that can be done in uncomplicated cases.

Dr. H. C. Beckett, of Scottsburg, Va., also
read a paper on the subject. The specific cause
of croupous pneumonia is undetermined. No age
has either a notable proclivity to the disease, nor
is anj' age exempt. It is perhaps most frequent
between the ages of 20 and 40, and after 60. In
adult life it occurs in males three times as often
as in females ; in females it occurs most frequent-
ly at the catamenial periods. Outdoor laborers
are more liable than indoor workers. Habitual
alcoholic drinkers, malarial subjects, convales-
cents from severe acute diseases, etc., are most
liable to the disease. En,-sipelas, measles, diph-
theria, small- pox, etc., are predi.sposiug causes.
Traumatism, especially in the aged, a previous
attack of pneumonia, are also predisposing causes.
It often prevails as an epidemic in the mountain-
ous regions of the South. The first five months
of the year are its season. Thus it is seen that
all things predispose to pneumonia that depress
vital action. Dr. Shaw, of St. Louis, believes
that perturbations of the vaso-motor centre in the
medulla causes pneumonia by impressions con-
veyed through nerves connecting this centre with
the stomach. As to Ircatnicut, use stimulants or

1889.

SOCIETY PROCEEDINGS.

535

depressants, as required. If both lungs are in-
volved, so as to leave little breathing surface,
bleed. In such cases venesection affords imme-
diate and remarkable relief Large hot poultices
over the lungs reduce blood pressure, while the
heat stimulates the heart. Aconite is preferable
to veratrum ; but he prefers antifebrin as the
antipyretic, to be followed by quinia, which lat-
ter he considers the sheet anchor in pneumonia.
He usually prescribes 5 grains every four hours
until the fever breaks. In the second and third
stages he generally combines ammonia, carbonate
and digitalis. The early exhibition of a large
dose of calomel is useful. Opium is useful to
allay pain and restlessness. Expectorants have
no place in the treatment of pneumonia. Blisters
at the beginning of the third stage hasten resolu-
tion. Alcohol is essential as a food and to sus-
tain the heart. Man}- believe that the disease is
contagious, and that four days is the period of
incubation.

Dr. Lewis G. Pedigo, of Roanoke, Va., read
a paper entitled,

SEDATIVE DOSES OF CALOMEL IN ACUTE CROUP-
OUS PNEUMONIA.

He stated that the title of his paper referred to
doses of 30 grains ^nd upwards. He gave a his-
tory of the use of this treatment in various acute
diseases by a few members of the profession for
years past, and then explained the method of ad-
ministering the drug in this treatment. He re-
viewed the condition of the secretions and the
various indications of treatment in pneumonia,
gave a systematic and detailed account of the
numerous and apparently diverse effects of the
large doses of calomel, classified these effects, and
showed how they were all dependent on two gen-
eral principles, namely, stimulation of the secre-
tions, and sedative influence on the nerves. He
argued the adaptability of these effects to the
chief indications in pneumonia. The entire pa-
per was based on clinical experiences, and one
case was briefly reported to illustrate the treat-
ment advocated. The important efi"ects claimed
were the promotion of the salivary, gastric, he-
patic and intestinal .'secretions, and unloading of
the portal circulation (followed by improved di- (
gestion and assimilation), increased and improved
action of the kidneys and skin, loosening of the
bronchial and pulmonarj- secretions, relief of
cough, lowering of temperature, and promotion
of sleep.

Honorary Fellow, Dr. Bedford Brown, of
Alexandria, Va., gave a

RESUME OF HIS PERSONAL EXPERIENCE OF FOR-
TY-ONE YE.ARS IN THE TREATMENT OF
CROUPOUS PNEUMONIA.

During this period of time, he has seen four or
five different methods of treatment adopted and
practiced, and finally discarded. First, as to the

depleton,^ plan, at first it was used in every case ;
then only in certain cases, and finallj' it was en-
tirel}' discarded. Then came the mercurial plan,
in which calomel in small doses, with Dover's
powder, with mercurial inunction, were used un-
til ptyalism occurred. The great majority of
cases recovered under this treatment. Then fol-
lowed the sedative treatment, consisting of the
use of veratrum viride, aconite, and ultimately
digitalis. The sedative treatment of Norwood
gave birth to all of our subsequent ideas of seda-
tion. This was an advance on the pure depletorj-
treatment, and resulted in real good. Then again
came the stimulant treatment. This was a still
further advance, and has brought more and bet-
ter fruits than any other single treatment. While
this also may be modified and combined with ele-
ments of other treatments with advantage. Dr.
Brown has not derived benefit from the pure anti-
pyretic treatment. He has, in former years, seen
much of the epidemic forms of typhoid pneumo-
nia, with a tendenc}' to collapse which was con-
stant and great. In this form he has used large
quantities of whisky — a quart per diem — carbon-
ate of ammonia, tincture of nux vomica, and
chloroform internally. In this form he has also
used, in connection with stimulants, solution of
the acetate of ammonia, tincture of nux vomica,
tincture of chloride of iron, with benefit. Dr.
Brown does not think, from his long experience,
that adherence to any one single routine treat-
ment exclusively will give as good results as the
mixed treatment, combining some of the good
features of all; but never forget the value of stim-
ulants and nourishment. He has seen cases of
pneumonia with slight fever, slow pulse, moder-
ately excited respiration, etc., recover without
medication.

Dr. J. H. Neff, of HarrLsonburg, Va., said
that croupous pneumonia is a disease of specific
origin, running a regular course ; but no one
knows the exact character of this poison. He
has alwaj's believed that it was not a purely local
disease, but a systemic disea.se of specific origin,
having its local manifestation in the infiammation
of the lung. It prevails mostly in populous dis-
tricts, e-specially as one approaches the tropics.
He agrees with Dr, Winston as to the exciting
causes. The predisposing causes are to be found
in the constitution of the patient and season of
the year. The disease being of a specific charac-
ter, must run its course, and therefore he has had
no faith in any abortive plan of treatment. A
great manj^ cases run their course to recovery
without any treatment whatever, other than the
ordinary attentions of humanity. He has seen
antipyrin do just as much in curing pneumonia
as calomel. In children, he alwa^'s uses a light
fiannel jacket, lined inside with oil silk. He
never gives a dose of calomel now. He does hot
condemn the use of aconite or veratrum viride ;

536

SOCIETY PROCEEDINGS.

[October 12,

but he finds good diet, etc., a much better class
of remedies. It is of the first importance to sus-
tain the strength of the patient, and especially
his heart.

Fraternal Delegate, Dr. J. G. Wiltshire, of
Baltimore, Md., said that stud3'ing the subject of
croupous pneumonia after Lepine, Sevestre, Char-
cot, etc., one must accept the theory that it finds
its origin in a specific pathogenic germ ; yet it
cannot be denied that there are certain meteor-
ological conditions that stand in a strong causa-
tive relation to its production — it occurring more
frequently in low temperature — one acting as a
specific, the other as an exciting cause. We are
constantly exposed to the invasion of the pneu-
mococci ; but for the want of the necessary con-
ditions to render the mucous membrane of the
lung a suitable soil for their culture and growth,
it is able to resist them for a time, onl}- to yield
when such exciting causes as cold and trauma-
tism supplement the specific influence of the
germ. Apropos of the theory that the pneumo-
cocci have other habitats than the lungs, he called
attention to the study of Sevestre of an epidemic
of broncho pneumonia, complicating cholera in-
fantum and other enteric troubles, in which he
found the microbes of pneumonia in the intesti-
nal tract, whence they were carried to the lungs
by the lymph channels. The treatment of croup-
ous pneumonia calls for heart sedatives, heat and
moisture in the form of hot cloths ; these, if used
in the first stage, may abort the disease. Should
it, however, pass into the stage of red hepatiza-
tion, a supporting and stimulating plan should
take the place of sedative one. Watch the tem-
perature and heart as closely as the powers of the
patient. Alcohol is important in the second and
third stages. Quinine and antipyrin, when used
together, are the best antipyretics. The)' not
only reduce the temperature, but preserve the
powers of the heart. Carbonate of ammonia does
the twofold work of aiding in liquefying and ex-
pectorating the fibrinous deposit, and keeping the
heart's force up.

Dr. Henry M. Patterson, of vStaunton, Va.,
remarked that if this is a specific disease, the
treatment given has certainlj- been at variance
with this idea. He does not believe that it is
simple hyperiemia of the lung. The gravity of
the attack depends on the amount of exudation.
How to remove the engorgement is the question.
At this period is the time to abort the disease if
possible. He may be ranked as liehind the times;
but his success with the lancet now is just as good
as it was when he began practice in 1851 ; and
that success is just as good as is that by other
plans of treatment now in vogue. He gives al-
cohol in the second stage in almost every case,
both for its food and stimulant qualities. He has
had some remarkably satisfactorj- results from
ergot.

Dr. Henry V. Gray, of Roanoke, Va., said
that the important question is, What produces
the great depression of the system in cases of
croupous pneumonia? If due to exudation in
the alveoli, that condition needs prompt attention.

Dr. George Tucker Harrison, of New York,
N. Y., read an elaborate Memoir of the late Dr.
James L. Cabell, of the University of Virginia,
which was ordered to be incorporated in the Re-
port of the Necrological Committee.

Dr. E. T. Brady, of the Southwestern Luna-
tic Asylum, at Marion, Va., read a paper en-
titled:

MENT.\L action — MATERI.\L ACTION.

The Doctor stated that he would treat the
title as a fact considering it established 1)\- the
following three propositions :

1. That mental impressions involuntarily orig-
inate physical action, and that material impres-
sions give rise to this involutary mental action.

2. That loss of cerebral substance is followed
by loss of physical or expressional function, and
that disuse of mental function is followed b}' a
corresponding atrophy of cerebral substance.

3. That abnormalities of organic function,
have as their sequence, abnormal ideation.

He devoted his paper to the support of these
propositions. In support of the first proposition,
he cited the phenomena of sweating, nausea and
vomiting from fright — the quickened circulation
and blushing of the lover or of wounded modesty,
the flow of tears and gestures of grief, joj-, etc.,
changes in expression and movement, in a dream-
ing sleeper, consciousness of the presence of a
limb, as evidenced b_v sensations referred to a
limb after amputation, claiming that such .sensa-
tions are not imaginary, but the outward projec-
tion of a previously stored impression ; also claim-
ing that all reflex action is evidence of material
impression as the cause of mental action.

In support of the second proposition, he pre-
.sented the records, clinical and post-mortem, of
.several cases, and cited the advances in cerebral
localization and microscopic pathology. He in-
cidentally recommended the adoption of vivisec-
tional experimentation as the means of execut'ng
the death penalty upon criminals. In support
of the third proposition, he referred to what had
been advanced under the other headings, calling
attention to the gradual and simultaneous decline
of the cerebral and mental powers in diseases of
the brain and cord.

The Kfpoii on Materia A/edica and Therapeu-
tics was presented by Dr. William E. Cooper,
of Wood vi lie, Va. From the phenol group comes
Plwnacctine- Bayer, a tasteless powder, freely solu-
ble in alcohol, less so in glycerin, and still less so
in water. It is a non-toxic, reliable, antipyretic
and antineuralgic. The usual dose of 7.5 grains
lowers the temperature from i.S° to 3.6° F. for
hours. It is best given in powders or soluble

1889.]

SOCIETY PROCEEDINGS.

537

pills. Sulfonal- Bayer promptly causes natural
sleep in from half an hour to two hours of several
hours' duration, in doses of 15 to 45 grains. It
does not act unfavorahU- upon the heart, respira-
tion, temperature or digestion. It creates no de-
sire to increase the dose. It is given in a wafer,
or it may be dissolved in soup or tea. Avivlene
hydrate, an insomer of amj-lic alcohol, is physio-
logically ranked between chloral and paralde-
hyde. It is a colorless, slightly oilj- liquid, boils
at 102.5' C; sp. gr. 0.81. It is freely soluble in
alcohol, but requires eight parts of water. It is
given with extract of licorice, or in red wine and
sugar. In doses of from 50 to 75 grains it causes
neither nausea, headache, indigestion, nor other
unpleasant after effect ; but more frequently than
other hypnotics, it induces refreshing sleep.
Methylal is a new hypnotic, is soluble in water,
rapidly eliminated, and leaves no ill effects. Dose
3 to 5 grams. Salufer (neutral sodium silico-
fluoride), requires i ounce of water to dissolve
2'b grains, it is a powerful unirritating surgical
antiseptic. For ordinar}" uses a grain is dis-
solved in an ounce of water to syringe out cavi-
ties, etc. It corrodes steel, but does not affect
sponges. Guaiacol, an ether, derived from beech-
wood creosote, is a colorless liquid, of aromatic
odor, slightly soluble in water, but readilj- so in
alcohol and fixed oils. It is used by inhalations
or in doses of a half to one minim, several times
daily in consumption. The solution should be
kept in colored bottles.

Third Day — Thursd.w, September 5.

Dr. R. S. M.\rtix, reporter on Section of Ob-
stetrics and Diseases of Women and Children,
read a paper on

ADVANCES OF DISEASES OF WOMEN.

Massage (Brandt's method) is reported to be
practised with great success by Dr. Boldt, of New-
York, in the following conditions : Chronic and
subacute para- and peri-metritis ; all non-acute
inflammator}' uterine diseases ; chronic and sub-
acute oophoritis ; catarrhal salpingitis ; all uter-
ine displacements, with or without adhesions,
unless dilated tubes are present ; rectocele and
cystocele ; uterine haemorrhages, not dependent
on neoplasms ; incontinence of urine dependent
on relaxation of the visceral sphincter ; hema-
tocele ; floating kidney, and prolapsus recti. It
is contra-indicated, according to some, in all
acute inflammatorj- processes ; dilated tubes, and
in all conditions where suppuration is suspected.
This treatment is not useful in patients with very
fat abdominal walls. The seances varj- from
three minutes to a quarter of an hour.

Dr. Martin exhibited a Oulerbridge dilator — an
ingenious instrument, which acts also as a drain-
age tube. In sterility dependent on stenosis this
introduced five or six days before menstruation

into the contracted cervix uteri and allowed to
remain. It is also of value in sterilitj-, due to
flexions. For full description see Medical Record,
April 20, 1889. Electricity holds a high place in
the treatment of carefullj' selected cases. Engel-
mann uses galvanism for inflammatorj- products
which admit of restitution, indurations, deposits
due to interstitial inflammation, certain neo-
plasms. Davis, of Birmingham, Ala., uses fara-
disms for subinvoluted uteri. It is useful in
many cases of retroversion, manj- so-called pelvic
inflammations, in amenorrhoea due to atrophy of
the uterus, and in menorrhcea due to relaxation of
the muscles. Manj- think electricity, after Apos-
tolli's method, important for uterine fibroids ; but
the dangers of sepsis must be guarded against.
Some think electrolysis of fibroids uncertain.

For carcinoma uteri Brown uses the curette
freely and applies, on a tampon, a .saturated solu-
tion of zinc chloride. Munde uses a weak solu-
tion of sesquichloride of iron. Schramm injects
half to one grain in an ounce solution of corrosive
sublimate into the diseased mass two or three
times a week, causing cessation of fetor and
purulent discharges, and lessening the frequencj-
of haemorrhages. The feeble absorptive power
of the degenerated tissue offers immunitj- from
mercurial poisoning. The following is an anti-
septic and sedative suppository extensively used
in Paris:

B.

s.

lodoformi gr. xv.

Camphorit; gr. jv.

Ext. belladoniicE gr. j.

01. tUeobroinae q. s.

Make one suppositor3-.

Put high up iu vagina at night.

High amputation of the cervix is advisable if
the disease has not passed bej-ond the internal
OS. If disease has not extended beyond the
uterus, hysterectomy is advised. As to uterine
fibroids, Coe scrapes awaj- the hypertrophied
muscosa. I'aginal hysterectomy has been done
successful!}-. During 1888, abdominal hysterec-
tomy was done 43 times with onlj- 9 deaths.
Uterine anteversio7is atid flexions are but rarely
congenital, but results of previous para-metritis.
Use antisepticized laminaria tents to soften the
tissue, and render intra-uterine treatment more
thorough. Use preliminary course of hot douches
and glycerine tampons, then straighten the uterus
bimanually, and hold in place by a pessary or
intra-uterine stem. Dilatation w^ith bougies and
the persistent u.se of hot w-ater, will usually effect
a cure. Goodell advocates thorough dilatation
with steel branched dilators, when dysmenorrhoea
is a prominent symptom. Wylie condemns pes-
saries, but dilates rapidly under thorough anti-
sepsis. Alexander s operation for shortening the
round ligament has grow-n in favor. Munde re-
ports 23 cases with excellent results. Kellogg
reports 65 successes out of 69 operations.

538

SOCIETY PROCEEDINGS.

[October 12,

Schucking has devised and practiced successfully
vaginal suture of the uterus in 18 cases for radi-
cal cure of retroflexed or prolapsed uterus.
Hysterorrhaphy finds favor in Germany, where
prejudice exists against Alexander's operation.
A case of lacerated cervix operated on by the re-
porter in May, 1886, was delivered of twins, each
weighing eight pounds, in Julj', 1889, without
further laceration. Herrick pares the lips and
holds them in apposition, not by sutures, but by
an elastic band shaped like the cervix, large
enough to cover the whole os and cervix, with a
small hole in the band to allow the secretions to
pass. Dr. T. Gaillard Thomas does not claim
that operations for diseases of women are espec-
ially liable to insanitv, but mentions six very
significant cases, in none of which were the kid-
neys at fault, nor could the sequel be charged to
iodoform poisoning.

REPORT ON ADVANCES IN-OBSTETRICS.

The reporter. Dr. Chas. W. Pritchett, of
Keeling, Va., first spoke of Voniiting of Preg-
naticv. Hewitt analyzes fifty selected cases, and
contends that these cases confirm his opinions;
that the vomiting of pregnancy is in most all
cases associated with and dependent on uterine
displacement, and thickening or induration of the
cervix. Gill Wylie attributes it largely to indu-
ration of the cervix. Jaggard ascribes it to en-
dometritis gravidarum. Treatvtcnt. — Gunther,
of Montreaux, advises galvanism. Green reports
cases cured by chloride of sodium. Collins and
William Duncan report cases cured by, the appli-
cation of 10 per cent, solution of cocaine to the
vagina and cervix. Rose recommends rectal in-
jection of carbonic acid. Ancesthetics. — Recent
writers accord antipyrin a very high place in the
first stage of labor — relieving pain and fatigue
while the uterine contractions are not interfered
with. Chloroform holds its own in the second
stage of labor. Budin advises chloroform only
to dull pain and not to complete antesthesia, un-
less to perform an operation more severe than the
application of the forceps. Swieicki, of Posen,
has used a mixture of nitrous oxide and oxygen
in the proportion of 4 to i. Winckel regards the
mixture as harmless and especially useful in cases
of elderly primiparte. Hypnotism is a failure as
an ob.stetric anaesthetic. Antiseptics. — The com-
parative results in hospitals in which antiseptics
are used and of those in which they are not, are
sufficient to show their great value in reducing
the mortality of the lying-in chamber. Corrosive
sublimate in weak solutions and in skilful hands
is still the queen of antiseptics and germicides.
Eclampsia. — There is yet considerable di.scord as
to the cause and treatment of jnierperal convul-
sions. Santos believes that the albumiiuiria is
the result of reflex irritation of the .sympatlietic
and renal nerves by the enlargement and, later

on, the contraction and retraction of the uterus.
Lusk says albuminuria is caused by renal insuffi-
cienc)', and is not the cause of the convulsions.
Paget denies the dependence of eclampsia on al-
buminuria, but attributes it to a reflex cause.
Mastitis. — According to Richardson this is the
result of septic infection, and he urges that the
child's mouth be kept perfectlj^ clean and the nip-
ple well washed with antiseptics. Monti advises
that the fissures of the nipple be painted with a
solution of gutta-percha in chloroform. Puerperal
septictemia. —It is disputed whether this disease is
dependent on one or more organisms, ^'idal
claims that there are at least two, and that there
is no characteristic difference between the germs
of puerperal septicsemia and erysipelas. Gusse-
row denies their identity and insists that erysipe-
las cannot cause puerperal septicaemia. Doyon
says they are one and the same. Others assert
that puerperal septicaemia is of an erysipelatous
nature and the fever typical of erysipelas.

REPORT ON ADVANCES IN DISEASES OF CHILDREN.

The reporter. Dr. A. S. Priddv, of Keysville,
Va., has not found any material advance except
in diseases of the alimentar}' canal. The re-
searches of Holt, Escherich and others with refer-
ence to intestinal bacteria were summarized with
the deduction that three facts must be kept in mind
in studying the effects of microorganisms upon the
human system : the nature of the organisms, the
dose and numbers in which they enter, and the
susceptibility of the patient. The two varieties
of bacteria which have been isolated and studied
in the intestines of 3'oung children are the bacte-
rium lactis aerogenes (found in the upper portion
of the small intestine), and the bacterium coli
commune. The first decomposes milk sugar, with
the development of lactic or acetic acid, to which
the acidity of the intestine is due. After a full
review of the subjects involved, the lessons are
drawn that the infant must not be overfed, and
that the milk (in bottle-fed cases) should be ster-
ilized, and the vessels themselves that hold the
milk should also be sterilized. Milk ivas first
sterilised for food m Munich, 1S86. Dr. Caille,
of New York, introduced sterilized milk as an
artificial food into this country in 18SS, and the
results have been favorably received. It remains
sweet for six weeks, while boiled milk can be kept
only four or five days even on ice. Stoinacli was/l-
ing for gastro- intestinal disease, first u.sed in
Prague in 1880, satisfactorily introduced by Sei-
bert in New York in 1888, is especially ser\-ice-
able in dyspeptic disorders attended with regur-
gitation of food, in cholera infantum, etc. Pass
a long, soft, velvet-eyed rubber catheter attached
to a fountain syringe, through the pharynx into
the stomach ; pour in a cupful of warm water,
while the child is in the upright position. Then
tilt the child forwards, and the water returns

1889.]

FOREIGN CORRESPONDENCE.

539

through the catheter. For intestinal irrigation,
pass a Nelatou soft rubber catheter (with a hole
in the eud instead of at the side) some 8 or 10
inches into the bowel. Through this catheter,
attached to a fountain sj^ringe, pass a quart or
two of warm water containing i drachm of sodi-
um salicylate to the pint of water. Though the
treatment is not new, it is onh- during the past
two years that it has become popular in this coun-
try— chiefly through the reports of Dr. Booker,
of Dr. H. P. Wilson's Sanitarium, of Baltimore.
It is useful in dysenter}', gastro-enteric catarrh,
acute and follicular enteritis, etc. Dr. Priddy has j
used the treatment successfully in a number of
cases of gastro-enteric catarrh, dysentery, etc.,
relieving the nausea, vomiting, tenesmus, etc.,
and curing his patients.

Honorary Fellow, Dr. George Tucker Har-
rison, of New York, read

A FURTHER CONTRIBUTION TO THE STUDY OF

THE ETIOLOGY .\ND PROPHYLAXIS OF

PUERPERAL SEPTIC INFECTION.

The doctrine of auto-infection, which has re-
cently been brought into great prominence, and
the industrious researches of the bacteriologists,
with the practical deductions from them, have
divided obstetricians into two parties diametri-
cally opposed to each other. The one side at-
taches all importance to the disinfection of the
obstetrician (Hermann's subjective infection) ;
the other regards it as a matter of nece.ssity to
subject the parturient woman, in a greater or less
degree, to antiseptic measures (objective antisep-
sis). The writer took the ground of those who
advocate the paramount importance of subjective
antisepsis, in the paper read before this society
in 1885, and has had no reason to change his
ground. Of course this position does not exclude
the thorough cleansing and disinfection of the
external genitals. The views of Kaltenbach were
quoted, who insists upon it that an obstetrician,
even with clean hands, can induce infectious
forms of disease. He believes that, as the sur-
geon disinfects his field of operation, so must the
obstetrician disinfect the parturient canal, as well
as the vicinity. Winter {Zeitschrift f. Gyn., etc.),
as the result of bacterial investigation, draws the j
inference that it is necessary to disinfect the cer-
vix and vagina to avoid auto-infection. StefFeck '
and Dolderlein arrive at the same conclusion.
The writer believes that if the demands made by
the bacteriologists should be generall}' acceded
to, and it should become a universally accepted
rule of practice that the cervix and vagina of
every parturient woman should be subjected to
thorough and energetic disinfection, an immense
amount of injury- would be inflicted. These
disinfective procedures deprive the vagina of its
phy'siological mucus, and render it more vulner-
able. It becomes more liable to the attack of in- ,

fective germs. Moreover, labor is mechanically-
retarded when the vagina lacks its normal mucus,
nor must it be left out of mind that disinfection
of the vagina and cer\-ix is a painful manipula-
tion. Probably the most serious objection which
can be urged against the auto-infection doctrine
is that it diminishes the personal responsibility
of the obstetrician, and that wholesome dread of
infection disappears, which every one should
have who examines a parturient woman. The
distinction was made between septic infection and
putrid into.xication. Cases of so-called auto-in-
fection are really cases of ptomaine intoxication.
The microorganisms of septic infection are strep-
tococci. According to Bumm, the streptococci of
erysipelas and phlegmonous inflammations are
identical. Bumm's careful and exact bacterio-
logical studies lend no countenance to the doc-
trine of auto -infection. Leopold's clinical ex-
perience is very striking. Of 150 women treated
without Vaginal douches, only nine had slight
febrile phenomena. When the cervix and vagi-
na were disinfected, there was a marked rise of
morbidity-. The doctrine of auto-infection is a re-
trograde movement, and tends to imperil our
present attainments in the prophylaxis of septic
infection.

i. To be concluded. \

FOREIGN CORRESPONDENCE.

LETTER FROM LONDOX.

(FROM OrR OWN CORRESPONDENT.)

Tetanus as an Infectious Disease — The Scottish
System of Admitting I'oliintary Patietiis into Lti-
natic Asylums — The Aficroscopic Examination of
Urinary Deposits — The Aritiseptic Poiver of Hydro-
naphthol — Miscellaneous Azotes.

Tetanus as an infectious disease is now attract-
ing a great deal of attention. At a recent medi-
cal meeting a member dwelt upon the virulence
of the soil when contaminated by the dejections
of tetanic horses. He insisted upon the frequency
of tetanus in wounds of the lower extremities.
Thus, in Havana, it was stated, out of 162 pa-
tients suffering from tetanus 132 had contracted
it from wounds of the legs and feet. The disease
is frequent in persons who after being wounded
get in contact with the soil, as in the cases of
comminuted fracture, in which the bones are
forced into the ground, and crushing of the bare
feet, also when the injury- is inflicted with an ag-
ricultural instrument. Experiments made with
pure soil and with a soil known to be impregnated
strongly support this view. Certain soils seem
to preserve their virulence much longer than oth-
ers, and stagnant water has been found to favor
the proliferation of the microbe.

540

FOREIGN CORRESPONDENCE.

[October 12,

The Scottish s}'Stem of admitting voluntary
patients into lunatic asylums appears to work
very satisfactorily. Last year the number of such
patients was fifty-five. Thej- are described as
persons whose mental condition is not such as to
render it legal to grant certificates in their case,
yet they are necessarih' sufferers who are suffi-
cient! j' conscious of their own condition to feel
the need of restraint. Unlike our habitual drunk-
ards who place themselves in "Retreats," they
cannot be detained for more than three days after
giving notice to leave if they persist in that de-
sire, and it appears that they are not registered
as lunatics. At the visits of the Medical Com-
missioners to asj-lums all voluntary inmates are
seen, and they have then an opportunity of mak-
ing statements in regard to their position. Where
there is reason to suppose that they fail to under-
stand the conditions of their residence, it becomes
the duty of the ofiicial visitors to explain. The
Scottish Commissioners in Lunacy- state that for
some years past nothing has occurred to shake
their faith in the advantages of the s^-stem or of
the law under which it is regulated.

A good suggestion has been made with regard
to the microscopic examination of urinary depos
its. In order to examine these deposits, it is nec-
«ssan,^ to allow the liquid to remain quiet for
some time. In hot weather the urine is liable to
undergo decomposition during this time, and to
avoid this it is proposed to add a solution of boric
acid and borax. This solution is obtained by
adding to a 12 per cent, solution of borax another
12 per cent, of boric acid and filtering while the
liquid is warm. To the urine to be preserved
about one-fifth to one-third of its volume of the
boracic solution is added, which enables the de-
posit to be collected before any decomposition
sets in.

Mr. A. H. Mason has recently been making
experiments upon the antiseptic power of hydro-
naphthol and finds it to be about fourteen times
as strong as carbolic acid, and in fact, out of thir-
teen substances of this class only one, corrosive
sublimate, was found to surpass it. He found
that as an antiseptic hydronaphthol, when dis-
solved in ordinary water, was not more than half
as powerful as corrosive sublimate when dissolved
in distilled water, but under such circumstances
as the surgeon meets with it is said to be more
effective than sublimate. As a germicide he con-
siders it to be at least as powerful as corrosive
sublimate for anthrax and more so for bacillus
subtilis, even when the latter was being used un-
der conditions most advantageous to it.

An interesting communication has been made
to The Lancet by Dr. A. H. Ha.ssall, the salient
point of which consists in the suggestion that all
phthisical patients should be provided with spit-
toons containing perchloride of mercury solution
for the reception of the sputa, whilst the use of

cloths or handkerchiefs for this purpose should
be discouraged.

Dr. Drysdale has had under his observation a
case where a man who had previously been in
robust health, and of a health}' famih', married a
woman in 1886 who had suffered from haemopty-
sis three years before her marriage, and who died
of phthisis pulmonalis. The husband had the
first symptoms of the disease in 18S7, a year after
marriage, and is at present suffering from chronic
phthisis. Dr. Drysdale contributes this case to
the discussion now going on as to the part played
by contagion in the spread of tuberculosis. Many
statistical facts point in the direction of such con-
tagion. Thus the disease is absent in Alpine dis-
tricts, thinly inhabited by a healthy population,
and it is most prevalent where people are most
crowded in large houses with flats, as in Paris
and Vienna.

At the General Infirmary, Leeds, the practice
is commonly adopted of washing out the perito-
neum after abdominal section, in which blood or
other fluids have been effused. The fluid, wheth-
er simple warm water or boracic lotion, is u.sually
poured into the wound from a jug, being intro-
duced into the cavity by means of a glass funnel
attached to a glass drainage tube by about 2 feet
of rubber tubing. The drainage tube is intro-
duced deep in the pelvis, by which means the
water enters exactly where it is wanted and wash-
es upwards and out of the abdominal wound all
blood clots or effused fluids. The drainage tube
is left in situ after by pressure removing as much
of the fluid as possible.

Some recent statistics of sleep, though they
may not prove anything of importance, are inter-
esting. Students sleep longer and are less tired
than other men. The time needed to fall asleep
is about the same in all three classes — 20.8 min-
utes for the men, 17. i minutes for students, and
2 1.2 minutes for women. In each case, however,
it takes longer for those who are frequent dream-
ers and light .sleepers to fall asleep than persons
of opposite characteristics.

Sir Morell Mackenzie has been presented with
the freedom of the city of San Remo, richly illu-
minated and enclosed in an elegant casket, in
recognition of his patronage of that city. This
act of appreciation, suggested by Mr. Squire, of
San Remo, was warmly responded to by the Mayor
and the inhabitants.

Within the last few weeks thirteen patients
from various parts of the country have been sent
to Paris at the expense of the Lord Mayor's Fund
for treatment at the Pasteur Institute. All are
suffering from bites of dogs suppo.sed to be rabid.

G. o, M.

In Jap.\n there are thirty-one schools of medi-
cine.

1889.]

DOMESTIC CORRESPONDENCE.

541

DOMESTIC CORRESPONDENCE.

A Xosological Problem.

To the Editor: — Will you kindly publish the
liiston' of the following case, allowing me to ask
through the columns of The Journal a solution
of what seems to me an incomprehensible noso-
logical problem.

Ethel J., aged 8, the daughter of healthy par-
ents, has never had any lingering or serious ill-
ness : digestion fairly good, bowels very inactive,
appetite good, though capricious, sleeps well,
subject to quite frequent attacks of headache. On
the evening of August 20, shortly after supper,
was seized with an attack of nausea and vomit-
ing. The ejected matter consisted of partialh'
digested food and a membranous substance of an
irregular shape, six inches in length by five
inches in width. On one side here and there were
little lumps of fatty matter the size of a small pea.

I have never in practice or in literature met
with anything like it, and would be pleased to
learn if any of the readers of The Journal
have. C. M. Ferro, M.D.

Tracv, Minn.

The Xe^v Offlclal Register of Pliysielans.

To the Editor: — Will you have the kindness to
notice in your columns for the benefit of your nu-
merous subscribers in Illinois, that this State
Board of Health has in preparation a new Official
Register of Physicians and Midwives, and sug-
gest that those who have changed their place of
residence or removed to other towns since Feb-
ruan,-, 1886, should notify the Secretary at
Springfield of such change of address without
delay. John H. Rauch,

Secretary- Illinois State Board of Health.

Springfield, 111., Sept. 30, 1S89.

.Sanitary Condition of Lios Angeles.

To the Editor: — In response to your editorial
entitled "The Sanitary Condition of Los Ange-
les" (Sept. 28), pardon me for a .statement of the
facts. "The paragraph by a local paper" is
simply claptrap, which grew out of a heated news-
paper contest prior to the sewer bond election, as
the figures will demonstrate.

Los Angeles, with a population of 80,000 in-
habitants in 1888, had a death-rate of 8.50 per
1,000. The death-rate for the current year is
8.89 per 1,000 inhabitants per annum. These
figures include "95 deaths from consumption
from foreign states'" for last year, with even a
larger proportion for the present year. These
figures also include the deaths of the Los Ange-
les County Hospital (located in the city), which
is no less than an interstate and international

■■ Annual Report of Health Officer J. W. Ree?e. M D., 1888.

hospital as well. I voted for the bonds, but
knowing the figures and the facts, I am con-
strained to saj' that the "gem of the Pacific
coast'' has, indeed, a clean sanitarj' "escutch-
eon." Vers' respectfully,

J. H. Davisson, M.D.,
Member City Board of Health.
Brj-son-Bonebrake Block, Los Angeles, CaL

BOOK REVIEWS.

Transactions of the Gynecological So-
ciety of Boston. New Series. Vol. I. Bos-
ton : Cupples and Hurd, 1S89.
This is a handsome volume of nearly 400
pages, containing 29 excellent papers, A prefa-
tory note states that the society, which was
founded in 1869, has published seven volumes of
its transactions covering the period between 1869
and 1872. The present volume contains papers
read since 1879.

Annual Report of the Supervising Surgeon-
General of the M.arine-Hospital Service
of the United States for the Fiscal
Year 1888 ; pp. 406.

A great deal of interest to the medical reader
will be found in this report, which includes,
among other matters, a description of the out-
break and management of the recent epidemic of
3^ellow fever in Florida : observations on the nat-
ural histor}' of epidemics of j'ellow fever b)- Passed
Assistant Surgeon John Guiteras, M. H. S.; a
report on the food of seamen coming into the
port of Philadelphia, by Surgeon P. H. Bail-
hache, M. H. S.; a report relative to food issued
to seamen on merchant vessels arriving at San
Francisco, together with a report of scurs'j- treat-
ed during the seventeen j-ears ending June, 1888,
by Surgeon H. W. Sawtelle, M. H. S.; selected
reports of special operations by various surgeons
of the service ; reports of a large number of fatal
cases, with necropsies. Much credit is due the
Surgeon-General, Dr. J. B. Hamilton, for the ex-
cellent manner in which his report is presented.

Lecture on Bright's Disease. By Robert

S.\UNDBY, M.D., Edin.; F.R.S.P., Lon.; Emer.

Sen. Pres. Royal Med. Soc; Physician to the

Birmingham (Eng.) Gen. Hosp., etc., etc., etc.

With fifty illustrations. New York: E. B.

Treat, 771 Broadw-ay ; 1889; pp. vi, 290.

In this attractive volume the writer has set

forth, in a lucid and readable form, the results of

thirteen years' clinical and pathological study of

Bright's Disease. The reader cannot fail to be

pleased, entertained and instructed b)- its perusal,

for it is one of those books that are ' ' easy to

read," while replete with information. It is

542

MISCELLANY.

[October 12, 1889.

thoroughly practical and admirably suited to the
needs of the practitioner. The various chemical
and microscopical tests for the detection of the
disease are well described, and the classical de-
scriptions of the various clinical features of dis-
ease are admirably illustrated by short selected
reports of the author's cases. The work is di-
vided into three sections, with subdivisions of
chapters as follows :

Section i. — General Pathology :
Chapter L Albuminuria.

" II. Pathology of Dropsy.

III. Pathological Relations of Tube
Casts.
" IV. Cardio- Vascular Changes.
" V. Pathology of Polyuria.
VI. Pathology of Uraemia.
" VII. Retinal Changes.
Section 2. — Clinical Examination of the Urine:
Chapter IX. History--Classification-Etiology.
" X. General Anatomy of the Kidney.

XI. Febrile Nephritis.
" XII. Lithaemic Nephritis.
" XIII. Obstructive Nephritis.
" XIV. Complications.
" XV. Treatment of Lithaemic Nephritis.
Books of this description do not gather very
much dust on the shelves of the general prac-
titioner.

MISCELLANY.

Health in Michigan. — For the month of September,
1889, compared with the preceding month, the reports
indicate that typho-malarial fever, whooping-cough,
typhoid fever (enteric^ and diphtheria increased, and
that cholera morbus, erysipelas and inflammation of
bowels decreased in prevalence.

Compared with the preceding month, the temperature
in the month of September, 1889, was lower, the abso-
lute and relative humidity were about the same, the
day ozone was less, and the night ozone was slightly
more.

Compared with the average for the month of September
in the three years, 1SS6-8S, cholera infantum, inflamma-
tion of kidney, whooping-cough and cerebro spinal men-
ingitis were more prevalent, and influenza, diphtheria,
puerperal fever and scarlet fever were less prevalent in
September, 1889.

For the month of September 1889, compared with the
average of corresponding month in the three years 1886-
'88, the temperature was slightly lower, the absolute and
relative humidity were about the same, the da)' ozone
was less, and the night ozone was more.

Including reports by regular observers and others, diph-
theria was reported present in Michigan in the month of
September, 1889, at 34 places, scarlet fever at 20 places, ty-
phoid fever at .47 places, and measles at 7 places.

Reports from all sources show diphtheria reported in
13 places more, scarlet fever at 2 places more, typhoid
fever at 7 pl.ices more, in the month of September, 1889,
than in the preceding month.

The bulletin "Health in Michigan," heretofore is-
sued by the Secretary of the State Hoard of Health have
mentioned the increase and decrease of those diseases in

which a difference of seven or more was shown between
the per cents of reports, stating the presence of the dis-
ease in the current week or month and in the preceding
week or month, or in the corresponding mouth in pre-
vious years.

Hereafter those diseases will be mentioned of which the
comparison shows an increase or decrease of 25 per cent,
from the preceding week or month, or from the normal,
as the case may be.

The new method has the eSect of calling attention to
changes in the prevalence of diseases, which like diph-
theria and scarlet fever are important, yet which
are not usually reported by a very large number of ob-
servers, and, therefore, under the old plan would not be
mentioned.

LETTERS RECEIVED.

Dr. George Purviance, Philadelphia ; Dr. .\. G. Root,
Albanv, N. Y.; Dr. Didama, Svracuse, N. Y.; Dr. W. K.
Sutherlin, Mansfield, O.; Dr. S. F. Illick, Detroit, Mich.;
Dr. S. T. Armstrong, New York ; J. Astier, Paris. France;
Dr. Greenley, West Point, Ky.; J. H. Chambers & Co.,
St. Louis, Mo.; Dr. J. W. Carhart, Lampasas, Tex.; Ca-
dogan N. Hatcher, Ouinc)-, 111.; Detroit Free Press, De-
troit, Mich.; Dr. J. Lucius Gray, Chicago ; Dr. E. R.
Fletcher, St. Paul, Miuu.; Dr. A. E. Prince, Jackson-
ville, 111.; Longmans, Green & Co., New Y'ork; Dr. Perrv
H. Millard, St. Paul, Minn.; C. W. Bennett, Quincy,
Mich. ; Dr. E. S. King, York Institute, N. C. ; Dr. Maris
Gibson, Wilkesbarre, Pa.; R. G. Dun & Co., Chicago;
Dr. Chas. F. Disen, Minneapolis, Minn.; Rio Chemical
Co., St. Louis, Mo.; Medical and Surgical Sanitarium,
Battle Creek, Mich. ; Fairchild Bros. & Foster, New York ;
Dr. C. B. Powell, Albia, la.; The Marlin Fire Arms Co.,
New Haven, Conn.; Sharpe & Smith, Chicago ; Dr. W.
C. Eustis, Farmington, Minn.; Wm. P. Cleary, New
York; Dr. F. D. Green, Richmond, Ind.; Dr. .\. Vander
Veer, Albany, N. Y. ; Street & Co., London, Eug. ;
Sharpe & Doiime, Baltimore, Md.; Dr. Henry O. Marcy,
Boston; Dr. .\. B. Judson, New York ; Thomas Gardiner,
Coronado, Cal.

Official List of Changes in the Stations and Duties 0/
Officers Serving in the Medical Department, U. S.
Army, from September 2S, i88g, to October /, 1889.

Major Benjamin F. Pope, Surgeon, leave of absence
granted in S. O. 54, Dept. Texas, August 17, 1S89, is
extended one month, by direction of the Secretarj- of
War. Par. 6, S. O. 224, September 26, 1889.

Capt. and Asst. Surgeon George W. Adair, granted leave
of absence for one month. S. O. 90, Hdqrs. Dept. of
the Platte, September 25, 1889.

Capt. Alonzo R. Chapin, Asst. Surgeon, is granted leave
of absence for fourteen days, with the approval of the
Secretary of War. Par. 10, S. O. 223, A. G. O.. Sep-
tember 25, i8Sg.

Asst. Surgeon Jefferson D. Poindexter, V. S. Army,
granted leave of absence for one month. S. O. 113,
Hdqrs. Dept. of Dak.. September 30, 1889.

Official List of Changes in the Medical Corps of the U. S.
Naiiyforthe Week Ending October j, /8Sg.

Surgeon Geo. V,. H. Harmon, detached from the U. S. S.
" Constellation " and ordered to Naval .Academy.

Asst. Surgeon C. H. T. Lownes, detached from the U. S.
S. "Constellation " and to Naval .\cademy.

Surgeon George F. Winslow, ordered to Marine Rendez-
vous, Boston.

.\sst. Surgeon Chas. P. Henry, ordered before the Retir-
ing Board for examination.

i^-b

THE

J ournal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.
PUBLISHED WEEKLY.

Vol. XIII.

CHICAGO, OCTOBER 19. 1889.

No. 16.

ORIGINAL ARTICLES.

CONCEALED PREGNANCY — ITS RELA-
TIONS TO ABDOMINAL SURGERY.

Read in the Section of Obstetrics and Diseases of Women, at the For-
tieth Annual Meeting of the American Medical Association,
J tine, iSSg.

BY ALBERT VANDERVEER, M.D.,

PROFESSOR OF DIDACTIC, ABDOMINAL AND CLINICAL SURGERY IN
THE ALBANY MEDICAL COLLEGE.

A half century ago a distinguished German
surgeon was called in consultation by a very' com-
petent obstetrician to a case in which the patient
had apparently^ been in labor for three weeks. A
Csesarean section was decided upon, and the ab-
domen opened, when, to the discomfiture of all,
nothing but intestines distended with gas were
found. That the Professor was chagrined and in
a vindictive frame of mind, was demonstrated by
the after-treatment, for he kept the abdomen
packed in ice, applied two hundred leeches to the
abdominal walls, and in addition subjected the
woman to three bleedings. The patient recovered,
and doubtless ever after desisted from trifling with
the resources of surgery. This case has never
been reported as a successful Csesarean section.
From then until now errors relative to the diag-
nosis of pregnancy, as a complication of abdom-
inal section, have occurred, and doubtless will
continue to occur ; no one has been free from the
liability to this error. The most eminent and
painstaking surgeon of extensive obser\'ation, as
well as the operator of few opportunities, have
alike the same experience.

When mine came I must confess to you that I
felt not a little humiliated. I asked myself after
a careful review of my notes, and those of my as-
sistant, "Have I exercised all the care that is
possible in the examination of my case, and has
my diagnosis been based upon good judgment? "
Text-books on obstetrics and gynecology fur-
nished but little aid or comfort. The few cases
reported were widely scattered, and many found
in the tables accompanying this paper were se-

NOTE. — For much that pertains to the preparation of this paper,
collection of cases, etc., I am indebted to Dr. Willis Goss Macdonald,
Assistant in Abdominal Surgery, Albany Medical College ; and I
wish also to extend my thanks to those gentlemen who were so
kind as to send me the history of their own cases hitherto unpub-
lished, and other references.

cured only after diligent, personal inquiry. Many
of the mooted questions of abdominal surgery
have already been settled, and we are little bene-
i fited by papers devoted to the treatment of the
I pedicle, drainage, or the detailed histories of
cases. I have thought that I might be able to
contribute something for the benefit of the pro-
j fession, by giving the results of my investigation
I of this subject. I shall relate to you the histories
of two personal cases of exploratory incision in
which pregnancy as a complication of fibroid tu-
mor occurred, and which was not diagnosticated
prior to the operation, either by myself or my
colleagues, after repeated careful examinations.
I purpose treating the subject with perfect frank-
ness. I have collected all reported cases, wherein
the same conditions existed, and personal inquiry
has secured the histories of many others which
are now presented for the first time. That the
; table is incomplete I know, for some of the oper-
ators have either perverted the histories of their
cases, or have suppressed them altogether. This
latter statement is capable of abundant proof.
We shall later, when we come to the considera-
tion of the table of cases, collect such facts as
seem warranted from the clinical histories, and
endeavor to draw from them such conclusions as
are justifiable.

Case I. — Abdominal Section, Exploratory. Op-
erator A. VanderVeer, M.D. Operation October
7. 1887.

Mrs. E. C. \V., set. 34, native of United States,
married and hy occupation a housewife. Family
history decidedly tubercular. Patient gave his-
tory of past ill-health, but aside from an expres-
sion indicative of much pain and suffering, she
seemed physically strong. First menstruation at
13, scanty and painful: menstruation always ir-
regular ; has suffered for extended periods from
amenorrhcea. No children, no miscarriages. Was
treated during 1883 for ulceration of the cervix
with leucorrhoea. June 5, 1887, was the date of
the return or her menstruation, but no flow ap-
peared, and on June 25, 1887, she noticed a tumor
in the left iliac region which grew rapidly and be-
came very painful. Patient had a slight show
July 4, also noticed a slight tingling and swelling
in the breasts ; no nausea or vomiting. Septem-
ber 30 I gave her a careful examination at my

544

CONCEALED PREGNANCY.

[October 19,

office and made the following notes : Breasts
slighth' enlarged and tender, areola not markedly
pigmented ; abdomen, to the height of the um-
bilicus, irregularly distended. Palpation revealed
a hard tumor on the left side, and a softer one
(semi-fluctuant), on the right side. No absolute
signs of pregnancy after repeated examinations.
Per vaginam, a natural cervix could be felt high
up and a mass at the left of the uterus was dis-
tinctly made out. I was in much doubt as to her
condition, taking into full consideration the prob-
ability of a normal or extra- uterine gestation, also
of fibroid or fibro cystic tumor of the uterus. I
advised that she enter the Albany Hospital for
further observation, which she did a few days
later. Upon examination and consultation with
Drs. Boyd and Townsend, having agreed upon
the physical signs already detailed, and having
introduced the sound into the uterus three inches
without result, in view of the distress and great
pain of the patient an exploration was deemed
advisable. A full explanation was made to the
family, an operation advised and consented to by
them, having in view the great probability of an
ectopic gestation. Abdominal incision revealed
two fibroids upon the left of the uterus, subperi-
toneal in character, and the remainder of the uter-
ine tissue, especially upon the right side, seemed
involved b)' multiple rayxomata of a softer con-
sistence. Adhesions were ver}- general, preclud-
ing its removal. No further operation being ad-
visable, abdomen was closed. Patient went on
well until fifth day, when localized peritonitis
developed and rapidlj- became general. On even-
ing of sixth day abdominal wound opened in con-
sequence of great distension of the bowels, due in
part to peritonitis and obstructive pressure of fi-
broids. A large dressing was saturated with se-
rous effusion. Wound was brought together by
strapping. Next morning drainage was intro-
duced, peritonitis subsided in a day or two, and
the case went on to recovery. Discharged from
hospital November 8, 1887, abdominal wound
complete!)- healed. November 13 I visited her at
a friend's home and found her presenting a very
good condition of health, and able to move about
the house. Advised the use of electricity, and
requested her to let me know later on how she
progressed.

December 24, Dr. H. F. C. Miller, of Renssela-
erville, N. Y., who had originally referred the pa-
tient to me, visited me and stated that he had
been called to attend Mrs. W. a few days previ-
ous. Arriving at her house he found her partially
delivered of a six months' foetus. The doctor de-
livered the placenta, noticing quite an enlarge-
ment of the abdomen remaining. Patient recov-
ered from her abortion slowly, and since I Have
had no opportunit)- for an examination.

Case 2. — Abdominal Section, IC.xploratory. Op-
erator A. Vander\'eer, M.D. Operation Mav 11,
1888.

Mrs. M. M. S., aet. 35, native of United States,
and by occupation a housewife. Family history
excellent, and before puberty enjoyed good health.
First menstruation at 14, always regular, but suf-
fered from dysmenorrhoea and menorrhagia. The
menstrual blood was always clotted. Married
seven j-ears, no children, no abortions. Three
years previous had an attack of general peritoni-
tis, from which she made a good recovery. Four
j^ears ago began to have a dull, dragging pain in
the right iliac region, and extending down the
thigh. A verj^ competent gjmecologist was con-
sulted, who regarded the trouble due to the pres-
sure of a displaced uterus.

For the last eight weeks she had menstruated
but one day, at the time for her menstruation.
About the middle of March, 1888, patient noticed
a small hard tumor in left iliac region which gave
rise to little discomfort. The tumor grew very
rapidly after discovery and was very painful, re-
quiring the free use of anodynes to keep the pa-
tient comfortable. The breasts were tender, but
the areola not markedly pigmented. The tender-
ness of breasts always occurred with menstrua-
tion. I saw her at her house in consultation with
Dr. J. R. Davidson, her family physician. May 6,
1888. Upon palpation I found a growth in the
left iliac, hypogastric, and extending upward in
the umbilical regions and rather beyond the me-
dian line. It was verj^ tender, nodular and boggj'
to the touch. Upon percussion was perfectly flat
and did not fluctuate. Auscultation revealed no
sign. Per vaginam the cervix could be made out
far back towards the sacrum, but the body of the
uterus could not be outlined. In the cul-de-sac
of Douglas a body the size of an egg could be
defined. Bimanually cervix and growth moved
as a single body. The uterine sound passed 3J/2
inches. Ballottement failed to elicit anything.
The vagina was not distinctly tinged. The pa-
tient was examined by Drs. Boyd, Townsend and
myself a few days later. Although in consulta-
tion the intra-abdominal condition could not be
agreed upon, from the urgency of the symptoms
an exploration was deemed advisable, believing
the growth to be a multiple, uterine fibroma, with
a view to hysterectomy or the removal of the
uterine appendages. The abdomen was opened
bj- the usual median incision, and upon examina-
tion of the growth it seemed sarcomatous in its
nature, springing from the broad ligament and
the body of the uterus. From the extent of the
pelvic adhesions, the great vascularity of the
growth and the l)ad prognosis of sarcoma, its re-
moval was not undertaken. The fourth day after
the operation localized peritonitis occurred, but
yielded kindly to salines and ice coil locally. In
the morning of the tenth day a slight show was
noticed, and at noon the patient aborted, the foe-
tus being about four months. There was no
flooding. Her condition rapidly became more

1889.]

CONCEALED PREGNANCY.

545

serious, and she died from exhaustion May 24, ' In addition to my personal cases I shall take
1888, Autopsy three hours after death. Uterus the liberty of presenting to you abstracts of the
implicated by large fibromyxoma, partially sub- ; histories of cases which illustrate the conditions
serous in character, was studded with hard, nod- ' that are properly open for discussion,
ular excrescenses, thirteen in number, and which

B

\D

Left anterior view. A. B. and C. fibroid in order of size. D,
broad ligament.

completely surrounded the uterus. The great
mass of the uterine tumor lay to the left of the
uterus. There were extensive adhesions of tumor
to the intestines and bladder. Cavity of uterus 4
inches in depth, and contained small portions of

N-3.

N^2.

Posterior view. .\. smaller ma.sscs left in cul-de-sac of Doug-
las. B, right Fallopian lube. C. right ovary.

the placenta. There was no fluid in abdominal
cavity, andbutslight evidence of recent peritonitis.
No further examination was made. For a clearer
idea of the tumor I invite your attention to the
photographs here presented.

Same as No. 2, with cavity of uterus laid open, and showing a
fibroid in posterior wall.

Casej.^ — Abdominal Section, Exploratory-. Op-
erator Dr. Cornelius Kollock. Operation May 21,
1889. Abstract. — A. C. F., set. 28, colored, mar-
ried and has one child, now 10 3'ears old. Gen-
eral health apparentlj^ good. Four years ago she
first noticed a fulness of tlie abdomen, more to the
right than the left side. When I first saw her,
(May 10) she was very much distended. The
j prominence was central and very high up. Tu-
mor movable, hard and nodular. Fluctuation
could not be elicited. Menstruation normal in
even,' particular. She positively affirmed that
she never missed a period save when pregnant
the first time. There was no vaginal tilting, the
OS uteri was closed, and the cervix as hard as car-
tilage. The sound was introduced nearly 4 inches
into the uterus, and she did not present a single
symptom of pregnancy. The tumor had become
so large that it produced severe dragging, dysp-
noea and discomfort. An exploratorj' incision
disclosed a very large .subperitoneal fibroid spring-
ing from the fundus by a broad pedicle. The
uterus was occupied by twenty- two other fibroids
varying in size from an orange to a cherrj-. A
supravaginal hysterectomy was done, and the
uterine cavity found to contain a macerated foetus
of two and one-half or three months. The pa-
tient was doing well June i. A recovery.

Case ^. — Abdominal Section for Multiple Fibro-
myxoma. Operator M. Pean. Operation Decem-

' The abstract of this case is made up from notes kindly fur-
nished by Dr. Kollock, who ha^ frankly stated the facts in this and
another case, and generously offered them for publication.

546

CONCEALED PREGNANCY.

[October 19,

ber 15, 1874. Abstract. — Madame B., aet. 37, a
widow for several years, always sterile. For sev- 1
eral years had suflFered from severe menorrhagia. i
Recently tumor had grown very rapidly and flood-
ing had been very exhausting. M. Pean diagnos- '
ticated fibromyxomata, and proceeded to their
removal, which he did by enucleation. The op-
eration was followed by abortion on the second
day. Gestation had advanced between four and
five months. Patient recovered.

Case 5. — Abdominal Section for Fibromyxoma.
Operator Professor Freund, Strassburg, contrib-
uted by Dr. J. W. Poucher, Poughkeepsie, N. Y.
Abstract. — Patient aet. 50, married many years,
always sterile. Fibroid had existed for some time
longer than discovered pregnancy. When the
uterus was opened, to his own and everybody's
surprise, Freund brought out a buxom fcEtus
which also seemed very much surprised, for it
immediately began to cry. It proved to be at
least eight months old and all right. There was
also a large fibroid which was very vascular. A
supravaginal hysterectomy was done to complete
the operation, and the result is unknown to me.
This case is now reported for the first time.

Case 6. — Abdominal Section, Exploratory; op-
erator, Robert Barnes, M.D. ; operation January
7, 1877. Abstract. — Mrs. C. had been married
for several 3'ears ; no children or abortions. Al-
ways menstruated punctually until three months
ago, without exce.ss, since which time menstrua-
tion has been suspended and pelvic pain has
arisen, with dysuria, retention and intra-pelvic
pain, accompanied by vomiting. A fortnight
ago swelling in the hypogastrium from pelvis
upward became marked, and the abdomen was
found partly filled by a tumor taken to be a
fibroid. January 24, 1877, Dr. Barnes saw the
case and found an enlargement of abdomen ex-
tending to a little above umbilicus on the right
side and not quite so high on the left. It was
tender and lumpy, and the os uteri was felt high
above the upper edge of the symphysis pubis,
small and compressed transversely. Sound passed
two and one -half inches. Behind tract of sound,
and apparently behind tract of uterus, another
dense tumor could be felt. By rectum the mass
could be felt rounded, filling sacral hollow. Two
days later Drs. Baber, Braxton-Hicks and Barnes
met in consultation and discussed the probabili-
ties of the ca.se. Under ether an attempt was
made to dislodge the tumor from the pelvis,
which was only partially successful. They
thought the probability preponderated in favor of
an ovarian tumor partially solid. It seemed im-
possible that fibroids could be developed .so rap-
idly. The condition of pain, retention, vomiting
and commencement of strangulation of impacted
mass made it imperative to give quick relief.
Gastrotomy was decided upon with this end in
view. Abdominal section revealed general peri-

tonitis. On summit and side of tumor were nu-
merous nodular projections. Trocar plunged in
and a little blood and foul air was obtained.
Tumor and uterus were removed by supra-vaginal
amputation. Uterine cavity contained three
months' foetus. Death from shock.

Case 7. — Abdominal Section for Fibro-Myxo-
ma ; operator. Dr. Alex. Patterson ; operation,
December 11, 1884. Abstract. — Mrs. M., aged
36, married nine years, menstruation always reg-
ular until last few months ; now it was entirely
suppressed. For years menstruation has been
profuse. August, 1884, the patient accidentally
discovered tumor in left side of abdomen about
the .size of a small plum. In September tumor
began to increase rapidly and to be accompanied
by great pain. September 22d a specially quali-
fied consultant was called, and his diagnosis was
hsematocele in Douglas' pouch and his advice
against operative procedures. Matters becoming
more serious an eminent surgeon was called, who
gave his opinion in ver^' decided terms that the
tumor was uterine fibroid and should be left
alone, as an operative procedure would only has-
ten a fatal result. I was called December 21st
and thought the case to be one of fibroid that
could be removed and the patient recover. In
the left iliac fossa, close to the pelvic brim, the
tumor was most readily encountered. It was
traceable across the lower abdomen, getting lower
to the brim on the right side. The growth was
firm, elastic, nodular, and painless on pressure.
Per vaginam, pelvis filled by small mass, and the
vagina was roofed across. Uterus completely
fixed. Wishing to be sustained I called a medi-
cal friend well versed in such matters, and after a
prolonged examination he decided the case to be
one of ovarian disease, probably double, and that
it should be removed. An endeavor was made to
introduce the uterine sound, but it could only be
made to pass one and one-half inches. Abdom-
inal section revealed multiple fibro-mj'xoma. A
supra-vaginal hysterectomy was done and uterine
cavity found to contain a four months' foetus.
Patient recovered without a bad symptom.

Case S. — Abdominal Section, Multiple Fibroid;
operator. Dr. George Granville Ban took ; opera-
tion April, 1884. Abstract. — When patient first
came under his notice, two years prior to opera-
tion, the tumor was of small size, but menstrua-
tion was excessive. Whether as a result of med-
ical treatment or otherwise, it was a singular fact
that the menorrhagia diminished until the flow-
became quite moderate and even scanty, while
the tumor kept on growing. For over three
months before operation menstruation had been
absent. As the patient was single his suspicions
were not aroused, and it was impossible to exam-
ine the uterine body, for the cervix was so drawn
up that the os could only be touched with the tip
of the finger, while the uterus was covered in

1889.]

CONCEALED PREGNANCY.

547

front by one of the tumors. After separating
omental adhesions to the larger of the two tu-
mors, which had undergone cystiform degenera-
tion, and turning out the whole mass, it was
easy to secure a very good pedicle at the level of
the internal os. He confessed be was rather glad
he had not diagnosed the pregnane}', for bad he
done so he probably would not .have performed
the operation. Uterus contained three months'
foetus. He was happy to say that when last seen
the patient was in excellent health and even con-
templating marriage.

Case g. — Abdominal Section, Supra -Vaginal
Amputation of Pregnant Uterus, Complicating a
Multilocular Fibroid Tumor ; operator, Dr. James
H. Etheridge. Abstract. — Mrs. A. B., aged 34,
no children, first experienced uterine symptoms
four years ago. Two years later suifered from
retroversion and impaction of the uterus, at
which time a sub peritoneal myoma was diag-
nosticated. In May, 1886, four years since first
symptoms, patient suffered from distressing nau ■
sea. Mammary changes supervened. In the
ensuing three months the tumor grew rapidly,
and Dr. Knox diagnosticated pregnancy. At
the expiration of three months he decided to pro-
duce abortion. August i, 1886, sound was intro-
duced into uterus four inches. Its withdrawal
was followed by a small amount of blood, the
nausea and vomiting ceased, and the mammary |
symptoms disappeared. Nothing further followed i
indicating the previous existence of pregnancy or
abortion, and the conclusion was reached that
conception had not occurred. The rapid en-
croachment on the abdominal organs, her dimin-
ishing strength, emaciation and suffering were
progressively killing her. From external exam
ination it was found that the tumor extended
from the right iliac fo.ssa across the abdominal
cavity in a straight line to the spleen. Its length
was apparently double or treble its width. It
was freel}' movable, free from adhesions, and
solid. It presented great tenderness in right iliac
fossa. Per vaginam, the cervix uteri was found
very high up in the left iliac fossa, and the fun-
dus uteri was apparently thrust into the right
iliac region. The whole tumor moved with the
uterus. A verj' slight resiliency, offered to con-
joined manipulation, led me to think that I had
to do with a fibro cystic tumor of the uterus.
The sound entered the uterus four inches and
seemed to pass toward the umbilicus ; tumor was
removed bj' supra-vaginal hysterectomy. Patient
died from septicsemia. Examination of the tu-
mor showed it to be fibro- myxomatous, and that
the uterine cavity contained a three months'
foetus lying in its unruptured membranes. Foetus
was evidently alive at time of operation. The
cervical canal was five and one-half inches long.
Weight of tumor, 10 pounds.

Case 10. — Fibro-Myxoma of Uterus Compli-

cated by Pregnancy. Reported by J. Lucas Wor-
ship, Esq. Abstract. — Mrs. C. C, aged 35, mar- '
ried two and one-half years, family history good,
previous health good. Six months after marriage
she suffered from severe pain in the left iliac
region, but continued her service. Later she be-
gan to enlarge and was examined repeatedly, but
no signs of pregnancy ever elicited save amenor-
rhoea. Never suffered from menstrual disorders.
Tumor grew very rapidly and was irregular.
Cervix was very high, firm and near the sacrum.
A diagnosis of malignant tumor of the uterus
was made and palliative treatment instituted, but
the patient died in two months. Post-mortem
examination revealed multiple fibro-myxoma of
the uterus and pregnancy. Period of gestation
at death, six months.

Case II. — An abstract of a personal letter from
Prof Czerny, of Strassburg. The case was oper-
ated upon January 7, 1881, for supposed ovarian
cyst ; The cervix uteri was elongated, but not
well defined from the fundus. No foetal pulsa-
tion. The uterine sound passed, without any
obstruction whatever, 21 centimetres, and, as I
thought at the time, through the tube into the
abdominal cavity. On making the incision
through the abdominal walls I at once recognized
a gravid uterus and immediately closed the
wound. I had evidently cut down to a gravid
uterus, which was iu an anti-flexed position and
contained a large, quantity of liquor amnii. I
must add that the patient, aged 31 years, who in
her capacity as midwife had delivered seventy-
five women, strenuously denied that she was
pregnant, and as firmly asserted that she had
had the menstrual flow within a few davs. There
was some deposit of pigment about tlie nipples
and areola. Without any bad results following
the laparotomy she was safely delivered April 28,
1 88 1. Some time after the cicatrix became in-
durated. This was remedied by making ellip-
tical incisions and applying sutures, with good
result.

INDICATIONS FOR OPERATION.

A study of the clinical histories, especially in
the cases of fibro-myxoma, shows that there was
an immediate demand for operative procedure.
Robert Barnes so tersely states the indications for
abdominal .section in his case (see case 6) that
the repetition is useful : "The condition of pain,
retention, vomiting and commencing strangula-
tion of impacted mass made it imperative to give
quick relief" To these symptoms exploratory
laparotomy reveals that other often fatal con-
dition, peritonitis. Alex. Patterson's case was
equally unpromising but happier in its results.
Pain has been a prominent symptom in nearly all
of the cases, often requiring the continuous use
of anodynes. Palpation gave so much distress
that, if done at all, it was imperfect and un.satis-
factorj'. The rapid growth of the tumor has led

548

CONCEALED PREGNANCY.

[October 19,

to dj-spncea, dysuria and constipation, or to more
active obstruction of the bowels, cedema of the
extremities, vomiting, emaciation and peritonitis.
Universal experience has shown that temporizing
with cases wherein there are symptoms such as
have been related has been uniformly disastrous.
The case of J. Lucas Worship, Esq., has been in-
troduced in this article for the purpose of illus-
trating this point. Teachers have been often too
prone to advise the waiting for extended observa-
tion. It seems to me that Mr. Lawson Tait has
carefully and clearly enunciated that which is the
best practice in one of his numerous controversial
papers (^Am.Jour. Obstetrics, vol. xxi, p. 295), in
which he says: "Conditions within the abdomen
are such that the life of the patient is evidently
threatened, or the conditions combine in such a
direction as to defy ordinarj' treatment and make
life unendurable. Do not let any doubt as to
accuracy of diagnosis stand in the way of an ex-
ploratorA' incision, for this will at once make a
complete diagnosis possible and open a road for
successful treatment."

DIAGNOSIS.

The influence of gestation upon fibro-myxoma
demands our consideration. The consistency of
the abdominal tumor has been variously described
as firm, doughy, soft, fluctuant, and, indeed, the
sense of fluctuation has led the surgeon more
than once to puncture the tumor with the needle
of the aspirator, or trocar. There can be no rea •
sonable doubt that the different degrees of density
are dependent upon three conditions, viz : the
structure of the tumor, its situation, and certain
degenerative changes. The growths made up
largely of muscular elements are more readily af-
fected by the increased intra-pelvic circulation of
pregnancy, become more cedematous and grow
more rapidU', than those in which fibrous ele-
ments preponderate. Intra mural fibro-myxo-
mata, from their more intimate connection with
the uterine walls, exhibit more active metamor-
phoses than do sub peritoneal ones with slender
pedicles. Pregnancy may also bring about necro-
tic degeneration and softening from pressure. If
the foregoing facts are sufficiently established,
then sudden enlargement and softening of pre-
existing fibro-myxoma is a valuable sign of preg-
nancy. But this rapid increase in volume has
not been uniformly observed {(iusserou' Cvc/., O.
G., vol. ix, p. 300). Again, as this rapid growth
is more frequently dependent upon increased
vascularity, causes other than pregnancy may
operate similarly. Tumors largely myxomatous
often markedly enlarge during menstruation and
grow with great rapidity. On the other hand,
fibro-myxoma, in which sarcomatous degenera-
tion takes place, or primary sarcoma of the giant,
or small round cells type, are verj- rapid in their
development and are attended with great pain.

I In the case of Worship (1. c.) the diagnosis of
I malignant disease of the uterus was made. A
priori, sudden increase and softening in a fibro-
myxoma, to be of value as a presumptive sign of
pregnancy, is dependent upon the exclusion of
primary sarcoma, or sarcomatous degeneration,
and the soft and rapid growing variety of fibro-
myxoma.

For these reasons, in those cases where the
diagnosis of pregnancy has been made upon the
obser\'ance of rapid increase in size and softening
in the fibro-myxoma, it is to mj' mind, although
quite enough to arouse suspicion, based upon in-
sufficient evidence. However, in connection with
amenorrhoea and mammary changes it is of great
value, and yet has not been referred to with uni-
formity bj' writers. Ectopic gestation may occur
in these cases, giving rise to the same changes in
the tumor (see cases of Smutz and Bayle).
Amenorrhcea is a valuable symptom when it oc-
curs. It will be noted that it occurred in eleven
of the twenty-six cases, the study of which form
the basis of the greater portion of this paper ;
yet there are circumstances which may materially
modify its vahie as a symptom. For example,
in my first case the patient gave a histor},- of hav-
ing suffered for extended periods from amenor-
rhoea. Again, in the case reported by Bantock
the menstrual flow had been growing more .scanty
for a long period and finally ceased. The men-
struation may continue, or an irregular flow may
exist during pregnancy (Munde, Bayle, Gusse-
row, and others). Abortion in cases of fibro-
myxoma is most frequently induced by flooding.
The sympathetic mammary disturbances which
are observed in pregnancy were noted in four of
the cases, but they are of themselves of no great
value. In my second case they were present, but
not more prominent than at any menstrual period.
"The gastric, mammary and nervous symptoms
of pregnancy sometimes result from ovarian dis-
ease." (Thomas.) Abdominal palpation, espec-
ially in the earlier months, can add but little in
the elucidation of the problem and often has mis-
led surgeons of great ability Auscultation may
reveal a bruit, but who will sa\' that it is the
bruit of fibroid or of pregnancy ? Later both pal-
pation and auscultation are invaluable, revealing
ballottement, quickening, and the foetal heart
sounds. The sign of pregnancy, to which, in
later years, Braxton Hicks has called particular
attention, the alternating contraction and relaxa-
tion of the pregnant uterus, may be entirely ob-
scured by the fibro-myxoma. English operators
have laid great stress upon this sign.

Per vaginam, the vaginal venous injection ob-
.served in pregnancy does not differ materially
from that occurring with the large fibro-my.xoma.
in which a concealed pregnancy may occur. In
none of the cases here reported were there such
changes in the cer\'ix uteri as are regarded char-

1889.]

CONCEALED PREGNANCY.

549

ABDOMINAL SECTION COMPLICATED BY PREGNANCY NOT DIAGNOSTICATED BEFORE OPERATION.

1

^ Condition

0 c

Symptoms, if any,
of Pregnancy Prior

Operator and Reference.

Mm 0

Jj Diagnosticated

Condition Found atJaJJf

Remarks.

< U
37 W

a. Before Operation.

Operation.

f^C

Oi

to Operation.

M. P^an. Chir. Chirurg.

oFibromyxomao

Fibromvx. of uterus] 4

R.

None stated

Rapid growing tumor, very

Pav^, '76, Vol. I. p. 677.

uterus.

and pregnancy.

m

large, patient a widow 9
years ; aborted 2d day ;
enucleation.

! Prof. Freund, pers'l com.

50 M

0 do do

do do

8

R.

None

Porro's operation.

Dr.J.W.Poucher. Pough-

keepsie, N Y.. who saw

the operation.

Geo. Granville Bantock,
Brit. Gyn. Jour., Vol, ii,
p. 65. also personal com.

J. H. Etheridge. Am. Jour. ,

J4 S

0 do do

do do

3

R.

Amenorrhcea for 3
months.

do do

4

4 M

0 do do

do do

3

D.

do also main-

do do

Obst.. Vol. XX. p, 69.

mar\- changes.

^

Meredith, Am. Jonr. Obst.,
1 Vol. xiv.. p. 923.

do do

do do

2

D.

Amenorrhcea for 2
months.

do do

0

Hofmeier. Die Myo To- A
mie, p. 76. etc.

I M

0 do do

do do

3

R.

Preg'cy not absolute-
ly excluded; amen-
orrhcea.

do do

7

Dirner. Centrbl.f. Gynak., 4
1S87. Bd. ii. p. 119.

9 M

0 do do

do do

2

R.

Amenorrhcea. . . .

do do Fcetus
dead and macerated.

8

Karstrom, Hvgeia for 3
April. 1SS5.

6 M

I Exploratory

do do

5

None

Porro's operation.

9

Kaltenbach. Centralb. fiir 3
Gvnekol.. tSSj. Bd. ii, p.

3 M

I Fibromyx. of uterus.

do do

2

R.

do

do do Disinte-
gration of tumor begun
fcetus macerated.

435-

10

Alex. Patterson, Glasgow 3
Med. Jour.. April, 1SS5.

6 M

0 do do

do do

4

R.

do

Porro's operation.

II

R. Barnes, St. Geo. Hospt.
Rept., 1S74-76, Vol. viii,

M

D Exploratory

do do

3

D.

Amenorrhtea ....

do do

12

Wesseige. Bull de I'Acad. 3
Rovai de Belgique, u
Cef. 3. No. 4.

5 M 1

Fibromyx. of uterus.

0

3

do do

D.

do ....

do do Called at-
tention to absence ol
signs of pregnancy.

13

A. C. Bernavs, Reprint 3
Clin. Rept. Surg. Cases.

5 S

do do
possibility of preg-
nancy.

do do

.2 w

t>3

D.

No symptoms stated
in report.

Porro's operation.

14

J. Lucas Worship, Esq.. ^

5 M

D Malignant tumor of do do

4

U.

None

Patient died in 2 months

Loud. Obst. Trans., Vol.

uterus.

without operation.

XIV, p. 305.

15

J. Henry, Gyn. Jour., 1871.
Vol. ix. p.'33i-

0 Fibromyx. of uterus.

do do

4

D.

do

Patient died in 2 hrs. after
operation.

:b

Prof. Weith, pers'l com. .

Cystoma ov. cyst. .

do do

2

D.

do

Died from intraperitoneal

h^emo^rhage.
Patient flooded very se-

17

Bavle, Annals de Soc. de

do do

do do

D.

do

M^d., St. Etienne.

verely.

IH

H. Tuholski, St. Louis 3
Polyclinic.

6 M

3 do do

do do

3

K.

Amenorrhcea 3 mos.
before.

Fcetus dead and macera-
ted ; patient suffering
from septicaemia.

TQ

W. Walter. Brit. Medical 2

9 M

4

I>

Amenorrh(ca, slight

Jour.. Vol. ii, 18S3, 718.

exploratory. 1 pregnancy.

mamm'y changes.

20

VanderVeer, Trans. N. Y. 3
State Med. Soc, 1888.

4 M

3 Exploratory, proba-
ble fibroid, extra-
uterine pregn'ncy.

do do

4

R.

do do

Explor. inc. closed; abort-
ed 2 mos. later; recover'd.

21

VanderVeer, not reported. 3

5 M (

5 Fibromyx, of uterus,
prob'ly explorat'y.

do do

4

D.

None

Aborted loth day after op-
eration, and died.

22

C. Smutz, Brit. Gyn. Jour., 4
Vol. iii, p. 691.

2 M c

Fibromyx. of uterus.

Fibromyxoma and
extrauterine preg.

D.

Amenorrhcea, slight
mamm'y changes.

Porro's operation ; death
from shock.

23

Thos. Keith, rep'd in dis. .
by Skene. Keith. Obst.
Tr., Kdindnrgh, 'S4-85.

. . c

do do

do do

D.

None

By after-history learned
'that fcetus has been dead
nearly 4 years.

24

Stoltz, County Diseases of .
Women.

. . c

do do

do do

V.

Not stated

2,S

C. Kollock. personal com. 2

i M I

Exploratory. ...

Fibromyxoma and

3

R.

None, absolutely . .

Found macerated fcetvis of

pregnancy.

2>f. or 3 mos ; menstrua-
tion normal in period
and quantity.

PREGNANCY IN BICORNATED UTERI, ETC.

I

A. McDonald. Obst. Tanr. 23

M 0

1
Fibromyxom a of Pregnancy in bicor-

R

1
V'ery ijgnorant pat.; Hysterectomy ; ut. cont'd

Edinburgh, '84-85, p. 76.

uterus.

nated uterus.

indefinite history.

macerated foetus. 5 lbs.

2

Schfossowski, Rev. Gen. .
de Clin., No. 13. 1889.

M 1

Exploratory I

'regnancy in right
corner of uterus.

7

R.

No def. sympt's; pat.
flooded severely.

Ftetus dead aud macera-
ted.

,^

^.T. Mund^, X. Y. Obst. .

4th mo. extrauterine :

'regnancy in corner
of uterus.

R.

'hys'l sympt's were

ncision in abd'n closed;

Soc. May 7, 18S9, per-

pregnancy.

all evid'ce of extra-

abortion ; recovery (let-

4

sonal com.
Dr. Janvrin

Extrauterine preg- 1
nancy.

'reo^nancy in corner
of uterus.

D

uter. preg. 4th mo.

ter ot May II, 1SS9).

S

Exploratory I

nterstitial-pregn*cy
thought probable.

3

No symptoms. . . .

Aborted and recovery.

acteristic of pregnancj'. The cervix has been de-
scribed as firm, compressed transversely, elongat-
ed, and has been located high up behind the
symphysis pubis, or back in the hollow of the
sacrum, or operators have been unable to palpate
it at all. Because of these distortions Hegar's

sign of early pregnancy has been of no assistance.
The use of the uterine sound in both of my cases
and in nearly all of the cases detailed (in table i)
has not aided in the diagnosis. So complete has
been its failure that any facts determined by it
should not enter into one's judgment of the case,

550

CONCEALED PREGNANCY.

[October 19,

ABDOMINAL SECTION COMPLICATED BY PREGNANCY NOT DIAGNOSTICATED BEFORE OPERATION.

Operator and Reference.

Condition

Diagnosticated

Before Operation.

Condition Found at
Operation.

[Sir Spencer Wells; Abdominal Ovarian cyst |Ovarian cyst and preg-

j Tumor, Philadelphia, 1S85. i nancy

sThos. Hillars, Australian Med.
I Jour., February, 1875.
J Wm. H. Byford, Byford's Dis. of
I Women. Med. and Surg., 4th
I Ed.. 753-

l Erskiue Mason, Byford's Dis. ot
Women and Med. Rec, N. Y
1S77, Vol. xii. p. 749-

5 Geo. Fortesque, Australian Med.
I Gaz., 18S4, Vol. iii, p. 169.

6Esmarcli. Kiel, personal letter,
; Kiel, 1877.

7'Pollock, London Lancet, 1S62, ii
i 277.

SBateman. Lon. Lan., 1869, ii, 410,
9 J . Marion Sims, Trans. American

Gvn. Soc, Vol. V, p. 108.
10 W. 'L. Atlee. Trans. Am. Gyn

Soc, Vol. V, p. 108.

do do

12 F. Bird, Trans. Am. Gyn. Soc.
Vol. V, p. 108,

13 G. Kimball, personal letter. . .

do

Dr. Dunlap, Trans. Am. Gyn.
Soc, Vol. X, p. III.

Thad. A. Rearay, personal letter.
J. C. Warren, personal letter . .

i8|A. Reeves Jackson, pers'l com. .
19 Hunter McGuire, personal com

S. D. Gross, personal com. from
Dr. J. M. Barton.

E. W. Cushing, Annals of Gyn
Boston, 1SS8, Vol. i. p. 335, also
personal communication.

O. Prince, personal com. . .

29

C. KoUock. personal com . . .

Geo. E. Jarvis, Abst. of Records

Hartford General Hospital.
H. A. Kelly, personal com, , .

Dr. Cameron, St. John's Hospt.,

Toronto, personal com. from

A. H. Wright.
Dr. Cameron, St. John's Hospt.,

Toronto, personal com. from

Dr. A. H. Wright.
Dr. Winckel, Munich, personal'

com. from operator.

do do

do
do

do

do
do

do

do
do

do

do do do

Ovarian cyst, nmltilocu-i do do do

!ar.

do do

do
do

do

do

do

do

do

do

do

do

do

do

do

do

do

do

do
do

do

do

do

do

do

do

Exploratory

do

do
do

do
do

do

do

do
do

do

do
do

do

do
do

do

do
do

do

Recov-
ered.

do
do

do

Recov-
ered.

do

do
do

do
do

Died.

do do do

Dermoid cyst of ovary

and pregnancy.
Ovarian cyst, pregnancy

do
do

do
do

do
do

Parovarian cyst and

pregnancy.
Ovarian cyst, large. . .

Ovarian cyst (?)
Exploratory. . .

Hydrosalpinx .

Ovarian cyst.

Parovarian cyst. 40 lbs.
and pregnancy.

Parovarian cyst and
pregnancy.

Small ovarian cyst, preg-
nancy, twins.

Ovarian cyst, pregnancy.

Large elongated ovary,
23<, in. long, % in. wide,
and pregnancy.

Hydrosalpinx and preg-
nancy.

Ovarian cyst, pregnancy

Sir Spencer Wells, Wells' Abd

Summary, p. 119.

do do p. 120.

Dr. John E- Summers, Omaha,

pers'l com. fr. Dr. R.C. Moore,

do do

Mr. Bnrd Shrewsbury, Wells'
Abd. Surgery. Ed. 1SS5.

Mr. Cook, London Lancet, Vol.
ii. 1865. ■

Ovarian cvst,
lar.

do do

do

Multilocular ovarian
cyst.

Ovarian cyst

do do

Ovarian cyst and preg-
nancy.
Ovarian cyst

do do

do do

do
do

do

do

do

do
do

do

do

do

do
do

do

do

do

do
Recov-
ered,
do

do

do

do

do

do

Died.

Recov-
ered.

do
do
do

do

do
do

do

do

do

Symptoms, if any,
of Pregnancy.

None stated.

None ....

None stated.

do do .

do do .
None ....
None stated.

do

do

do
do

Pregnant uter. punc-
tured by trocar; Cees-
arean section.

do do patient
single woman,
do do

Preg. uterus punctur-
ed, wound closed by-
sutures, abort'n and
death ; patient sin-
gle woman.

Trocar puncture of
preg. uterus ; Por-
ro's operation.

Delivered of a healthy
male 6 mos. afler
operation.

The cyst was tapped
4 mos. before opera-
tion and pat. abort-
ed at that time.

Patient went to terra

safely.
Pat. died 2 mos. later
from vomiting of
pregnancy.

do do Patient went to term.

Absolutely no signs Patient abort'd 2d day

of pregnancy. after operation.

Pregnancy suspect'd Died from peritonitis,
but positively de
nied by patieiit.
Preg'cy suspected byjDied from peritonitis,
att. physician, who
explored uter. dayi
before operation.
Operator misled by
statements of phy-
sician.
No symptoms
do do

do

do

do do noted or

suspected.
None stated. . . .

Anienorrhcea .

do

None

None stated. .
None

do

do

do

Patient aborted, sank
rapidly and died.

Pat. aborted and died.

Patient safely deliv-
ered at term.

Patient safely deliv-
ered at term.

Patient aborted same
night.

Patient safely deliv-
ered at terni.

Patient safely deliv-
ered at term.

Safely deliv. of twins,
all well 3 mos. after.

Patient aborted on 3d
day and died.

Safely dcliv. at term
bv forceps of living
child.

Safely delivered at
term .

Has now nearly
I reached full term.

|Pat. safely deliv. ji]^
I mos. after op.; when
uterus expos'd child
moved vigorously.

do 'Abortion on 6th day.

do stated

do ....
do stated..
do . . . .

Abortion .
.\bortion.

and I am in great doubt if it should be used at I statement that there were no signs of pregnancy
all. Besides/the great difficulty of introduction | present. Granted that in a given case of fibro-
and the danger of perforating the uterine walls | myxoma the diagnosis of pregnancy is made,
are not altogether innocuous. In sixteen cases : how does the operator know that the gestation is
there were either no signs stated, or an emphatic I not ectopic, or that it is not located in a rudi-

1889.]

CONCEALED PREGNANCY.

551

PREGNANCY UNCOMPLICATED BY NEW GROWTHS.

4J

Condition

Operator and Reference.

Diagnosticated

Condition Found at

Result.

Symptoms, if any,

Remarks.

0

Before Operation.

Operation.

of Pregnancy.

1

Olshausen, personal com. Dr.

Ovarian cyst

Pregnancy and hydram-

Recov-

None stated

Mistake discovered af-

F, C, Bressler.

nion.

ered.

ter abd'l incision.

2

Wm. Vanan. Phila. Med. and

do do

Pregnancy and hydram-

do

None stated ; patient

Successful Ca;sarean

Snrg. Kept., 1888. Vol. ix, 457.

nion.

wilfully deceived
operator.

section.

3

0. Prince, personal com ....

Fibromyxoma

Pregnancy

do

Patient deceived op erator by giving his-
tory of prof, menstruation and grad-
ual increase for long period.

<1

Jas. Overton, Nashville Med.
Jour.. Julv, 1S66.

Ovarian cvst

do

do

None stated

An amusing ace t giv-

en in Nashville Med.

S

Journal-

Warren, Brit. Med. Jour., Vol.

Extrauterine pregn'cv.

do

Died.

Mammarv changes,

Porro's operafn ; cor-

ii. iS?i.

nausea and vomit-
ing; expulsion of
decidual raenib.

oner investig'd case
& op'r exonerated.

6

Joshua Bradford, personal com.
Dr. W. W. Dawson.

Ovarian cyst

do

do

Operator misled by statem's of patient's
husband and physician.

7

Henrv Miller, personal com.

do do

do

Both op'tors now dead

Dr. D. W. Yandall.

and cases u n pub-

S

Geo. W. Bavless, personal com.

do do

lished, hence partic-

Dr. D. W. Yandall.

ulars are unknown.

Q

K. E. Montgomery, pers'l com.

Enlarged retroverted

Pregnancy

Recov-

No symptoms, but

Safely deliv'd at term ;

from operator.

uterus, pregnancy sus-
pected.

ered.

enlarged uterus.

well since.

ID

Prof. Czerny, Strassburg, pers'l

Elongated cer\'ix, uterus! do

do

Mammanv changes.

Safely deliv'd at term ;

com . from operator.

antiflexed, pregnancy
not suspected.

good recovery.

II

Joseph Price. Philadelphia, per-
sonal com. .

Adherent ovary and pel-
vic adhesions.

Pelvic adhesions and
pregnancy.

do

None

mentary horn of a bicornated uterus. Experi-
ence has shown that these errors have occurred,
and if the diagnosis is to be exact, diflferentation
is demanded. But the possibility of the diagnosis
of simple ectopic gestation before rupture of the
tubal sac and haemorrhage is at least vigorously
assailed, not only abroad, but in America. Mani-
festly this is no time for entering into the discus-
sion of the merits of this last important question.
I would not have it understood that, in my opin-
ion, the diagnosis of early pregnancy as a com-
plication of fibromyxoma, /. e. before the fourth
month, is impossible in all cases, but that the
diagnosis is at the best a matter of presumption,
and that it is often impossible when immediate
operative interference is demanded. With no
desire to be critical, I must say that many of our
text-books give very meagre accounts of preg-
nancy as occurring with fibroids. Barnes, after
writing at length, came to the conclusion "that
the chief characteristic in the complication was
the want of uniformity in the uterus." His state-
ment regarding the diagnosis of pregnancy with
ovarian cyst is equally as clear. Thomas makes
no mention of the complication, and Byford, after
referring to the mistakes made bj' himself, Sims,
Wells and others, says : "A careful examination
of the cervix uteri, the abdomen and the breasts
for evidences of pregnancy will seldom fail to
make the diagnosis of this complication clear."
Hart and Barbour, Eramett, Hewitt, Simpson,
Scanzoni, Courty and many obstetric authors
either do not mention the complication, or advise
waiting. Prof Skene relates the histories of two
cases wherein pregnancy occurred with fibroids,
and in which the diagnosis was not made until
months later. Karl Schroeder expresses the

opinion "that it may be exceedingly difficult to
differentiate between simple fibroids and fibroids
complicated by pregnancy." Hirst i^Am. Sys.
Obstetrics) says: "In rapid growing soft myx-
oma the diagnosis may be exceedingly difficult
or impossible." Gusserow (Cyd. O. G., vol. ix)
rather neglects early pregnancy, but attributes
the error in the latter stages to carelessness. The
editor of the last edition of "Speigelberg's Mid-
wifery," 1887, makes the statement that, "as a
rule, there is very great difficulty, especially in
the cases of intra-mural growth, since, at any
rate during the first four or five months, they
often conceal the pregnancy. The most careful
examination may not elucidate the case." After
the fourth or fifth month the error has occurred
but three times. In Karstrom's case ascites as a
complication obscured the diagnosis. In the case
of Prof. Freund, of Strassburg, the patient, 50
years old, always sterile, presented no .symptoms
that led even to a suspicion of pregnancy. It is
only fair to Dr. Bernays to say that he suspected
the possibility of pregnancy, but from the history
of the case there seemed no ground for the sus-
picion, and the suspicion was not confirmed in
consultation.

There is no error in diagnosis which brings
the physician into so much undeserved dis-
repute in the popular mind as a failure to
recognize the presence or absence of preg-
nancy. Yet I am familiar with several cases
where this error has either led to abdominal
section, or all the preparations for one have
been made. Recently a member of the Brit-
ish Gynaecological Society amused a meeting
exceedingly by relating a case wherein a specially
I qualified operator journeyed many miles to a case.

552

CONCEALED PREGNANCY.

[October 19,

After his arrival, late in the afternoon, he exam-
ined the case carefully, decided the growth to be
fibroid, and that it should be removed. Being
much fatigued by his journey he decided to re-
main and perform the operation the following
morning. Earh- the next morning he was grave-
I3' informed that his services would not be re-
quired, as the patient had, during the night,
given birth to a fine baby, and the tumor had dis-
appeared. Xor does this experience stand alone.
Others have brought cases to the operating table
with a dilating os uteri. Of the nine cases of
simple pregnancy found in the table, five of them
occurred earlj- in the histon,- of abdominal sur-
gerj-, when methods of differential diagnosis were
not as well taught and practiced as now. I want
to call your attention particularly to the case of
Dr. Wm. V&rian. From the history of the case
I have no doubt that many, if not all of us, would
have been led into the same disagreeable error.
Dr. Prince had a similar experience. The fre-
quency of the complication of undiagnosticated
pregnane}' in single women will be noted in the
tables. I am reminded of a remark attributed to
the late Prof. MacNaughton, in answer to the
inquiries of an anxious mother who had called
him very late one night to see her daughter, who
had just returned from a ball in a blissful state of
intoxication: "Ah, madam, the best slip, the
most cautious fall ; your daughter will be better
in the morning." It is well to have the quaint
saying of the good old Scotchman always in
mind when single women present themselves
with abdominal tumors, and we should never be
in a hurry to operate. The history obtained
from the patient, and often from her relatives as
well, will be full of deceit at least, and may be,
as in Prince's case, made to fit minutely a variety
of actual disease. Such cases should be subjected
to the most painstaking physical examination ;
nor should any protestations upon the part of the
patient deter the surgeon from making a complete
examination of the vagina and breasts, as well as
of the abdomen. His judgment must be based
entirely upon the physical examination.

Pregnancy as a complication of ovarian cyst is
met with considerable frequency-, and is not al-
ways diagnosticated before operation. We can
hardly enter into the discussion of the symptoms,
for in the twenly-eight cases that go to make up
the table none are stated save in one ca.se, amen-
orrhcea. In some of the cases the operators state
that there were absolutely no signs of pregnancy.
The period of gestation in twenty-one cases was
before the fourth month. Three others occurred
in single women, and the remaining two ca.ses
were at about the fifth month. The presumptive
signs of pregnancy occurring with fibro-myxoma
are, in cases of ovarian cyst, obscured or modi-
fied : yet to some of them greater diagnostic
value can be attached. Close attention to men-

I strual disorders will occasionally determine the
fact that the patient's menstruation has been per-
fectly normal until a recent period, when it has
ceased altogether. This is sufBcient ground for
suspicion. The examinatiou of the breasts
should be a matter of routine ; yet the evidence

! obtained will be of no great value. The vaginal
examination here will be of greater value than
with fibro myxoma. If the uterus can be pal-
pated and found regularly enlarged, yet indepen-
dent of the tumor, if the cervix is softened and
OS patulous, if the vaginal walls are tinted, then
there exists strong presumptive signs of preg-
nancy. Hegar's sign in such cases, if demon-
strable, makes the diagnosis absolute. Palpation
of the abdomen in the earlier months, when the
error occurs, is of no value. When the uterus
rises into the abdomen, then palpation and aus-
cultation are with ballottement, and the sign of
Braxton-Hicks sufficient, as a rule, to make the
diagnosis. But the pregnant uterus may be ob^
scured anteriorly by the large cyst ; it may be
retroverted and impacted in the pelvis, or drawn
up and dislocated laterly by the rapidly increas-
ing cyst, so that it will be impossible to explore

I it satisfactorily ; then the diagnosis is impossible.

! When the slightest suspicion of pregnancy exists
in connection with ovarian cj^st, the use of the
sound is absolutely unjustifiable, although it
seems, in the ca.ses where it was used, that it
onlv confirmed the error in diagnosis. Accumu-
lated experience has shown conclusively :hat ab-
dominal section for ovarian cj-st in the pregnant
woman should be done generally and without the
previous induction of abortion.

Conclusions: — i. Finalh", from the study of the
seventy cases, I am convinced that the errors of

' diagnosis are dependent, in a large proportion of
the cases, upon conditions which make it abso-
lutely impossible, when these conditions recur in
other cases, to avoid the same diagnostic conclu-
sions.

2. That it is the duty of every operator, before
making an abdominal incision, to secure person -
all}-, or by a specially qualified assistant, a fully
classified, written statement of the facts which go
to make up the clinical history of the case, to-
gether with the results of the physical explora-
tion made by tlie operator and his consultants,
using a formal blank statement (that of Sir Spen-
cer Wells, for example), so that no facts may be
omitted. That no part of this duty should be
delegated, except under super\-ision, to internes
of hospitals.

3. That the probable diagnosis should be based
upon the physical signs contained in the notes,
corroborated, with few exceptions ( uiunarried and
ignorant patients), by the rational signs con-
tained in the clinical history, and not by simple
abdominal palpation and "the dim light of a pel-
vic examination."

1889.]

CHRONIC ENDOCARDITIS.

553

4. That whenever the slightest probabilitj- of
pregnancy exists, it should be fully explained to
the patient and her friends.

5. That the necessitj- for operative relief and
the consequences of delay or neglect should be

tions and are often ignorant that they have any
disease. On the other hand, we, with equal fre-
quency see patients in whom the same valvular
lesions are attended with the most serious symp-
toms and with death. It is, therefore, a matter

carefully stated to the parties interested, before of practical importance to determine as accurately
obtaining their formal consent to the operation. ' as we can why it is that some of these patients

6. That it is the duty of every operator to re-
port fully all such cases, that the methods of
diagnosis may be improved, if possible.

7. That it is the duty of the profession at large
to maintain that pregnane}' may be absolutelj'
concealed, especially prior to the fourth or fifth
month, by other intra-abdominal conditions.

do so well and others so badly. For it is in this
way that we are most likely also to determine a
rational treatment for the disease.

It seems evident that uearlj' all the most im-
portant symptoms of chronic endocarditis are due
to the disturbances produced in the distribution
of the blood throughout the body. It is by these

Bibliography in addition to references found in disturbances of the circulation that the cerebral

tables

Barnes, Simpson, Hart and Barbour, Hewitt,
Jones, Courty, Scanzona, Hagar and Kaltenbach,
Pean, Hofmeier, von Flammerdingle, Tait, Wells,
Thomas, Emmett, Skene, Byford and Goodell.

Obstetrics — Barnes, Playfair, Simpson, Leich-
man, Schroeder, Speigelberg, Cazeaux and Tar-
nier, Eusk.

Reports — "London and Edinburgh Obstetri-
cal," "St. George and Guy's Hospital Report,"
"Journal British Gynaecological Society," "Amer-

and pulmonary symptoms, the loss of nutrition
and the dropsy are produced. The problem before
us, therefore, is to determine why in some cases
of chronic endocarditis there are disturbances of
the circulation, and why in other cases there are
not.

It might seem at first that the solution of this
problem is an easy one, that the disturbances in
the circulation are simply in proportion to the
stenosis or insufficiency of the valves. A very
moderate experience, however, is sufficient to

ican Journal of Obstetrics," " Annals Gynsecol- show that this is not the case. The problem is a

ogy," "Transactions of the American Gynaeco-
logical Societ}'," etc.

complicated one, and the disturbances of the cir-
culation are due to a number of causes which act
singly or together.

We may enumerate these causes as follows :

The endocarditis.

The dilatation and hypertrophy of the
tricles.

The inflammation or degeneration of the
of the heart.

The inflammation of the coronary arteries.

The abnormal heart action.

The associated pulmonary emphysema, chronic
endarteritis, and chronic Bright's disease.

To follow out the mode of action of all these

ven-

wall

CHRONIC ENDOCARDITIS.

/?ead in the Section 0/ Practice 0/ Medicine at the Fortieth Annual
Meeting of the American Medical Association. June 28. iSSq.

BY FR.\NCIS DELAFIELD, M.D.,

OF NEW YORK.

It is proper that I should offer to you some rea-
sons for selecting so ordinary a disease as is
chronic endocarditis as the subject for this paper.
But the ordinary diseases are, after all the impor-
tant ones, and often as we see them we never | causes is not possible in a paper of this character,
realh' know them well enough. Any fresh rec- I confine myself to the consideration of three of
ord of facts, any new way of grouping, or of look- them : The endocarditis; the abnormal heart
ing at these facts must be of some little service, action ; and the secondary and complicating
It is the object of this paper, therefore, not to ' changes in the kidneys. Not that the others are
give a systematic account of endocarditis, but to unimportant, but that these three are perhaps the
draw attention to some features of the di.sease ; ; most important of all.
not to give a history of the views of other ob- i. The Endocarditis.

servers, but to state simply what I have put to- In thinking of persons with valvular lesions,
gether from my case books and post-mortem we must remember that some of these persons,
records. while under our observation, are suffering from

Of the ordinary diseases few are more common chronic endocarditis, and that some are only suf-
than is chronic endocarditis. In few of them is fering from the changes produced in the valve by
there so great a variety in the severity of the an endocarditis which no longer extsts. In the
symptoms. From the condition of a trifling in- ; one case they suffer from a chronic inflammation,
convenience to that of a distressing and fatal di.s- 1 in the other from a deformity. It may be in-

case there seems to be no limit to its various
phases. We constantly meet with patients whose
heart valves are seriously damaged and who yet
enjoy good health, can follow laborious occupa-

deed that such deformity leads to progressive
changes in the cavities and walls of the heart. But
this is much less likely to happen than if the
changes in the valves are also progressive.

554

CHRONIC ENDOCARDITIS.

[October 19,

Chronic endocarditis may directly follow acute
endocarditis ; it may be developed after a long
interA-al in valves damaged b}' an old attack of
endocarditis ; it may from the first be a chronic
lesion. We find, especially in children, an un-
interrupted history of cardiac symptoms begin-
ning with an acute attack and continuing as a
chronic disease for years. We find in older per-
sons with marked cardiac symptoms developed
late in life a history of an acute endocarditis in
childhood, from which they had apparently re-
covered. We find in adults the gradual develop-
ment of one cardiac symptom after another, so
slow and so gradual that we can hardly date the
beginning of the disease.

Chronic endocarditis, when it has once com-
menced, seems to have a natural tendency to per-
sist and to involve other portions of the endocar-
dium. The cases vary as to the activity of the
endocarditis and the intermissions in the course
of the inflammation. It is apparently possible
for tlie endocarditis to stop at any time, and the
valves will then undergo no further change.
Chronic endocarditis is a productive inflammation
with the formation of new tissue, but without
exudation. In its most active form there is a very
considerable growth of cells and also a death of
cells, so that the inflamed endocardium is thick
ened in some places, ulcerated in other, and on
the roughened surfaces thus made, thrombi are
formed. This is the most active and dangerous
form of the disease. In its more chronic form
the growth of cells is not as great, the cells do
not die, the basement substance is thickened. Al-
though the surface of the endocardium is some-
what roughened, and small vegetations are often
formed, there are no thrombi.

In either form of inflammation there may be
added degeneration or calcification of the inflam-
ed endocardium and of the thrombi. It may very
well happen that the patient, after sufiering from
the chronic form of endocarditis for years, may
then develop the more active form in the same
valve, or in one of the other valves.

In the more active form of the disease a large
number of the cases run their course within six
months from the time of the commencement of
their symptoms. A considerable number do not
live longer than six or seven weeks. The symp
toms are pronounced : Disturbed heart action ;
delirium, convulsions, paraplegia ; cougli, hsemop-
tysis, dyspncea : nausea and vomiting ; dropsy;
loss of flesh and strength and auEeraia, and a ri.se
of temperature. These patients are apt to get
rapidly wor.se, but there may be intermissions,
and the inflammation may stop altogether. It
seems evident that in the treatment of these pa-
tients we must remember that they are sufiering
from an inflammation of .some activity, and that
rest in bed, the use of cold or of counter irritation
over the heart are measures likely to be of use.

On the other hand, in the slow form of endocar-
ditis the disease lasts for many years. There are
usually intermission in its course, and it may
stop altogether at any times. Many of the patients
have no symptoms. In those who do, .some one
symptom is first developed and then, as the dis-
ease progresses, others are added. These patients
are regularly better for an out of door life, with
as much exercise as they are able to take.

2. — The Abnormal Heart Action.

It is po.ssible for a chronic endocarditis to run
its entire cour,se with a perfectly regular action
of the heart. This, however, is the exception.
The rule is, that the heart's action is disturbed,
and this disturbance is often the most important
feature of the disease, and furnishes the principal
indication for treatment. Such disturbance of
the heart's action may be due to :

a. The endocarditis existing as an inflamma-
tion of some activity and producing changes in
the heart's action in the same way as does an
acute endocarditis.

b. Such a degree of stenosis, or insufficiency of
the valves as will mechanically interfere with the
heart's action. This often does not become a
factor of much importance until the stenosis or
insuSiciency are well marked, and for this reason
it is easy to be deceived as to the character of the
lesion.

c. Dilatation and hypertroph}' of the ventricles
are often present, and certainly have their effect
in changing the character of the heart's action.

d. Chronic mj'ocarditis and disease of the cor-
onary arteries produce the most extreme and in-
tractable disturbances of the heart's action. For-
tunatelj' they are not very common.

e. Contraction of the smaller arteries through-
out the body with increase of arterial tension and
venous congestion. This condition, although a
frequent complication of endocarditis, nephritis,
endarteritis, emphysema, and occurring as an in-
dependent condition in some cases of angina pec-
toris, is yet something concerning which our
knowledge is imperfect. Whether contaminated
blood irritates the arteries, whether the nervous
centers are irritated by the contaminated blood
or in what waj' the contraction of the arteries is
produced, we do not know. But such a contrac-
tion is produced and lasts for hours, days or
months. The same patient may never have but
one such attack, or he may have man\'. In patients
who have had many attacks, the muscular coat of
the small arteries is thickened. Such a contraction
of the arteries at once changes the character of
the heart's action. It becomes rapid, forcible,
feeble and tunuiltuous. The degree of the car-
diac disturbance is apparently in proportion to
the degree and suddenness of the contraction of
the arteries, but is not related to the severity or
extent of the endocarditis. In the early stages
of endocarditis we very often see patients who

I889.J

CHRONIC ENDOCARDITIS.

555

complain of dj^spnoea on exertion and on lying
down with precordial pain. Otherwise they feel
perfectly well and have normal urine. We find
the heart enlarged, its action rapid and forcible,
and a murmur indicating disease of one of the
valves. The radial pul.se is distinctly tense. If
by treatment the arteries are dilated the dysp-
noea disappears, the heart's action becomes nat-
ural and the patients feel well. Or, in a further
advanced and progressing endocarditis we may
follow patients for years who, in spite of their en-
docarditis, feel well except when they have at-
tacks of contraction of the arteries. When they
have such an attack dyspnoea and other sj'mp-
toms are developed and continue for weeks or
months. Then as the attack subsides, the symp-
toms disappear and the patients feel well. The
first attacks yield readily to treatment. But as
time goes on the attacks are more frequent and
more obstinate. The pulse is tense, but small.
The heart's action is no longer forcible, but
feeble or tumultuous. Occasionally we see pa-
tients who go on with a chronic endocarditis for
many years, but with few or no .S3'mptoms. Then
with a slight pleurisy, or pericarditis, or without
discoverable cause a sudden, extreme and intrac-
table contraction of the arteries is established,
causing the most urgent dyspnoea and continu-
ing up to the time of the patient's death. The.se
attacks of the contraction of the arteries are at
first readily relieved by the drugs which dilate
the arteries — nitrate of amyl, chloral h\'drate,
nitro-glycerine, opium and potassium iodide. The
patients do well with an out-of door life and reg-
ulated exercise. But as the endocarditis ad-
vances and the valves are more damaged, espe-
cially by stenosis, these attacks are less readily
relieved, and it becomes necessary to keep the
patients more and more quiet.

i. Unknown causes which apparently act
through the nerves which regulate the action of
the heart. These form a large, important and
obscure group of cases. In .some of these cases
the abnormal heart action is associated with ad-
vanced disease of the valves, and it is onlj' by the
results of treatment that we can discriminate how
much of the disturbance of the heart's action is
due to the valvular lesion, and how much to
nervous influences. The pulse is of low tension,
feeble and rapid. The heart's action is feeble or
exaggerated. The condition of the patients is
often very bad, and yet in some of them very
marked improvement is obtained by treatment.

These patients at first require complete rest, then
massage and later regulated exercise. The most
efficient drugs are digitalis, strophanthus,cafFein,
convallaria and barium chloride. The heart
seems to be always really a weak heart even
though its action is exaggerated. It is often
natural to believe that there is degeneration or
inflammation of the walls of the ventricles, but

yet after death no such changes are found. In
other cases the endocarditis is not advanced, the
valves are but slightly narrowed or insuflScient,
there is little or no change in the size
of the heart. The heart's action is rapid,
either feeble or exaggerated. The pulse is soft
and rapid. The patients often have pain or ab-
normal sensations referred to the heart, the gene-
ral health may be very much impaired. Although
these patients have endocarditis, yet it is really
the abnormal heart action which makes them ill
and calls for treatment. Some of these patients
are very easily managed, the heart's action soon
becomes normal, the pain disappears and the pa-
tients feel well, although the lesion of the valve
still exists. Some of them, on the contrary, do
not improve. The disturbance of the heart's ac-
tion and other symptoms continue, but yet the
patients do not die, nor get worse beyond a cer-
tain point. There are, however, occasional cases
in which the heart's action becomes very bad,
the patients are very feeble and die. After death
we iind but moderate changes in the valves and
no changes in the walls of the heart. The man-
agement of these cases is apt to be difficult. At-
tention to the diet, the general health, the habits,
the cliTnate, the exercise is of especial importance.
Of drugs, one or other of the cardiac stimulants
is often indicated.

3. The secondary and complicating changes
in the kidneys.

Of the persons who suffer from chronic endo-
carditis a large number never have any compli-
cating disease of the kidneys. In the persons
who die from endocarditis it is rare to find nor-
mal kidneys. In judging of the frequency of the
kidney lesions the mo.st certain criterion is the
autopsy. During life it is not sufficient to ex-
amine for albumen and casts, which are often ab-
sent, but the quantity of the urine, its specific
gravity, and the proportion of urea to the ounce
of urine must also be determined. Advanced
changes in the kidneys often exist in patients
whose urine is said, after a superficial examina-
tion, to be normal.

In persons who die from chronic endocarditis
we find :

Chronic congestion of the kidney.

Chronic degeneration of the kidney.

Chronic nephritis.

I. Chronic congestion of the kidney.

The kidneys are of medium size, or large.
Their weight is increased, they are hard, uni-
formly congested, their surfaces are smooth. The
epithelium of the cortex tubes is opaque, flat-
tened or swollen. The glomeruli show a dilata-
tion of the capillaries, with more or less thick-
ening of their walls and the swelling of the cells
which cover their walls. In the stroma there is
nothing but some exaggeration of the subcapsu-
lar areas of connective tissue which are found in

556

CHRONIC ENDOCARDITIS.

[October 19,

normal kidneys. The arteries are normal, the
pj'ramid veins are congested and sometimes di-
lated. The urine is diminished in quantit}' at
the times when the heart's action is bad, and re-
turns to the normal when it is better. It is ap-
parently never increased except from accidental
causes. The specific gravity is usually between
1020 and 1025, but ma}^ for a time be down to
loio, or up to 1035. The quantity of urea is
rarely less than 10 grains to the ounce, it ma}- be
as high as 21 grains. The specific gravitj- and
the quantity' of urea must be judged by examin-
ing the urine of 24 hours for several days,
with the proper allowance for diet and exercise.
Albumen and casts are absent or present in very
small quantities. The effect of the congestion of
the kidneys on their functions is simplj- to dimin-
ish the quantity' of urine. The quality of the
urine is good, and the exudation from the vessels
amounts practically to nothing. Apparently the
only way in which this lesion of the kidney can
add to the symptoms of the endocarditis, is bj-
the diminution in the quantity of the urine.

2. Chronic degeneration of the kidney. ,
The kidneys are considerably' increased in size

and weight, weighing together from 16 to
20 ounces. Their surfaces are smooth ; fhe cor-
tical portion is thickened, of pink or white color,
the pyramids are red. The gross appearance is
that of the so-called large white kidney. The epi-
thelium of the cortex tubes is swollen and opaque.
In the glomeruli there is dilation of the capilla-
ries. There are no changes in the stroma, or in
the arteries, the pyramid veins may be congested.
The quantity of the urine varies with the changes
in the action of the heart, sometime abundant,
sometimes scanty, sometimes suppre.ssed. The ,
specific gravity is not diminished, nor is the pro-
portion of urea to the ounce decreased. Albu-
men and casts in small quantities are more fre-
quently present than with chronic congestion.
While it is difiicult to separate the kidney symp-
toms from the heart symptoms, yet one has the
impression that this kidney lesion is more serious
than chronic congestion, and has its effect in in-
creasing the symptoms of the endocarditis, espec-
iallj' the loss of nutrition and the anjemia.

3. Chronic nephritis.
A chronic inflammation of the kidneys may

follow chronic congestion or chronic degeneration,
it is then evidently a direct result of the endo-
carditis ; or it may be developed as an independ-
ent inflammation and is to be regarded as an as-
sociated and not a secondary lesion.

a. Chronic nephritis following chronic conges-
tion of the kidney. The kidneys remain increas-
ed in size, or become somewhat smaller. The
capsules are adherent, the surface of the kidney
is finally nodular, the consistence of the organ re-
mains hard, and the general venous congestion
continues. The epithelium of the cortex tubes

is opaque, swollen or flattened. The tubes mav
contain coagulated matter. The straight tubes
of the cortex and pyramids may contain cast mat-
ter. The capillaries of the glomeruli are swollen,
their walls are thickened, there is an increase in
the size and number of the cells which cover the
capillaries. There is a considerable growth of
connective ti.ssue in the stroma distributed ac-
cording to the arrangement of the normal subcap-
sular wedges. Within these masses of new con-
nective tissue the tubes and glomeruli are atro-
phied. The walls of the arteries may be thick-
ened, the capillar\' veins in the cortex may be
dilated and their walls thickened. The quantity
of the urine varies verj' much at diSerent times in
the same patient, sometimes it is above, sometimes
below the normal. The specific gravity falls to
1020 or 1016. The proportion of urea to the
ounce is somewhat diminished. Albumen and
casts in moderate quantities are regularly present
at some time in the course of the disease, but dur-
ing much of the time they are entirely absent.
The patients seems to be especially liable to spas-
, modic dyspnoea and to loss of flesh and strength.

b. Chronic nephritis following chronic degen-
eration of the kidne}'. The kidneys are large,
their surfaces are smooth, the cortex thick and
white, the pyramids red. The epithelium of the
cortex tubes is opaque, flattened or swollen. The
convoluted tubes contain coagulated matter, the
straight tubes cast matter. The capillaries of the
glomeruli are dilated and the cells covering the
capillaries are swollen. There are no changes in
the arteries. The quantity of the urine varies at
diflTerent times, often it is very scanty. The spe-
cific gravity keeps close to the normal, or may
even be above it. The proportion of urea to the
ounce of urine is not diminished. Albumen is
regularly present in considerable quantities, casts
are somewhat less constant. The patients who
have this form of nephritis are apt to exhibit the
ancemia and dropsy in a very marked degree and
to get wor,se rapidly.

Chronic nephritis is associated with chronic
endocarditis, but apparently not caused by it.

Such an association of chronic nephritis with
chronic endocarditis is of very frequent occur-
rence. Either one of the lesions may be devel-
oped the first, either one ma}- be of the most im-
portance.

In all of these cases, while there is much va-
riety in the gross appearance of the kidneys the
changes in structure are much the same. The
epithelium of the cortex tubes is degenerated ;
some of the glomeruli are converted into fibrous
ti.ssue, in others there is only a growth of the tuft
cells : there is a considerable growth of connec-
tive tissue in the stroma ; the walls of the arteries
are thickened. There are, however, two points
in which these kidneys differ from each other.
The quantity of exudation from the blood vessels

i889.]

PROPERITONEAL HERNIA.

557

and the rapidity of the changes in the kidney. To j of Brooklyn, in the Annals of Surgery, March,
these two points of difference correspond the dif- 1888.

ferences in the clinical histories. We may, there- . For this reason I have thought it worth while
fore, for clinical purposes distinguish three forms ' to bring the subject before this body for consider-
of chronic nephritis. ation and discu.ssion.

I. Chronic nephritis with large and continued In studying the literature of properitoneal her-

exudation of serum from the blood ve.ssels of the
kidney into the tubes. The urine is sometimes
diminished, .sometimes very much increased in
quantity. The specific gravity is lowered, often
at about 10 16. The proportion of urea to the
ounce of urine is diminished. The urine constant-

nia I have come to the conclusion that very many
cases .must have come under the observation of
American surgeons who did not classify them as
thej' would have done had they understood them
thoroughl)'. One reason for this conviction rests
upon the titles which are at the head of a number

ly contains considerable quantities of albumen i of articles upon hernia, as they may be found re-
and numbers of casts. The patients do badh'. ' corded in the Index Catalogue of the Surgeon-
Dropsy, ansemia, loss of flesh and strength and General's Library at Washington. Another rests
chronic uraemia are the regular symptoms. upon the fact that since the careful studies of this

2. Chronic nephritis with moderate and inter- ; subject by Streubel, Kronlein and Kiister in Ger-
mittent exudation from the blood vessels. The ; many have been published, a considerable number
urine is more or less increased in quantity, ex- ' of cases have been specifically recorded in that
cept when the patient has an attack of contrac- and in other countries.

tion of the arteries, then it is diminished. The It must not be supposed that this fact indicates
specific gravity is lowered. The proportion of a mere refinement in diagnosis. It means much
urea to the ounce of urine is diminished. During more than this ; for, before these studies were
much of the time no albumen or casts are present, 1 made, the history of properitoneal hernia was one
but from time to time when the patient is doing i of unvaried disaster. The diagnosis was, we maj'
badly in other ways they appear in moderate j say, invariably made on the post-mortem table,
quantities. These patients usually live for a num- j Since Kronlein pressed his opinions upon the at-
ber of years, slowly getting worse. They are es- ; tention of his professional brethren the state of
peciall)- liable to attacks of contraction of the affairs has been very different. Now this form of
arteries with dyspnoea, headache, sleeplessness ' hernia can not only be diagnosticated during the
and convulsions. I life of the patient, but it can also be successfullj'

3. Chronic nephritis with little or no exuda- | treated.

tion from the blood vessels, the nephritis ad- 1 In a general way a properitoneal hernia may
vancing verj- slowlj-. These kidneys are consid- , be said to be one which occupies an abnormal po-
ered by some authors to be examples of fibroid \ sition within the abdominal or pelvic wall in front
degeneration, rather than of chronic inflamma- j of the peritoneum. Sonnenburg has suggested
tion. The urine shows no change except that [ that the term preeperitoneal would be more exact,
the specific gravity and the proportion of urea I This is true ; but we maj', I think, hold to the
from year to year are gradualh' lowered. Some j term proposed by Kronlein, lest we introduce con-
of the patients never have any renal symptoms, j fusion by a change which is not important.

Some of them have attacks of contraction of the
arteries. vSome of them simply lose some flesh
and a great deal of strength and die quietly.

PROPERITONEAL HERNIA.

Read it} the Section of Surgery and Anatomy atthe Fortieth An-
nual Meeting of the American Medical Association, held at
Xe7Lport,June. iSSg.

BY CHARLES W. DULLES, M.D.,

SURGEON TO OrT-PATIENTS IX THE HOSPITAL OF THE UNIVERSITY

OF PENNSYLVANIA, AND IN THE PRESBYTERIAN HOSPITAL,

IN PHILADELPHIA.

The subject of properitoneal hernia is so little
known in this countrj' that I believe that there
have been but three cases with this title recorded

by American surgeons. One of these I reported ' cape from the" usual route of the inguinal canal
to the Philadelphia Academy of Surgerj', Decern- \ and the scrotum are : properitoneal, intermuscular

A true properitoneal hernia lies between the
parietal peritoneum and the ov-erlying mass of
muscles, or — when pelvic — -the bones. There is
also a form of hernia which occupies a position
between the planes of the abdominal muscles,
which may be called "intermuscular;" and an-
other which lies outside of them and just beneath
the skin and superficial fascia. For the last Kiis-
ter has proposed the term ' ' hernia inguino-super-
ficialis," and he divides it into three varieties : i,
hernia inguino-superficialis abdominalis ; 2, her-
nia inguino-superficialis cruralis ; and 3, hernia
inguino-superficialis perinealis; as they occupy
respectively- the region of the lower abdominal
wall, of the thigh, or of the perineum.

The three principal forms of hernia which es-

ber 6, 1886; the second was reported by Dr. Hart-
ley, of New York, in the N. Y. Medical Record,
about a week later ; and the third by Dr. Torrey,

and superficial hernia.

I have now collected and studied the histories
of thirty-four cases of properitoneal hernia. In

558

MUSCULAR SPASMS.

[October 19,

twenty-seven cases the diagnosis was never estab-
lished until alter the death of the patient; in
seven cases it was made during life and all of the
patients were saved ; one without operation and
six after operation. This fact alone would justify
an attempt to spread the knowledge of this form
of hernia.

The history of cases of this sort seems to be
that they are, for the most part, originally in-
guinal heniiae, and often accompanied bj- an un-
descended testicle. After occupying the inguinal
canal for a certain time, the obstruction offered by
the incarcerated testicle, or sometimes by a truss,
forces the protrusion, under a strain, out of the
canal and into the loose tissue between the peri-
toneum and the muscles, or between the muscles
themselves, or between the whole mass of muscles
and the skiii and superficial fascia. They usually
occupj' a positiou above and parallel to Poupart's
ligament, and simulate an encysted hydrocele of
the spermatic cord. They are sometimes so large
that they overlap Poupart's ligament and hang
down over the thigh. Prof. S. D. Gross has re-
corded a case of this sort. Thej^ often extend up-
ward and outward as far as the anterior superior
spine of the ilium. On investigation they can
often be grasped in the hand through the abdom-
inal wall and felt as distinct and movable tumors.

The treatment of properitoneal hernia is usually
by a cutting operation. I have found the record
of only one case which was successfully treated by
taxis ; and m}- investigations lead me to the belief
that this is the most dangerous way to treat it.
The most natural plan is to make a free incision, -
similar to that for incarcerated inguinal hernia,
and to follow this up with whatever dissection is
necessarj' to restore the bowel to the cavity of the
abdomen.

Probably the best method of operating would
be to make an incision through the Imea alba, as.
if for a laparotomy, and to draw the intestine back
from the hernial sac, instead of pushing it back as
in the usual operation of herniotomy. Bj' this
means there ought to be no danger of a reduction
C7i ?»asse, which is the most dangerous thing which
can happen in such operations.

For further information in regard to this whole
subject I cannot do better than to refer you to the
writings of Streubel, Kronlein, Treudelenberg and
Kiister, of which — with others — I have given a
. list in a paper published in the Medical Xcxcs,
January 22, 1887, and to the excellent paper by
Drs. Hartley and Torrey to which I have referred
above. 4101 Walnut St.

Dr. Long, U. S. Marine-Hosp. Service, said
that he had operated for radical cure twenty-four
times in cases of reducible hernia, with two fail-
ures to cure. There had been no fatalities or
even apparent danger to life. He had had some
experience that might interest the members of the

Section. In one of his cases he had operated and
discharged the patient two months subsequently
apparently cured. This patient was readmitted
to hospital eight months after with pneumonia
and died. The speaker made a careful dissection
of the hernia after the death of the patient. The
operation had been a modified Czern)''s in which
the stump had been sewed up between the pillars
of the ring, hoping to secure union and have the
stump act as a plug. He found on dissection that
there was union between the pillars throughout
the length of the opening, but no sign of the
stump enclosed. On the inside he found a small
cone-shaped (with the top of the cone cut ofi")
portion of the peritoneum resting against the in-
ner surface of the ring. The top of the section of
cone was nearly '4 of an inch thick, and certainly
of itself offered considerable resistance. Dr. Long
thought favorably of McBurney's operation and
did not think, in the light of experience, that
sewing the stump of the amputated sac in the
ring was of any advantage whatever. In his
twenty- third case he met with a condition of
things that was peculiar. There was no super-
fluous fat and the sac was easily reached, but the
adhesions between it and the tunica vaginalis
were so intimate that it seemed impossible to sep-
arate them. During the operation he unwittingly
opened the cavity of the tunica vaginalis, and
subsequently opened the sac, thinking by insert-
ing his finger he could more easily effect a sepa-
ration. This was- found impossible, and the
wound in the sac was closed and the mass re-
turned, and the pillars closed. The external
wound was left open, hoping to reinforce the
parts by cicatricial tissue. He hoped for a good
result in this case in spite of the difliculties. As
to the matter of particular operations, choice of
sutures and kind of stitches, they were matters
to be relegated to the choice, fancy or experience
of the operator. The speaker said that he had
experimented with varieties of catgut. He for-
merly used the catgut preserved in juniper oil be-
cause of its great pliability, but found that it
would undergo solution in from four to six daj-s,
while that prepared with chromic acid. No. 3
size, will hold for from twelve to eighteen days
before undergoing solution, and by that time we
will have accomplished all that may be expected
from sutures. There is no question as to the ad-
visability of curing hernia by surgical measures.

PAINFUL MUSCULAR SPASMS AFTER
FRACTURE PERFECTLY CONTROLLED

BY SULFONAL.
BY EDMUND .\NDRK\VS. M.D ,

SENIOR SrRCIvON OF MKKL'V IIOSI'IT-VL, ETC.. CHIC-^OO.

The ordinary anodynes and antispasmodics
do not give us full satisfaction in the muscular

1889.]

MEDICAL PROGRESS.

559

spasms following fractures. It is true that they
help somewhat, yet even under the influence of
morphine the patient, though quiet when awake,
is aroused from his sleep by repeated painful con-
tractions, which continue for days to be a serious
source of distress.

In three such ca.ses I have given sulfonal in
doses of 15 grs., repeated if necessar}', say once
in four to six hours. In each case the medicine
has stopped the spasmodic twitches completely,
giving the patient a wonderful relief If further
experience confirms this result, sulfonal will be a
great boon to surgeons and to their patients.

There are other varieties of reflex spasm which
may perhaps be relieved by the same remedy.
For instance, in hip disease, the inflamed head of
the femur provokes frequent nocturnal spasms of
the adjacent mu.scles, causing the patient to awake
with a scream. Extension apparatus generally
controls this, but in many instances an adjuvant
is needed for a time, and sulfonal may prove to be
as effective for this purpo.se as it is in fractures.

It is probable that numerous other varieties of
reflex spasm may be equalh' benefited by the rem-
edy, so that investigations ought to be made in
this direction.

No. 6 Sixteenth St., Chicago.

MEDICAL PROGRESS.

Chloroform Accidents.— Apropos of a recent
discussion in the Paris Academic de Medecine,
Prof. Dastre classifies the causes of fatal acci-
dents resulting from the administration of chloro-
form as follows : Primar}- syncope, respiratory or
cardiac; secondary syncope; toxic apnoea. In the
first class death results from the first inhalations
(initial shock) ; this occurs from reflex cardiac
syncope in nervous, impressionable individuals
weakened by suppuration or haemorrhages, or in
individuals otherwise healthy who suffer from ir-
regularity of the heart's action (in animals with
those which exhibit habitual cardiac irregularity,
as the dog), or they arise from reflex apncea under
analogous conditions. In the .second class (sec-
ondary or bulbar syncope) narcotism is more ad-
vanced; the heart's action maybe arrested sudden-
ly or gradtially ; the arrest of respiration may be
slow and progressive or sudden from tetanic spasm
of the glottis. The third cla.ss of cases comprises
those of fatal intoxication in which the agent has
been administered too freely or for too long a time,
and the anatomical elements, particularly the nerve
elements, have lost their vitality. In this form of
chloroform poisoning there is a destruction of
mechanism which seems to involve derangement
of the entire respiratorv' apparatus.

The real danger in the administration of chlo-

roform is from the effects produced upon the heart
and not from those tipon the respiratory organs.
In the case of heart failure we are practically
without resource, while in the case of respiratory
insufficiency we have a remedy in artificial respi-
ration. In opposition to the generally accepted
opinion, the arrest of the heart's action is a phe-
nomenon of excitation and not of paralysis or
paresis. This is true of at least four out of five
cases.

As a remedy for chloroform intoxication Prof.
Dastre proposes a mixed form of chloroform ad-
ministration. Inasmuch as in the majority of
cases it is the stimulation of the inhibitory cardiac
apparatus that is concerned, section of the two
vagi nerves would constitute the theoretical rem-
edy. This being inadmissible, we have still a
practical and delicate means of arriving at the
same result, /. e., the administration of atropin.
This is really equivalent to section of the vagus,
which destroys the excitability of the cardiac
filaments as well as their bulbar nucleus. At-
ropin, however, should not be employed alone
on account of its excitative tendencies, which
may be obviated by the concomitant administra-
tion of its antidote, morphine. The action of the
combination of atropin, morphine and chloroform
has been experimentally tested in the case of dogs.
The dog is infinitely more subject to chloroform
accidents than is man. In the laboratory of Sor-
bonne one dog in three was lost b)- accident.
During the last ten years all the dogs have been
anesthetized by the mixed method, and in hun-
dreds of cases of narcosis there has not been a
single death. The mode of procedure is as fol-
lows : Ten minutes before the operation a sub-
ctitaneous injection is made of a solution contain-
ing 2 centigrams of muriate of morphia and 2
milligrams of sulphate of atropia per cubic centi-
metre. Of this half a cubic centimetre per kilo-
gram of the animal's weight is used. The ad-
ministration of chloroform is then begttn, 2 or 3
grams being sufficient to produce a perfect anaes-
thesia la.sting two hours — a much less quantity
than would otherwise be required, while the
economy in its use greatly diminishes the danger
of fatal results. This mixed method has also
been used in human surgery, particularly by M.
Aubert and his surgical colleagues of Lyons, who
employ the following formula : An injection is
made from fifteen to thirty minutes before the
operation of i ' 2 cubic centimetre of the following
solution :

Muriate of morphia 10 ceiitigr.

Sulphate of atropia 5 milligr.

Distilled water 10 grams.

M. Aubert gave an accotmt of his experience
with the method (Soc. Biol., April 21, iScS^) in
these terms : "I know of nothing more desirable
or practicable. The advantages are the following:
I, safety; 2, the great rapidity with which sleep

56o

MEDICAL PROGRESS.

[October 17,

is produced; 3, the absolute repose of the patient;
4, the quick return of consciousness ; 5, the ab-
sence of unpleasant sequelae such as vomiting.
Some of my colleagues have at my suggestion
employed the method, and M. Gayet particularly
recommends it in ophthalmological surgery."
The number of instances of its employment now
mounts up (1887) into the thousands, and with-
out the occurrence of a single accident. — La Se-
maine Medicate, August 28, 1889.

The Tre.\tment of Oz.bna with Glycer-
ine.— At a recent meeting of the Society of Mili-
tary Surgeons in \'ienna. Dr. Sidlo strongly rec-
ommended the treatment of ozsena with glycerine.
His method consists in daily washing out the
nasal cavity with a 2 per cent, solution of chlo-
ride of potassium, to which 10 per cent, of glycer-
ine has been added. This is followed up with
the insertion of rolls of cotton soaked in a mix-
ture of one part of gl5'cerine and three parts of
water, the tampons being allowed to remain in
place for an hour at a time. Using this method,
he claims good success in the management of
ozaena. The method requires some weeks to
efifect a cure ; but no one who has treated ozaena
often will think a few weeks too long to devote
to any method which is likelj- to be successful.
The one proposed by Dr. Sidlo is so simple, and
apparently so rational, that it certainly .seems
worthy of further trial, and if other medical men
can cure such cases as he has cured in this way,
it will be a verj' useful addition to our therapeu-
tic resources. — Medical and Surgical Reporter.

Antipyrin in Diabetes. — Drs. Gley and
Germ.-\in See report a number of cases of artifi-
cial glycosuria in dogs, in which the good effects
of antipyrin in this affection were well illustrated.
To a dog passing 13 grams of sugar a day, one
gram of antipyrin per diem was given for eight
days, at the end of which time the amount of
sugar had fallen to eleven grams. At another
time the quantity of sugar was reduced by the
same means from about ten to less than six
grams. Dr. See has also employed the drug in
the treatment of glycosuria in the human subject
with good results. Lepine and Porteret have
shown that antip}'rin has the effect of retarding
the transformation of glycogen in the liver and
muscles into glucose. M. Huchard has pre-
viously related several cases of polyuria and gly-
cosuria, in which the exhibition of antipyrin was
followed by good results. The latter author be-
lieves that this drug has a special utility in bul-
bar neurosis, among which he classes diabetes,
polyuria and exophthalmic goitre. — Revue Gene-
rate dc Cliniqiie et de Tlurapeutique. — The Medi-
cal Record.

For THE Relief of Coryza.— Dr. Kohler

recommends inhalations of camphor as affording
great relief in the early stages of an acute coryza.
He puts one teaspoonful of powdered camphor in
a rather deep vessel, half fills the latter with
boiling water, and covers it with a paper cone.
The end of this cone is torn of so as to just fit the
nose. The warm camphor-laden vapor is then
inhaled through the nose, not the mouth, for a
period of from ten to fifteen minutes. This pro-
cedure is repeated every four or five hours. After
the third inhalation, even the most stubborn
catarrh, says Dr. Kohler, will be found to have
completely disappeared. Any laryngeal catarrh,
which may be present at the same time, will be
found to be considerablj' benefited by the action
of the camphor vapor. — Zeitschrift fiir Therapie.
— Tlie Medical Record.

Urethral Vegetation Removed by the
Aid of the Endoscope. — Dr. F. R. Eversole,
of St. Louis, reports a case in which, by the aid
of the endoscope, he diagnosed the presence of a
venereal growth in the urethra, four inches from
the meatus, and successfully removed it with the
curette. The application of a 10 per cent, solu-
tion of cocaine was useful in checking the haem-
orrhage. He also finds the endoscope useful in
cases where there is great difficulty- in passing
bougies through tight strictures. The use of
cocaine makes the introduction of the endoscope
comparatively painless. — St. Louis Polyclinic,
August, 1889.

Atrophy' of the Optic Nerve. — Dr. Wig-
GLESWORTH finds that optic nerve atrophy is fre-
quently met with in general paralysis usually as
a late symptom, though it sometimes occurs
earl}-. He narrates a case in which the optic
atroph}' was the first sign of the disease preced-
ing by .some time the mental symptoms. Dr.
Percy Smith and Dr. Yellowlees cite similar
cases. — Brit. Med. Jour., Sept, 21, 1S89.

Suspension Tre.^tment. — Dr. A. B. Shaw,
of St. Louis, gives the results obtained in three
cases by this method. The treatment extended
over a period of about eight weeks, with seances
ever}- two to four days. The tractile force used,
as measured in pounds by a spring balance,
varied from 50 to 128. Two cases of tabes dor-
salis and one of cerebro-spinal sclerosis were
treated ; the patients were all aged, respectively,
32, 66 and 47 years. The results obtained were
extremely satisfactory in all instances. — W'ee/cly
Medical Review, Aug. 31, 1889.

Digitalis in Pneumonia. — M. Petrescii, of
Bucharest, claims that pneumonia can be aborted
in its early .stages by giving large do.ses of digi-
talis, e.g., 4 to 8 grams of the leaves in infusion
dailv.

1889.]

EDITORIAL.

561

Journal of the American Medical Association

PUBLISHED WEEKLY.

Subscription Price, Including Postage.

Per ANPfTJM, IN Advance $5-oo

Single Copies 10 cents.

Subscription ma^' begin at any time. The safest mode of remit-
tance i.s by bank check or postal money order, drawn to the order
of The Journal. When neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
letters.
Address

Journal of the American Medical Association,

No. 6S Wabash Ave.,

Chicago, Illinois.
All members of the Association should send their Annual Dues
to the Treasurer, Richard J. Dunglison, M.D., Lock Box 1274, Phila
delphia, Pa.

London Office, 57 and 59 Ludgate Hill.
SATURDAY, OCTOBER 19, 1889.

PUERPERAL ECLAMPSIA.
Of late, much affectation of unbelief in the so-
called urinsetnic origin of the very large majority
of cases of puerperal eclampsia has crept insidi-
ously into the literature of the subject. This fact
is particularly apparent in recent American con-
tributions. For example, in the second volume
of the American System of Obstetrics, Parvin gives
a most confused account of the causation of this
disorder, while Hirst, the editor of the System,
asserts that " ver}' little is known about the eti-
ologj- of the disease." We have ventured to
characterize this agnostic state of mind as an af-
fectation, since the.se and all other authorities
base the entire prophylaxis and very much of the
therapy upon the notion that in the very large I
majority of cases, eclampsia is the expression of
a toxaemia, conditioned upon functional or or-
ganic disease of the kidneys, or upon the obstruc-
tion to the flow of urine through the ureters.
Thus all authorities urge the qualitative and
quantitative examination of the urine in every i
case of pregnancy. In event of pathological al-
buminuria, or in case of au}^ other significant
alteration in the quality or quantitj^ of the urine, !
the mandatory indications for preventive treat-
ment are fulfilled only by the rigorous restriction
of diet to milk, the systematic use of the hot
water bath, and the prompt induction of prema-
ture labor when other means fail to relieve the
symptoms. All these preventive measures indi-
cate a practical faith in the theor\- of renal inade-
quacy that belies the confession of ignorance just
mentioned. I

It has been well said that it is an anachronism
to doubt the identity of puerperal fever with
the infectious wound- diseases. The same remark
is applicable to unbelief in the doctrine of the
renal origin of puerperal eclampsia in the very
large majority of cases. For Carl Braun (1857)
demonstrated the dominant influence, as a causal
factor,of acute renal inadequacy, while Harberts-
MA (1871) has shown the occasional etiological
significance of obstruction to the flow of urine
through the ureters. These teachings to-day rest
on evidence, cumulative from observation and ex-
periment, that is conclusive, and that in kind and
degfree closely resembles the proof of the Semmel-
weiss theory of puerperal fever.

The idea conceived b)- the individual practi-
tioner as to the causation of puerperal convulsions
is of the utmost moment to his patient, since upon
this conception must depend all treatment, pre-
ventive and curative. Under all these conditions,
has one the right to "count it a bondage to fix a
belief" or to afi"ect " free will in thinking?"

Doubtless some of the confusion on the subject
is due to the use of the term eclampsia as indica-
tive of a disease, and not merely as the name of a
symptom. Perhaps it would be better to desig-
nate the condition in the concrete case more ex-
actly by speaking of the eclampsia of Bright's
disease, of urinary absorption, of acute yellow
atrophy of the liver, and the like. Then, too, it
is absolutely necessary to exclude from the notion
of puerperal eclampsia, and to eliminate from the
record of cases, convulsions due to epilepsy, hys-
teria, tetanus, meningitis, cerebral tumors, acute
anaemia, and the like. Convulsions owing to
such causes obviously have no relation to the
morbid state under discussion.

As before remarked, the Braun-Halbertsma
doctrine of eclampsia does not include all cases,
although it is adequately explanatory of nearly
all cases. The urinaemic theory, as presented
above, is not an universal proposition.

Stumpf (1886) succeeded in the demonstration
of aceton in the distilled urine of a few eclamp-
tics, and of sugar in the urine of a few others.
He is of the opinion that, under abnormal decom-
position processes, there is released a nitrogen-
free, toxic substance — possibly aceton or an allied
body with the same reactions — -which, during
excretion, irritates the kidneys to the point of
nephritis, destroj-s the coloring matter of the

562

CI.ARK UNIVERSITY.

[October 19,

blood, alters the activity of the liver cells, causes
the presence of sugar, the destruction of the
hepatic parenchyma to the degree of acute yellow
atroph}^ with the production of tyrosin and leu-
cin, and finally, by irritation of the encephalon,
determines coma and convulsions (Winckel).
What ma)' be the cause of these abnormal de-
composition processes, whether it be an agent of
infection, exogenous in origin, or whether it
arise within the body of the fcetus, Stumpf does
not pretend to say. In this connection the cases
of eclampsia associated with hsemorrhagic hepa-
titis, ver\' lately reported by GrsT.w Braun, are
of extraordinary interest. There are not lacking
those that regard many forms of the nephritis of
pregnancy as the expression of infection. The)'
seek to explain in this way the remarkable cases of
Stumpf and Gustav Braun. It has been asserted
that microorganisms may enter the body through
the atrium of the intestinal tract, circulate in the
blood, determine destruction of tissue and capil-
lary embolism in the kidneys, liver and other
vi.scera, or produce toxic effects through their
leucomaines. In passing it may be remarked
that these observers allow bacteria to play a
closely similar role in nephritis as it occurs in
men and non-gravid women. For the present,
however, the cases are too few in number and
the facts altogether too meager to admit of gen-
eralization. But enough has been learned to
stimulate research, to necessitate more exact ana-
tomical diagnosis, to compel more thorough
chemical examination of the fluids of the living
and of the dead body, and, finally, the claims of
the bacteriologist demand closest attention.

PHYSIOLOGICAL DIFFICULTIES AT THE CLARK
UNIVERSITY.

From the Worcester Gazette ys^ learn that the
curators of the Clark University have encount-
ered unforeseen diESculties in the way of obtain-
ing physiological and other trained teachers from
German universities. The curators had desired
to secure certain young Germans, highly trained
according to the modern methods, who would be
willing for a limited luimber of years to teach at
the new university, in the expectation that the
way would be left open for these men to return
to their home university without detriment to
their future at the institution of their choice.

There was no paucity of such young profes-
sors who were willing to come to America tem-
porarily to teach at Worcester and other places,
but the governing powers at their universities, as
a rule, declined to look favorably upon such tem-
porary absences. They have declined to grant
any such furloughs. .\ few of those German in-
structors may come over, but it will be virtual to
an expatriation or exmatriation from their home
institutions.

It would seem reasonable, from our American
point of view, to expect that some German uni-
versit)' would seize upon the opportunity' as an
opening for the extension of its influence, as if
invited to establish a colonial graft of the
higer methods of learning, but no, they
are content in themselves, and have nothing
to spare to others at a distance. It would
seem as if the liberalizing tendencies of the pres-
ent day had stopped short at the gates of the uni-
versities. But the American skirts are not clear,
and it will not comport with the existing condi-
tions of our statute books to proffer too much
criticism. Our laws have not been so framed
that we can promise the v.armest kind of welcome
to educators who maj- decide to come to our
shores. For who can promise the latter that
they will not have to run the gauntlet of the
alien- labor contract law? It is a hard saying,
but a fact, nevertheless, that here are two of the
most advanced of modern nations, conspiring to-
gether, for differing ends of polic)- or politics, to
put a stumbling-block in the way of the diffusion
of an advanced education. The.se policies of gov-
ernment are wrong and cannot persist : for if
there be no common ground between nations in
a question of education, there should be no com-
ity in any relation. Of all the people on the face
of the globe who should have a free passport to
come and go at their good pleasure, the scholarly
teacher and the teachable scholar are the ones
who should be favored. They, together with the
scientific explorer, should be accorded the fullest
international liberty and every degree of wel-
come. This experience of disappointment at the
Clark University merits the profession's atten-
tion, for the reason that medicine has much to ex-
pect from the preparations that have there been
made for the development of physiological and
psychological studies to an extent that has not been
reached at any other institution in this country.

1889.]

EDITORIAL NOTES.

563

In the interest of profound medical research, it is to
be hoped that this disappointment of the curators
will be only temporar3\

THE RUSH MONUMENT.

Our readers will find in the present number of
The Journal, under the head of "Domestic
Correspondence," a letter from Secretary At-
kinson calling the attention of the Secretaries of
the various medical societies in the United States
to the Resolution adopted b}' the Association at
its last annual meeting at Newport.

We sincerely hope that every society will re-
gard that communication as a personal appeal,
and that at once and everywhere efficient action
will be taken to secure at an early day the accom-
plishment of the desired result. Let the officers
of every medical organization interest themselves
in this matter, and be sure that their individual
work is well done.

Among the benefactors of mankind whose deeds
are worthy of special remembrance there are none
more conspicuous than are found in the medical
profession, and among the names of medical men,
there is no one which we more delight to honor
than the name of Benjamin Rush.

EDITORIAL NOTES.
HOME.
The Detroit Academy of Medicine. — The
following were elected officers for the ensuing
year at the annual meeting held last mouth :
President, Dr. Henry A. Cleland ; Vice-President,
Dr. F. C. Heath ; Secretary, Dr.Wm. B. Sprague ;
Treasurer, Dr. W. J. Cree.

Thk Price of Quinine has again fallen and,
consequently, the large holders thereof are suffer-
ing from an attack closely approximating ague.

Dr. D. D. Richardson, of Philadelphia, has
been elected Superintendent of the Diamond
State Insane Asylum, Farnhurst, Del.

The Meeting of the American Academy
ok Medicine. — The annual meeting of this med-
ical organization, of which Dr. Leartus Connor
is President and Dr. R. J. Dunglison is Secretary,
will convene in Chicago on November 13th and
14th. The academy is composed of men who
have been graduated from literary colleges, and
it has for one of its purposes the .securing of like

preliminary education by students previous to
their entrance upon the studj' of medicine. From
the well- known ability of its active members and
the number of valuable papers to be presented,
we may confidently anticipate a most interesting
meeting.

Dr. Thomas A. Davie, surgeon for the North-
ern Pacific Railroad Companj', died recently at
Tacoma of typhoid fever.

California State Medical Society. — The
Pacific Medical Jounial saj^s : It will be remem-
bered that at the last meeting of the State Medi-
cal Society it was enacted that one qualification
necessary for membership should be continuous
membership in the regular local medical societ)-.
This action has been widely discussed and most
favorably commented upon by the Eastern medi-
cal press. It is looked upon as a capital method
for cementing the profession, binding together
the various medical organizations and encourag-
ing them to work in harmony and effectually.

What Will You Do ? — The next three months
afford a favorable opportunity to enlarge the sub-
scription list of The Journal. It is within the
power of each of our readers to secure one new
subscriber. Every member of the American Med-
ical Association is a stockholder in The Journal
and, as such, should use every effort to increase
its circulation and influence. To those who will
get up clubs we will make special terms. Will
each of our readers write us, sending a list of
physicians to whom sample copies should be
sent? Be in earnest in this matter. The larger
subscription list we can obtain before the close of
the year, the better Journal we can give j^ou for
1890. What will !'(?« do ?

Special Notice. — The American Academy of
Medicine is endeavoring to make as complete a
list as possible of the Alumni of Literary Colleges
in the United States and Canada, who have re-
ceived the degree of M.D. All recipients of both
degrees, literary and medical, are requested to
forward their names at once to Dr. R. J. Dungli-
son, Secretar3% S14 N. i6th street, Philadelphia,
Pa.

The American Rhinological Association
closed its seventh annual session at Chicago last
week. The new officers elected are ; President,
Dr. A. G. Hobbs, Atlanta, Ga.; First Vice-Presi-

564

EDITORIAL NOTES.

[October 19,

dent, Dr. A. B. Thrasher, Cincinnati ; Second
Vice-President, Dr. E. R. Lewis, Indianapolis ;
Secretary' and Treasurer, Dr. R. S. Knode, Omaha; i
Librarian, Dr. John North, Toledo ; Member of'
Council, Dr. C. H. von Klein, Dayton, O.

FOREIGN. I

The great amphitheatre of the School of Med- !
icine at Paris was destroyed by fire last week. I

Dr. Lauder Briinton will pay a visit to India
to test the results of the Hyderabad Chloroform
Commission.

The German Dermatological Society will
hold its next annual meeting at Berlin in connec-
tion with the International Medical Congress.

Dr. Karl Frankel will fill the new chair of
Hygiene and Bacteriology in the University of
Konigsberg.

Queen's College, Birmingham. — A new the-
atre has been recently fitted up for lectures on med- 1
icine, etc., the former medical school being now
reserved for anatom}'.

An Anti-Vaccination Congress was recent-
h' held in Paris. The President, M. Boeus, a
Belgian, stated that small-pox is not so fatal as is
believed, also that the use of candles, instead of,
gas or lamps, which give a strong light, prevents [
small-pox patients from being marked.

The Depopulation of France is causing the
French legislators a great deal of anxiety. A
correspondent of the British Medical Journal sug-
gests that it would be wise to move for a strict
inquiry into French baby-farming, and adopt en-
ergetic measures to prevent the loss of infant life
attending this system.

The Admission of Women to the Belfast
Meuic.\l School. — The British Medical Journal
says : An application was recenth' made bj^ three
young ladies to the medical professors of the
Queen's College, Belfast, to have the medical
classes thrown open to women. The Arts cla.sses
of the College were opened to women some j'cars
ago with results in every way satisfactory, and we
understand that the above application has been
favorably entertained by the medical professors.
The next question will be the opening to women
of the medical practice of the various hospitals,
especially the chief teaching institution in Belfast,
the Royal Hospital. It is believed, however, that

no difficulty is likel}- to arise on this side. Ex-
perience has shown that young men and young
women can be taught conjointly at the bedside
without inconvenience.

Choler.a in Asiatic Turkey. — Bagdad and
Bussorah have, according to a correspondent of
the London Times, been visited by an epidemic
of cholera. The disease was first noticed in ob-
scure inland spots, whence it spread to the port
of Bussorah, near the head of the Gulf of Persia.
From the first, the Ottoman Government left noth-
ing undone in the wa}' of quarantine to prevent it
spreading up the Tigris, but all efforts proved un-
availing. At Bagdad a severe outbreak has oc-
curred, man)' dying daily ; in the absence of sj's-
tematic registration, it is impossible to sa^^ how
many.

Native Women in the Medical Schools
of India. — The Provincial Medical Journal says :
At the present moment there are some 200 native
women studying medicine in the medical schools
at Bombay, Calcutta, Lahore, Madras, Hyderabad
and Agra, which is the last one to open a class to
the sex. Some will take Indian University de-
grees, some will come here, or go to the Conti-
nental or the American schools, to earn.- their
education as far as possible, though the majoritj-
will never proceed further with their studies than
to be classified as " hospital assistants. " At the
outset of the movement it was difficult to find
Indian girls sufficientlj- bold to break through
the traditions of centuries, and come forward to
adopt the profession ; but now there is almost an
embarras du choix, and rigid supervision is exer-
cised in the selection of those only who are intellec-
tually and physically equal to the training. The
National Association now has eleven fully quali-
fied lady doctors practicing in various parts, and
of these five were trained in England and six in
India. It now onh^ permits ladies to designate
themselves " doctors " if their education has been
sufficient to permit them to be registered under
the Medical Acts in force here, and gives to less
highly qualified women the titles of "Female
Assistant Surgeon," or "Female Ho.spital As-
sistant." It is pleasant testimony to hear that
the strictly " unsectarian " scope of the National
Association did not prevent ladies of the various
medical and Zenana missions from giving it all
the help and counsel in their power.

1889.]

TOPICS OF THE WEEK.

565

TOPICS OF THE WEEK.

THE LATE SESSION OF THE NEW YORK STATE MEDICAL
ASSOCIATION.

I'nder the above heading we quote an editorial from
the Medical Record of October 5, as follows :

The recent session of this Association was character-
ized by an exceptionally large attendance, and much
manifest interest in the proceedings. The topics dis-
cussed made a home-like appeal to the general prac-
titioner, whose zeal is in the direction of the "first care;"
they were practical, well selected, exhaustive and
scholarly. Many new men, destined to make their mark,
surprised both themselves and others with the applause
gained by their ambitious endeavors and the results of
their work. There were some disappointments, owing
to the failure of a rather crowded programme and the ab-
sence of certain advertised participants, but, on the whole,
these drawbacks were more than compensated for by the
eagerness of volunteers to fill the gaps, so that there was
no real dearth of substantial material.

The set discussions on the collective-investigation
plan, which seem to have come to grief across the ocean,
were both satisfactory and successful. The themes se-
lected, such as "Tubal Pregnane}-," the "Treatment of
Hernia," and the "New Hypnotics," were timelv and
well treated. We may saj-, in fact, that they were ex-
ceedingly well handled, and so far as the detailed ques-
tions were concerned, assigned to those who were able
to speak by authority. There were very little crudities
of thought or looseness of statement, but, on the con-
trary, much honesty of investigation, some skeptical in-
terrogation, and a deal of logical candor.

Much as we have deplored the Code schism, we are
fain to acknowledge that, when families become too
large, the component individuals may gain in energy
and benefaction by separating for the purpose of house-
keeping on their own account ; at all events, in the pres-
ent instance, sympathy appears to drift somewhat
toward the young couple, especially when zeal and
honest endeavor go hand in hand. Certainly, if the
Association aim for influence and additions to our stock
of knowledge, not only the profession but the public at
large cannot fail to be benefited — the field is large, the
harvest ripe, and the laborers none too many.

THE HISTORY OF ORTHOPEDIC SURGERY IN AMERICA.

From the very able and interesting address of the
President, Dr. E. H. Bradford, delivered in Boston,
September 17, 1S89, at the third annual meeting of the
American Orthopedic Association, and reported in the
Boston Medical and Surgical Journal, we present the fol-
lowing :

The history of orthopedic surgery in America can
never be thoroughly written, as the earlier facilities for
presenting cases and recording methods were necessarily
imperfect in a new country. The earlier American bib-
liography, prior to i860, which, through the kindness of
Dr. Billings, has been copied for me from the catalogue

of the Army Medical Library, shows not only much that
is of interest, but indicates by what is implied as much
as by what is published, that much excellent work was
done which escapes the annalist.

The first triumph in orthopedic surgery in America is
the classical operation by Rhea Barton {North American
Medical and Surgical Journal, 1827, p. 279), the founder
of osteotomy for correction of deformity, as McDowell is
the founder of ovariotomj'.

Physick's Fixation Hip Splint, described in 1831 ;
Chase's paper on the " Treatment of Club Foot Without
Tenotomy " {American Journal oj Medical Sciences),
1841 ; Miitter's work on "Club Foot" in 1S45 — all indi-
cate the intelligent interest taken in the subject. Ex-
cision of the hip was first performed in this countrj- by
Dr. Wilcox, of Eastern Pennsylvania, as early as 1S49.

The stimulus of Stromeyer's achievements was quickly
felt in .\merica, and tenotomies were done bv Rogers
(1834), Dickson (1835) and Detmold (1837). To the lat-
ter belongs the credit of the first published tenotomy,
the tenotomies of the two former surgeons not havino-
been recorded. Detmold also acted ex cathedra, as it
were, for he was fresh from the teachings of Stromeyer.
The interest taken by general surgeons of the time in
orthopedic surgery is indicated by the remarks of Valen-
tine Mott, as quoted by Miitter, of Philadelphia, and by
the well-known work on " Orthopedic Surgery," by Dr.
Henry J. Bigelow, published in 1845, and which to-day is
a model of excellence, and one of the best of publica-
tions to illustrate the French school of orthopedic sur-
gery, the dominant school of the time. . . . Speakinty of
the history of orthopedic surgery in New England he
saj'S :

Dr. Buckminster Brown has been kind enough to
write for me the following outline of the history of ortho-
pedic surgery in New England, which I quote in full :

" The history of orthopedic surgery in New England
commenced in 1838, when Dr. John Ball Brown, of Bos-
ton, treated nine cases of spinal disease and curvature.
Dr. Brown was for several years associate surgeon with
Dr. John C. Warren, and afterwards consulting surgeon
at the Massachusetts General Hospital. For some years
previous to the above date he had given much attention
to this class of complaints. In 1839 Dr. Brown received
from Paris a copy of a publication of M. Bouvier, in
which he describes the operation for the section of ten-
dons in club foot ilevised by Delpech, together with the
introduction by Stromeyer of subcutaneous tenotomy,
his own (M. Bouvier'si modification of this method. He
also received at the same time the apparatus employed
in the after-treatment. Dr. Brown at once decided to
perform this operation and to pursue the method of
treatment described.

"On February 21, 1839, he did the operation on a little
girl 4 or 5 years of age, who had talipes varus. The
treatment was successful. So far as was known to Dr.
Brown, this was the first time that subcutaneous tenoto-
my had been done in America. He afterwards learned
it had been done once previously by Dr. Detmold, of
New York. Dr. W. J. Little, of London, about this time
published his first work on "Club Foot and Analogous

566

TOPICS OF THE WEEK.

[October 19,

Distortions," and this was a great assistance to the
American pioneer.

" The various French treatises on this and kindred
■subjects by Guerin, Bouvier, Chassignac and others were
also welcome aid during the earlier years. He imported
from Europe various instruments and drawings of appa-
ratus, invented many and modified others.

" From the date above named Dr. Brown had an ex-
tensive experience in this branch of surgery, and his
reputation spread widely. Patients, not onlj- from the
neighboring States, but from the South and from the
West, and even from the Sandwich Islands, journeyed to
Boston for the purpose of being placed under his care.
In TS49 he opened, in a house hired for the purpose, a
small hospital for the treatment of orthopedic cases. Dr.
Brown continued in the practice of orthopedic surgery
until his death, which occurred in 1862.

" Dr. Brown's treatment of talipes was essentially
modelled on that of Little and Bouvier. In lateral cur-
vature he adopted, to a certain extent, the course pur-
sued by Jules Guerin, with modifications and improve-
ments of his own ; and in spinal caries fixation was the
point aimed at.

" In 1846 Dr. Buckminster Brown returned from
Europe, where he had followed the practice of Little,
Stromeyer, Guerin and others. He immediately com-
"menced practice in his profession, at first combining the
orthopedic branch with general practice, and finally con-
fining himself to the former. From this date to the
present, he has from time to time published some of the
results obtained from his practice and experience.

" In 1861 Dr. Buckminster Brown took charge of a
ward in the Samaritan Hospital, for treatment of de-
formities."

The Children's Hospital in Boston, opened in 1866,
though not an orthopedic institution, necessarily de-
manded treatment for cases of this sort, and has de-
veloped in this direction to such an extent that its or-
thopedic clinic may be said to be one of its most promi-
nent features.

The increase of interest in this branch of surgery is
■marked in a practical way by the foundation of special
hospitals. On May i, 1863, the Hospital for Ruptured
and Crippled, of New York, was opened by Dr. Knight,
and is now one of the largest hospitals of its kind iu ex-
istence. In 1866, an Orthopedic Dispensary was opened
in New York, by Dr. C. F. Taylor. In 1873 it was en-
larged into a hospital. Dr. C. F. Taylor was appointed
consulting physician, in 1868, to St. Luke's Hospital,
and in 1S72, Dr. Shaffer was ap])ointed visiting consult-
ing surgeon there. The interest in the treatment of de-
formities by Dr. J. K. Mitchell, of Philadelphia, was
active, and led to the establishment of an orthopedic
hospital in that city.

I,OC.\I, MKDICAI, .SOCIETIES.

We transcribe from the Atlanta Medical and Surgical
Journal for October the following editorial:

With the advent of cooler weather, the time has ar-
rived when medical societies all over the land are buck-
ling on the armor and preparing for their winter's work.

The hot months, relaxing alike to the mental and physi-
cal energies, have caused a cessation of society ■work for
a time. But now that the profession is settling down
once more to its regular labors, the demands of the local
medical societies upon the recognition and attention of
the medical man should not pass unheeded. It is to be
regretted that the advantages of such associations for uni-
ted professional work are not more fully recognized, or
if recognized, that such recognition is not more univer-
sally translated into practice. That medical societies are
the most potent instrumentalities for the advancement of
medical science is a fact that cannot be gainsaid bv any
observant man. A moment's thought will convince any
one that the best results that are obtained in this direc-
tion are almost invariably wrought out under the stimu-
lating influence of the contact of mind with mind. The
practitioner is thereby lifted out of the ruts into which
every one is so liable to fall when working by himself
alone, and he learns that there are other works of prac-
tice and other lines of thought outside of those to which
he has become accustomed. The tendency of society
work is to broaden a mau's views of medical matters, to
enlarge his field of vision, and thereby to make his dailv
practice more satisfactory to himself and more beneficial
to his patients.

These are facts which are too patent to admit of argu-
ment. Yet there are many men of good standing in the
profession who are never seen in the medical societj'.
Why this should be so it is difficult to understand. It is
true that the arduous duties of a large practice leave but
little leisure for anything else; yet the men who have
large practices are the very ones who will derive the most
benefit to themselves by occasionally stepping aside from
the practical application of their wide experience to com-
pare their views with those of other men, and to avoid
thereby the tendency to routine which is inseparable from
unremitting professional toil. Moreover, the social ele-
ment which always enters to a greater or lesser extent
into all societies is promotive of a friendly professional
feeling and a proper esprit de corps, which is apt to drop
out of sight altogether when every man is working on
his own independent schedule.

To the younger portion of the profession the value of
the medical society cannot be overestimated. There he
has the opportunity to avail himself of the experience
of older and ■«iser men and to learn lessons iu practice
which cannot be learned from the generalizations of his
text-books. Next to actual individual experience there
is no school so valuable to the young practitioner as the
medical society.

We would therefore urge upon our readers the desira-
bility of the formation and support of organizations of
this kind. In thinly settled districts two or more coun-
ties might advantageously unite and hold monthly meet-
ings at some accessible point. In the cities aiul larger
towns where societies already exist we would urge a more
general membership and a more frequent attendance of
meetings. The result of such a course would soon be
felt in an elevation of the tone of the profession, a pro-
motion of scientific and accurate medical knowledge, and
a belter ethical sjurit everywhere. Petty jealousies and
animosities would disappear, knowledge of medical sci-
ence would be promoted, and the profession would be
brought nearer to that plane which we all recognize as
alone worthv of a noble and lofty calling.

1889.]

PRACTICAL NOTES.

567

PRACTICAL NOTES.

SALICYLIC ACID IN MALIGNANT SCARLATINA.

Dr. Shakowski has administered salicylic
acid with the greatest success in 125 cases of
grave scarlatina occurring in children, the mor-
tality being reduced to 3'j per cent. Ordinarily
his method of administration was in the form of
a mixture consisting of one part of salicylic acid
to seventy-five parts of water and thirt}- parts of
syrup of orange peel, a teaspoonful of this being
given every hour during the day and every two
hours during the night. He writes that under
the influence of this remedy the temperature is
rapidly reduced, in certain cases, even at the end
of forty-eight hours, the temperature falling four
degrees. Habitually all traces of fever disappear
after the tenth day of the disease. Nevertheless,
the author advises to prolong the treatment for
some time longer than this in progressively de-
creasing doses, so as to avoid any danger of re-
lapse. Through the use of this remedy the au-
thor believes that he has avoided the most serious
complications of scarlatin'a, such as urceraia, ana-
sarca and diphtheria. He claims that this medi-
cation will only be ineffectual when given too
late — that is, after the fourth day of the disease,
or when there exists some grave chronic compli-
cation.— Revue mensuel des Mai de V Enfance. —
The Therapeutic Analyst.

white wax and water — to all others in compound-
ing prescriptions.

Salicylic acid maintains its reputation, and has
come to stay ; 3 per cent, in hair tonics where
there is an oilj' scalp; 10 to 20 per cent, in alco-
hol and water as an efficient parasiticide; a drachm
each of o.xide of zinc and salicylic acid to the oz.
of siarch, in checking e.Kcessive perspiration of
the a.xilla and feet ; these are among the uses of
salicylic acid.

Anthrarobin, in a 10 per cent, ointment, has a
marked effect upon psoriasis, without producing
inflammation or staining as much as chrj'sarobin.
Alkali baths increase its action.

Ten per cent, naphthol ointment has an increas-
ing reputation in scabies; menthol, in 5 to 15 per
cent., with a little alcohol and glycerin, is a most
serviceable antipruritic, and takes away the pain
of epilation ; campho phenique, i drachm to the
oz. of vaseline, often gives complete rest to an
intolerable itching. — Indiana Medical Journal.

SOME OF THE NEW SKIN REMEDIES.

BcLKLEY stated in his address as chairman of
the Section on Dermatology, at the Newport
meeting, that resorcin and ichthyol have not ful-
filled the expectations incited by Anno. They
are not indifferent, but their use is restricted. The
thorough and continuous use of a zinc ointment,
containing 20 grs. each of salicylic acid and ich-
thyol, produces excellent results in infantile ecze-
ma. Resorcin is a parasiticide, useful in ring-
worm, seborrhoeic eczema and psoriasis. It is
u^>efu! in acne (5 per cent, in alcohol and water)
to check the oily secretions. Too much is irrita-
ting and discolors the epidermis.

Lanolin has but limited uses also. It will not
do alone as a basis for ointments; 25 per cent.,
with other fats, keeps the skin soft and pliable.
It has been pushed by the trade, but is little used
by dermatologists.

The New York Dermatological Society has
taken strong action against making vaseline, cos-
moline, etc., the basis of ointments in the coming
revision of the Pharmacopoeia. They are good
for lubricants in scaly skin troubles, and to carry
carbolic acid as an antipruritic. Even albolene is
too soft for a protective, and Hebra's diachylon
ointment is still at the head. Bulkley prefers the
unguentum aquae rosse — almond oil, spermaceti,

A SIMPLE METHOD OF TREATING UMBILICAL
HERNIA IN INF.\NTS.

Dr. Walter Chrystie, Physician to the Chil-
dren's Dispensar)', University Hospital, writes to
the Medical Neics:

If the treatment of umbilical hernia in the ear-
lier weeks of infant life has proved as trouble-
some and annoying to others as to the writer,
this description of a simple and effective method
of treatment will not be out of place.

Agnew and others use a button of cork covered
with chamois skin, and held in place by a broad
strap of porous or rubber adhesive plaster encir-
cling the trunk. Elastic bands, pads fastened to
the binder, hard rubber spring trusses, and vari-
ous more complicated devices are also recom-
mended. Most of these methods I have used, all

I with discomfort to the child and unsatisfactory
results. Porous plaster invariably irritates the
skin, as does rubber adhesive plaster, and their
removal causes a paroxysm of crying when the
consequent straining is most undesirable. All
absorbent pads become malodorous from retained
perspiration, and are constantl)- moist from the
daily baths. Bands extending around the waist
interfere with respiration, peristalsis, and the de-

i velopment of the abdominal and lumbar muscles.

I Elastic bands are bj- far the worst in this respect.

! Pads fastened to the binder are constantly slip-
ping out of place. The same may be said of
trusses, which have the additional disadvantage
of hurting a child that is not handled carefully.

j An apparatus for successful treatment should

' be non absorbent, non-irritating, and of such ma-
terial that it will remain in place for at least a
week, notwithstanding daily bathing. It should

\ not interfere with peristalsis, respiration or devel-

jopment, and must be free from the possibility of

568

PRACTICAL NOTES.

[October iq,

hurting a carelessly handled child. Such requi-
sites are combined in the following device, which
differs slightl}', but in important particulars, from
others.

It consists of a hard-rubber, slightly oval,
plano-convex lens, with a greater diameter of 3
cm. and thickness of 6 or 7 mm. ; on the plane
surface are two small wire loops facing each
other at a distance of 2 cm. This is attached to
the center of an adhesive plaster strap, 2 cm.
wide, and long enough to embrace three-fourths
of the child's body, by thrusting the wire loop
through the plaster and a small safety-pin through
the loop. No plaster other than a reliable em-
plast. resin, of the Pharmacopoeia should be used.
In using, the hernia is reduced by the pressure
of the button, and the warmed plaster quickly ^
applied while the child is quiet. This will re-
tain its position for from one to three w.geks, un-
less considerable soap is used in the bath. When
removal is desired, a few moments' soaking with
soap and water will loosen it unnoticed by the
child. If redness of the skin is produced, the
cause will be found in the adulteration of the
plaster with turpentine or Burgundy pitch.

WHITE LEAD IN THE TREATMENT OF ERYSIPELAS.

(By E. Stl-\-ER, M.S., M.D., of Rawlins, W.
T.) — During the last four or five years I have
treated a number of cases of erysipelas with ordi-
nary white lead ground in oil, thinned to a proper
consistency with Japan dryer, and so prompt and
efficient has been its action that I desire to call
attention to its merits.

I have tried quite a number of the most highly
lauded remedies, including the combination of
sulphichthyolate of ammonium and lanolin, which
is claimed by many to be a .specific in this dis-
ease, but in my hands white lead paint has ex-
erted a more favorable influence than anything
else. It ver>- promptly relieves the burning pain
and feeling of tension which are so marked in
severe cases ; it limits the spread of the disease
process, and forms an impermeable covering over
the affected parts, thereby preventing the dissem-
ination of diseased particles. If this disease, as
is now generally admitted, be caused by patho-
genic microorganisms, this power of the treatment
to limit the spread of the disease germs should
lead to its more general adoption. — Medical News.

the incubation period in infectious DIS-
EASES.

Dr. James Finlayson {Glasgow Medical Jour-
nal, May, 1889), in preparing a code for the reg-
ulation of the school attendance of children ex-
posed to or affected by infectious diseases, found
that there was a decided diversity of opinion
among authorities ss to duration of the incuba-
tion period and as to the time 01 quarantine for

children that had been exposed. The incubation
period in scarlet fever is given as low as i day
and as high as 14 days, with an average duration
of quarantine from 10 to 14 days; measles, from

3 to 17 days — quarantine 16 days ; rotheln, from

4 to 21 days — quarantine from 16 to 21 days;
mumps, from 4 to 24 days — quarantine from 21
to 24 days ; whooping-cough, from 4 to 14 days
— quarantine from 16 to 21 days; chicken-pox,
from 2 to 18 days — quarantine from 18 to 21
days ; small-pox, 5 to ig da5'S — quarantine 16 to
18 da)-s ; diphtheria, i to 14 days — quarantine 10
to 1 2 days ; enteric fever, i to 30 days — quaran-
tine 28 days; typhus fever, i to 21 days — quaran-
tine 21 to 28 daj's ; erj-sipelas, i to 13 days —
quarantine 10 days. As in the United States
local ordinances involving this question require
the physician to furnish a certificate to the child,
the periods of quarantine above given may .serve
as precedents. — Neu- York Medical Journal .

TO STERILIZE MILK.

It is not necessary {Dietetic Gas.) to invest in
a sterilizing apparatus, as any housekeeper can
arrange one equally efficient for herself. All that
is necessary is to have some bottles, capable of
containing the milk to be used in a day ; each
large enough to contain what will be needed at
one time. These bottles and their corks should
be thoroughly cleansed by boiling in a solution
of washing soda. The corks should be selected,
and of the best variety. When the milk is brought
to the house it should be placed in these bottles,
which should be arranged on a wire frame in a
pot of water, and boiled for fifteen minutes. They
should then be corked securely and placed in the
refrigerator with the ice upon them, not under
them. In the country they may be lowered into
the well. Milk thus treated will not only keep
sweet and fresh, but almost anj^ impurity it may
originalh' contain will be rendered innocuous.
The flavor of boiled milk is unpleasant to many
persons ; but this may be remedied by the addi-
tion of a little coffee or cocoa. At any rate one
must not expect too much in this world, and for
the sake of safetj^ put up with the unpleasant
taste, or learn to like it. — T/ie Canada Lancet.

CASTOR OIL AS A MENSTRUUM FOR COCAINE.

Dr. S. Mitchell writes in the New York
Medical Record of the happy results following the
use of castor oil as a .solvent for cocaine. A pa-
tient had been attacked with herpes zoster, the
eye being much affected. Great pain was felt
from the hard cicatrix resulting from the healing
of a vesicle. Ca.stor oil was applied as a lubri-
cant, and the doctor then conceived the idea of
adding cocaine. A 5 per cent, solution was used,
by which the pain was relieved. Recovery was
rapid — Druggists' Circular.

1889.]

SOCIETY PROCEEDINGS.

569

SOCIETY PROCEEDINGS.

Medical Society of Virginia.

{Concluded from page S39-)
Dr. I. S. Stone, of Lincoln, read a paper giv-
ing an account of

SOME GYNECOLOGICAL WORK OF THE PAST YEAR

The author stated that his cases were treated in
his private sanatorium, where they could have
good surroundings, nursing, etc. Four cases of
abdominal section for tumor of the peritoneum
with cancer of transverse colon, salpingitis, chronic
peritonitis following salpingitis, and one Battey's
operation, were respectively reported. The speci-
mens shown (three in number) were characteristic
of the disease in question. Other cases of lacer-
ated cervix and perineum were alluded to briefly
but not separately reported. The author still ad-
vocates Emmet's operation for lacerated cervi.x,
but says he does not so frequently perform it as
before. One case of modified hysterorrhaphy was
mentioned in which Alexander's operation was
done on the left side and a partial hysterorrhaph)'
on the other. It was ascertained that many
minor disorders, not surgical, were to be success-
fully treated by massage, electricity and over-
feeding known as the Weir-Mitchell method.
The author has had several years of experience
in treating these ca.ses, and justlj' claims that a
verj" large percentum of cases come under this
heading. Electricity was not spoken of at length,
but enough was said to show some skepticism in
regard to its value in all save in nerve compli-
cations.

Dr. John W. Scott, of Gordonsville, Va., was
the reporter on

PR.^CTICE OF MEDICINE.

After reviewing much of the germ theory as
causative of a number of diseases, he concludes
that we must look to local sanitary improvements
rather than to quarantine alone for the prevention
of epidemics, such as Asiatic cholera, yellow fever,
etc. Gibier maintains that the bacillus of yellow
fever closely resembles that of cholera. During
the year ending Ma}^ i, 1889, Pasteur treated
1,673 persons bitten presumably by rabid dogs, I
and lost only three b}- hydrophobia after the con-
clusion of the treatment ; six died during treat '
ment, and four dev-eloped the di.sease a fortnight
after leaving the institution. The microbe of
typhoid fever is the bacillus of Ebertb and GafF-
kj'. It is of tenacious vitality, and may live for
months in decomposing faecal matter, increasing
in numbers at a temperature of 62.5° F. Drs.
Kalb and Bartlett claim {Brit. Med. Jour., Jan.
5, 1889) what is next to an abortive treatment of
typhoid fever by mercurial inunction. This treat-
ment must be commenced before the ninth or

tenth day. Cold baths are being again advocated.
Ehrlich's diagnostic sign of enteric fever — reac-
tion in the urine with one of the aniline deriva-
tives— has been verified by Dr. Taylor (Lancet,
Maj^ 4, 1889). Tuberculosis is a specific infec-
tious di,sease, the constitutional manifestations of
which are secondary to the bacilli, and due to
toxic influences evolved during their increase of
growth and number. The number of the bacilli
in the sputa bears no relation to the progress of
the disease. The dry sputa is chiefly concerned
in the propagation of the disease. The disease
can be transmitted only through the medium of
Koch's bacillus. It is not in the ordinary sense
hereditary. The presence of the bacillus in the
sputa is of positive value, but not of negative
value in diagnosis. A rational prophylaxis is
practicable, and we must still look more to pre-
vention than to cure of tuberculosis, as no non-
injurious antiseptic has yet been brought forth
successfully. The infectiousness of scarlet fever
suddenly decreases about the sixth day and in-
creases again about the twelfth, reaching its max-
imum by the sixteenth. The telluric origin of
tetanus is gaining advocates. The disease may
be produced by inoculation with earth which has
recenth' been in contact with organic matter.
The treatment of locomotor ataxia bj' suspension
is approved, but with the injunction to be cau-
tious in watching the effect on the patient during
the operation of suspension itself No case of
Pott's paralysis ought to be regarded as desperate
until after failure of suspension. Weil's disease
is due to septic poisoning, and hence it is pro-
posed to call it septic or infectious icterus. Dr.
Scott's observations on the treatment of whoop-
ing cough by inhalations of the oil of eucalyptus,
is beneficial in shortening the length and in ame-
liorating the severit}' of the paroxysnis, and in
prolonging the intervals between the spells. His
method was to pour from one to two drachms of
the oil on .sponges, and suspend several of them
during the day from convenient places in the
room ; at night, from the head of the bed, so as
to let the oil be constantly inhaled. A number
of abuses of hygienic rules were mentioned, in
the hope of getting practitioners to properly in-
struct their patients with regard to them, such as
the common errors in our schools, the aversion of
wives to becoming mothers, etc.

Dr. a. Jacobi, of New York, read a paper on

ENTERALGIA .\ND CHRONIC PERITONITIS.

Enteralgia is always an irritation of a branch
or branches of the sympathetic nerve. Its cause
lies in the nerve or the intestinal tissues or its
contents. Hysteria, hypochondria, malaria, gout,
poisons, etc., may start the disea.se ; or the pain
may be reflected from spinal, liver, genito urinary
or skin disease, sudden chilling of the skin being
a frequent cause. The pathological changes are

570

SOCIETY PROCEEDINGS.

[October 19,

congestion or inflammation, with their results.
Acid food, certain drastics, hard scybal^e, fer-
menting foods, etc., are the common causes of
enteralgia. The attacks are indefinite in length
or suddenness. The temperature is rarely rai,sed ;
the pulse is irregular ; the skin becomes cold and
clammy; sometimes dysuria, nausea, vomiting,
constipation or diarrhcea occur. The tumiditj' of
the abdomen changes its place under palpation,
etc. Priapism and seminal discharges may occur
with spastic rise of the testicles.

A common cause of enteralgia, often overlooked,
is chronic peritonitis of secondary nature. New
abdominal formations, peritoneal adhesions,
swelled pelvic glands, etc., point to previous
peritonitis. Floating kidnej' may start peritoni-
tis, and thus become fixed in its dislocated posi-
tion. Vertebral disease, psoas and iliac abscesses,
hip-joint abscess, etc., may cause chronic peri-
tonitis, oftentimes not recognized except post-
mortem. Catarrhal "female diseases" are fre-
quent causes, as are violent cohabitation, the
puerperal state, etc. Biliary calculi, perinephri-
tis, splenic and pancreatic diseases, infantile in-
tus-susception, a preceding attack of peritonitis,
etc., are also causes Simple intestinal catarrh
grows speedily into enteritis. Peritonitis is like-
wise communicated to the muscular and mucous
tissues, and thus extends the oedematous infiltra-
tion, paralysis, and hence constipation. Thus
also diarrhoea, intestinal ulceration, without per-
foration, may cause local peritonitis. Diagnosis
of chronic peritonitis is not always easy. Respir-
ation need not be accelerated in pelvic peritonitis,
perimetritis and pericystitis. Vomiting is some-
times wanting ; diarrhcea is not infrequent, but
constipation is the rule ; the abdomen may be
tumid, and the horizontal position is often un-
comfortable. The seat of inflammation or adhe-
sion may sometimes be told by placing the patient
on his back, extend and then flex the extremi-
ties, and then use pressure, soft hard, sudden and
gradual. Often, however, it is best to make deep
pressure ; if no pain, relieve the pressure sudden-
ly ; when localized pain may be felt. Change of
position of the bowels may arouse pain ; sharp
pain, after full meal, may point to adhesions of
the stomach ; if pain occur three or four hours
after eating, look for chronic colitis ; if after
quickened inspiration, then peri-hepatitis, etc.
\'ariabilit)' of pain depends on degree of irrita-
tion or congestion. Extensive pelvic peritonitis
may not give pain except when waked up bj-
defecation, cohabitation, micturition, etc. In
peri-cystitis, when urine is about half voided, and
the bladder begins to contract, more efficiently, a
localized pain above the pubes, increased by press-
ure, develops much resembling the spasmodic
pain of vesical catarrh. I'latulence, etc., develop
enteralgia in chronic peritonitis. Stenosis of the
bowel, twisting, adhesions, etc., result, thus in-

terfering with the intestinal functions. In short,
the sequelae of chronic peritonitis are very various.
The indications of treatment of enteralgia of
chronic peritonitis are determined by its results
and symptoms, such as intestinal sluggishness,
adhesions, etc. Subacute and acute peritonitis
require absolute rest, support for the knees, ice
or hot applications according to circumstances,
opiates, etc. Some are now recommending large
doses of magnesia sulphate and turpentine ene-
mata ; but a treatment under which an occasional
patient may escape death must not supersede one
which has proven to be successful in most cases,
and beneficial in all. Localized attacks, mainly
in the right hypochondrium, demand local appli-
cations ; a few leeches occasionallj' and morphia
subcutaneously may be required. Old adhesions,
etc., are not amenable to medicines. Great phy-
sical exertion, pressure on abdomen, etc., must
be avoided. Keep bowels regular. Wear a snug
bandage over the whole abdomen for years after
the last complaint of pain. Generally this band-
age, held down by a perineal band, gives imme-
diate relief. Without the immobility given by
it to the sore intestine, he does not expect a case
of chronic peritonitis to do well.

Dr, John Ridlon, of New York, read a paper
on

SOME PRACTICAL POINTS IN THE TREATMENT OP

HIP DISEASE, WITH SPECIAL REFERENCE

TO THE USE OF THOMAS' SPLINT.

Only the mechanical treatment of hip disease
was considered, and that from the points of most
interest to the general practitioner of medicine
and surgery. The difficulties of obtaining, ap-
plying and satisfactorily caring for any of the
forms of traction apparatus were pointed out.
Plaster of Paris, when applied from ankle to ax-
illa, was considered as a comfortable and satisfac-
tory dressing, but not easy to apply to manj-
cases. Traction in bed by the ordinary Buck's
extension and weight and pulley was not to be
used except as a temporarj^ expedient. On the
other hand, traction after the manner of Howard
Marsh was ver}' useful in tho.se cases where trac-
tion was mdicated, and rest in bed not cdntra-
indicated. Thomas' splint would prove of great
service to those who were satisfied to treat tuber-
cular joint disease in any part of its course with-
out traction, to those who were so circumstanced
that they could not use traction in their walking
cases, and to those who believe that immobiliza-
tion, and not traction, is chiefly indicated in the
management of these cases. The splint can be
made by any blacksmith and harness maker, and
should not cost more than $2.50. Splints, pat-
tens and wrenches were shown, and their con-
struction, application and management explained.
It was urged that the splint should not be con-
sidered as essentially a walking splint, but that

1889.]

SOCIETY PROCEEDINGS.

571

it was of more service while the patient was still
confined to the recumbent position. With it the
patients are not necessarily confined to bed as is
the case when Marsh's method is employed.
When the involuntary muscular spasm has sub-
sided, patients are allowed to go about on
crutches and a high patten. When the disease
is believed to be cured, the crutches and patten
are dispensed with : after a few months the splint
is shortened up so as to allow of motion at the
knee, and thus worn for a few months longer.

Dr. Joseph A. White, of Richmond, Va.,
presented the

REPORT ON ADVANCES IN OPHTHALMOLOGY,
OTOLOGY AND LARYNGOLOGY.

He Stated that there had been no brilliant dis-
covery- and no new field of research opened up in
this line of work, while much had been done in a
quiet way to advance the diagnosis and treatment
of these special diseases. In ophthalmology, the
discussion on iridectomy in cataract extraction
would fill volumes — the tendency of most writ-
ings being a return to the "simple extraction."
In the opinion of the reporter, both simple ex-
traction and extraction with an iridectomy have
their application, and a surgeon cannot confine
himself to either. The after-treatment has also
been modified, and some writers even go so far as
to dispense with the commonest rules of conser-
vative surgery, allowing the person operated on
to walk about as usual, with the unprotected,
eye open and the other closed by a piece of plas-
ter. The reporter thought prudence would sug-
gest the same rest, quiet and surgical precautions
against failure, as in other surgical procedures.
In dctaclied retina. Prof Schoeler, of Berlin, has
reported cures from injections of tincture of
iodine, into the vitreous and sac, but as yet, no
method of treatment has proved satisfactorj-.
Transplantation of tlic cornea has been an experi
mental operation only, and with the exception of
one case of Von Hiepel's, which was a partial
success, all the attempts have proved failures,
and even the so called successful ones. In de-
fects of the ocular muscles, with or without re-
fractive errors, headache, eyeache, etc., can be
relieved by proper adjustment of the muscular
action of the two eyes by prisms or anatomy. Dr.
George Stevens, of New York, ascribes all kinds
of reflex nervous disturbances, such as chorea,
epilepsy, mental aberration, etc., as well as sick
headache, neuralgia, etc., to the nerve irritation,
resulting from imperfectly acting ocular muscles,
and reports numerous cases of cures by the opera-
tive correction of the defect. Time will demon-
strate the value of this view in regard to epilepsy,
mental trouble, etc., but the reporter thinks there
is no doubt of their correctness in regard to head-
ache, eyeache, etc., as he has had extremely fa-
vorable results in such cases by following Dr.

Steven's method of tenotomy, resection of the
recti muscles for their relief. Dr. Stevens in the
past year has presented an instrument called a
phorometer, which simplifies the determination
of muscular defects, and is valuable in the saving
of time and in producing greater accuracy-. In
his own experience the reporter finds that the
modified tenotomy of a contracted tendon and re-
section of its antagonist gives better results in
strabismus than the ordinary^ method of com-
plete tenotomy, giving more perfect motion and
a better chance for fine ocular vision.

In otology and laryngology, there is little to
report, beyond noticing the facts that the de-
pendency- of aural diseases upon nasal troubles is
becoming more generally recognized, and that
the treatment of nasal diseases is becoming more
strictly surgical — so-called catarrh being radically
relieved only by surgical measures and not by
local applications, which are only useful for
cleansing and antisepsis.

PRIMARY IRITIS — ITS DIAGNOSIS AND TREAT-
MENT,

was the title of a paper read by Dr. J. Herbert
Claiborne, Jr., of New York. After an ana-
tomical description of the iris and contiguous
parts, he remarked that it was important to re-
member that in a condition of health, the edge of
the pupil rested on the anterior surface of the
lens in moderate dilatation. The diagnosis was
to be made by the signs rather than the symp-
toms of the disease. The chief signs were peri-
corneal redness, steamy cornea, clouded aqueous,
discolored iris, small pupil, irregular and puck-
ered edges of the pupil, etc. Tenderness on pres-
sure in the ciliary region was the symptom indi-
cating a high stage of ciliary congestion, but not
necessarily of cyclitis. Treatment was com-
prised under the great "therapeutic trilogy,"
local depletion, dilatation of the pupil, and sys-
temic treatment. Local depletion was best ob-
tained by that leech that takes deepest hold, sucks
the longest and draws mo.st blood. Bleeding
should be encouraged by hot applications to the
bites. The position for the leeches was in the
temporal fossa, in a horizontal line with the
outer canthus of the eye, to drain the temporo-
malar branches of the lachrymal arteries. He
preferred to combine cocaine with mydriatics on
account of the greater mydriatic power of such
combination, and the analgesic effect of cocaine.
He preferred duboisin (i per cent.) combined
with cocaine (6 per cent.). With regard to sys-
temic medication, he uses blue ointment, salicy-
late of soda, iodide of potassium, the iodide com-
bined with bichloride or the biniodide of mercury,
antipyrin and Russian or Turkish baths, and
quinine for its general tonic effect. He laid
much stress on the value of salicylate of soda, es-
pecially in rheumatic iritis. It was also of great

572

SOCIETY PROCEEDINGS.

[October 19,

value in the specific forms of the disease, as as-
sisting the action of the other agents. There is
no need of opium or morphia in iritis. If the
pupil could be dilated, pain would cease ; if it
could not be antipyrin was a good substitute for
morphia. Too much stress could not be laid on
the importance of the early treatment of iritis
with regard to preserving the sight. The re-
sponsibility of treatment rests on him who sees
the case first.

Dr. Lewis G. Pedigo, of Roanoke, reported on

ADVANCES IN NEUROLOGY AND PSYCHOLOGY.

He regarded the development of the suspension
treatment of locomotor ataxia as the most import-
ant step of progress in neurologj' in the past
twelve months, and devoted considerable time to
the consideration of this subject. Other items of
progress in neurology were reviewed ; the prob-
lems of asylum management and general care
and treatment of the insane received due atten-
tion. A brief allusion was made to Stephen
Smith's project of a law for commitment and de-
tention of the insane. The present status of
various questions of medical jurisprudence w-as
presented at length. The latter part of the paper
was devoted to hypnotism and allied phenomena.
This part of the paper was illustrated by actual
experiments before the society on a subject who,
the doctor claims, is one of the very best and, in
some respects, most remarkable hypnotic subjects
in the world. He succeeded, bj' his own modi-
fication of the Bernheim and Charcot methods, in
throwing this subject into the hypnotic trance in
about one-third the time required by Bernheim
to hypnotize his very best subjects. La Petite
Hypnose and La Grand Hypnose (in its three
stages), as delineated bj' Charcot in Salpetriere,
were demonstrated in clear and rapid succession.

A paper by Dr. E. M. Magruder, of Char-
lottesville, Va., was presented, reporting two
cases of

NEURECTOMY FOR FACIAL NEURALGIA, WITH
RECOVERY.

His first case was a gentleman, aged 71, who
had the persi.stent neuralgia for fourteen years
that no medicine cured, although he had con-
sulted eminent specialists. Seven drops of fluid
extract of gelsemium every three hours gave
greater relief than anj' other medicine, except
morphia ; but all medicines failing, the patient
was chloroformed, and with strict antisepsis an
incision was begun below the lower orbital margin,
over the infra -obital foramen straight downwards,
parallel with the nose, towards the lip and end-
ing on a level with the lower border of the alae-
na.si — about an inch incision. The fascin and
fibres of the levator labii superioris were torn
through with the handle of the scalpel and the
ner\'e expo.sed at its exit, where it divided into
its branches. Each branch, the palpebral, the

nasal and the labial, spreading into a fan shape
as it neared its destination, was dissected out as
far as it could be followed without mutilating the
face too much. The main trunk was then seized
with forceps at the foramen, drawn out as far as
j po.ssible without breaking it, and cut off close to
the bone, after which the various branches were
divided at their farthest point of dissection. The
wound was closed with fine silk sutures. There
was at first considerable paralysis of the side of
the face and loss of sensation, but these disap-
peared except from the right half of the upper
lip, which is still without motion or sensation.
There has been no recurrence of the neuralgia.
The patient feels like a new man.

Case 2 was a lady, age 58, who has had facial
neuralgia for ten years. At first it was confined
to the left lower jaw, never passing the middle
line of the chin, but afterwards extended to the
left external ear, temple and side of the head
above and behind the ear (auriculo- temporal) to
the left side of the tongue (gustatory), and then
to the left side of the floor of the mouth (mylo-
hyoid). The diagnosis was neuralgia of the in-
ferior dental nerve, with reflex and sympathetic
phenomena exhibited by the auriculo temporal,
gustatorj- and mylo-hyoid nerves. As to treat-
ment, teeth had been extracted, analgesics had
been used, etc., and finall}' total neurectomy of
the inferior dental ner^'e, including its branches,
was done with cure. In the operation avoid in-
jury of the facial artery and Steno's duct. Enter-
ing the scalpel just in front of the posterior bor-
der of the ramus, just below the parotid duct and
lobe of the ear, a curvilinear incision was made
downwards, half an inch in front of the inferior
maxillary angle, then forwards a little above the
lower border of the ramus, and upwards just be-
hind, and avoiding the facial artery, stopping
short of the line of Steno's duct above. The flap
thus shaped was rai.sed by shaving the masseter
muscle from its attachment to the outer surface
of the ramus and the bone laid bare. With a
half inch trephine he cut out a button of the bone
from the center of the outer plate of the ramus,
exposing the ner\-e in its bony canal. Seizing
the proximal end of the nerve with forceps, strong
traction was made from the direction of its origin.
It was then cut off' with scissors close to the bone
as it entered the circular cavity made by the
trephine.- Then, the wound being stuffed with
moist anti.septic cotton and the haemorrhage
stopped with pressure, a second incision was
made, an inch long, horizontal in direction, over
the mental foramen (below the root of the second
bicuspid tooth), beneath the depres.sor anguli oris,
disclosing the mental nerve and its branches be-
neath the last named muscle. The nerve was
grasped with forceps and pulled upon, but broke
off" at its point of exit. The branches were then
di.ssected out and cut off as far as possible from

1889.

SOCIETY PROCEEDINGS.

573

the foramen. Then returning to the first wound often oxalate of lime crystals, and especiallj' pig-
over the ramus, and chiselling away the wall of ments in the urine. It gives a peculiar change
the dental canal, or one-eighth inch from the cir- in color to the urine during Pary's copper test
cular cavity in the ramus, so as to expose this fo" sugar. Diabetes indicates grave systemic dis-
end of the nerve, which had been divided by the , ease ; but it should be differentiated from hydruria
distal side of the trephine, it was drawn out of | and polyuria. Icteric urine stains white cloth
the dental canal with forceps in its entire length i yellow, but its diagnostic value is not of practical
from the ramus to the mental foramen. In all, ' use. In short, the value of urinalysis extends to
3-' 8 inches of nerve structure were removed. The , every disease characterized by pathological urine,
wounds were closed and the patient was perfectly as the Bright's disease, pyelitis, cystitis, etc.
relieved without any return of neuralgia since. Numerous urinalj-ses made by him tor physicians

had enabled the practitioner to determine their
diagnoses and oftentimes save the lives of pa-
tients.

Dr. a. F. Kerr, of Williamsville, Va., re-
ported a case of

EXTERNAL GL.\NDERS, OR F.A.RCY IN M.\N.

The paralysis of the left side of the face disap
peared in about two weeks.

The lesson learned is : In all operations for
facial neuralgia remove as much of the trouble-
some nerve and its branches as the anatomical
formation of the parts will possibly allow without
rendering the procedure too grave.

Dr. C. R. Cullen, of Waldo, Fla., read a The rarity of the di.sease, especially in mount-
paper on ainous regions justified, he thought, a note or
r.^ilroad injuries. two about the case. Glanders is an infectious

He reported eight cases of railroad accidents. ' '^'^f^^' principally of domesticated equine ani-
He urged that doctors not engaged in the service , ™^^^\ ^"^ communicated to other ammals, and to
of railroads insist upon the same compensation

man by inoculation of the glanders bacillus. It
when they are called upon for such service, that originates in solipeds, although it has been

IS received by doctors engaged in the railroad
service.

Dr. Hugh Bl.\ir, of Richmond, Va., read a
paper on

DIAGNOSIS BY MEANS OF URINARY ANALYSIS.

known to originate in cloven footed animals.
Having originated, infection occurs only for a
short distance through the atmosphere, or the
disease may be communicated through the inges-
tion of infected matter, or through the seminal
secretions to the female in coitus, etc. In man,
Harley says the state of the urine is a key to | the chief source of infection is the horse — it
the condition of the body. While some diseases ' being rarely communicated from man to man.
may not affect the urine, morbid urine indicates The point of attack is usually an abrasion upon
di.sease. Renal inadequacy (notable absence of the skin or mucous membrane. The incubative
urea and other solids), due to want of the neces period is from one to four daj^s in inoculated
,=ary nerve influence, is shown by the low specific , cases. The wound becomes tense, swollen, pain-

gravitj' of the urine, other causes being excluded
In overworked nervous systems, excess of alka-
line phosphates in the urine occurs. Probably
the nervous system is fed with phosphorus to

ful, with a dark or yellowish erysipelatous red-
ness, and the edges become puffy and everted.
A sanious matter i.ssues, and the surrounding
lymphatics become swollen and red, and the

licithin. The best way of supplying phosphorus ■ glands become enlarged and tender. Constitu-
to licithin is to give hypophosphites. If indiges-
tion and improper metabolism occurs, deleterious
matters accumulate in the blood ; if of nitrogen-
ous character, the kidneys excrete them, if they
are able. Destructive metamorphosis of albumin-
oids in the liver forms urea. Uric acid crystals,
easil}' recognized by the microscope, appear in

tional disorder acts in a few days — languor, ex-
treme weakness and prostration, with aching in
the limbs and head, rigors alternating with fever,
or a continued fever after the first violent chill :
sometimes there is nausea and vomiting, and
even diarrhoea. When not due to external inoc-
ulation, the febrile symptoms appear first, and

the urine in some functional hepatic disorders 1 then the other conditions, which have been noted

and lesions, causing gout, chronic 1 ephritis, renal
calculi, etc. If the crystals do not appear, excess
of urates, acid urine, with high specific gravity

first in the description of cases due to external
inoculation. The phlegmonous swellings along
the lymphatics become abscesses, and discharge

are present. Litlurmia (uric acid in the blood) j small quantities of a thick slimy pus. The re-
sulting sores become ulcerous with grayish base.
Temperature rises perhaps to 104°.

His case was a young healthy man in 1886.
He contracted glanders from treating a mare sup-
posed to have "greased heel" or " scratclies."
He first noticed a painful swelling on the point
of the second finger of the left hand, which had

is a chronic condition of the overworked and
over -anxious, is not so serious as gout, but is
ever active in causing obscure and distressing
symptoms. It points to chronic functional dis-
turbance of the jrortal circulation, and is recog-
nized by the high .specific gravity of the urine,
its acidity, excess of lithates and phosphates, and

574

SOCIETY PROCEEDINGS.

[October 19

been slightly cut with a pen knife. The swell-
ing was yellowish, edges of wound everted and
puffy, and discharged a thin sanious material ;
the surrounding lymphatics became enlarged and
all the fulness of the history' of glanders in man
was complete. Treatment began with a brisk
purge, followed by quinia and muriated tinc-
ture of iron, and an exclusive milk diet.
The swellings on the forearm were freelj' laid
open and cauterized with nitrate of silver, all
diseased tissues removed, and the resulting sores
packed with iodoform, over which was laid medi-
cated jute. Subsequent washings were made
with carbolized water. Recovery was prompt.

Dr. W. W. Parker, of Richmond, Va., read
a paper on

A FEW ORIGINAL OBSERVATIONS ON BLOOD GRAV-
ITATION IN HEALTH AND DISEASE.

of which the following is a synopsis :

I. The first wound ever inflicted upon the
human body was probably upon one of the ex-
tremities, and the relief following the elevation
of the wounded member was the first illustration
of blood gravitation in disease. 2. A case re-
ported of the wonderful curative power of ele-
vating the leg at 80°, of a boy struck in the tibia
by a base-ball. 3. A singiilar case of death from
the application of a mustard- plaster to the ankle,
being an exception to the rule, yet establishing
it. 4. The gravitation of blood in the stomach
made useful in preventing emesis in certain cases.
5. A remarkable case of acute inflammation of
the neck of the bladder, in a woman, with reten-
tion of urine, at once removed by the forcible
elevation of the hips of the patient. Other cases
reported. 6. The avoidance of varicose veins
of the legs in shop- keeping men and women by
sleeping on a double inclined plane ; and the im-
portance of those predisposed to apoplexy, sleep-
ing with the head well elevated. 7. The effect
of the position of the body in phthisis, in liver
and other congestions. A case of an infant with
suffocating catarrh at once relieved by the eleva-
tion of the head and chest. 8. A beautiful illus-
tration found especially in the herbivorous or
grazing animal of nature's plan of counteracting
the hurtful gravitation of blood to the brain, q.
A lesson suggested from these considerations and
facts to those unwise doctors and deluded people,
who think "a man cannot die till his time
comes." That mechanical law in the body is as
inflexible as the same law in the machine, and
loss and ultimate destruction will come as certainly
from neglect of these laws, to the one as to the
other.

Dr. A. C. Palmer, of Norfolk, Va., prepared
a paper oil

OUTLINE TESTS EOR MUSCULAR INSUEEICIENCIES
OF THE EYE, WITH REPORT OF A CASK.

Leaving out of consideration cases of strabis-

mus, etc., he confined attention to the more
minute forms of insufficiencies, known by the
term heteroplwria. In strabismus one eye soon
accustoms itself to see the object looked at, while
the other is idle as to effort at vision ; but in
heterophoria there is acute normal vision, in
which every detail of an object is seen, but the
external rectus of one or both eyes is just too
weak to prevent the internus rectus muscle from
turning the ball in, just past the normal axis.
Eyes such as these have to swing a very little
way to make the image seen with one eye a little
to one side of that seen with the other, and the
confusion resulting- is all the worse from the very
fact that each eye sees so clearly that neither
image can be ignored. The patient has before
him two similar images which are continually
receding from and blending with one another;
but he will involuntarily overcome this blurring
of outlines if he can possibly spur up the externus
muscle to pull the eye out to its proper place.
Just these insulficieucies or strains produce more
mischief than true strabismus. Heterophoria is
subdivided into esophoria (eyes tend to turn in
too far), exophoria (tend to turn out too far), and
hyperphoria (where one eye swings on a higher
level than its fellow). Prisms deflect an image
towards their apices or their edges. The relative
strength of each of the four recti muscles, in their
normal conditions, are first presumed to be ascer-
tained. Thus the externi should diverge the
eyes sufficiently to make the image single when
prisms of 8° are placed before them with their
bases in. The interni, after a little trj'ing, should
converge sufficiently to single images when
prisms of 50° are placed before them, bases out.
If a patient with neurasthenia presents, place
him in an erect position and direct his vision on
a lighted candle, 20 feet off"; then cover each eye
alternately and notice whether the light moves
up or down, or to the right or left. This paralax
test, introduced by Dr. Alexander Duane, of New
York City, often establishes at once the form of
insuificiency ; but should it not do so, then use
the prism tests, which the paper describes in de-
tail. Dr. Palmer then explained the application
of glasses to overcome each of the insufficiencies.
Dr. D. Mayer, of Charleston, W. Va., read a
paper on the

USE AND ABUSE OF OBSTETRIC FORCEPS.

He showed that when the forceps are properly
used they are not damaging ; that harm may
come when used too late ; that the time has ar-
rived in obstetric advances when the practitioner
will be compelled to use them, because intelligent
women demand their application to shorten their
period of suffering.

Dr. L. B. Anderson, of Norfolk, \'a., pre-
sented the Report on Hygiene and Public Health,
in which he classed the etiological factors into

1889.]

DOMESTIC CORRESPONDENCE.

575

(i) those which are known, (2) those which are
purelj^ hj-pothetical and chimerical, such as ma-
laria, vegetable parasites, bacteria, etc., (3) those
that are partly demonstrable and partly hypo-
thetical, namel}- ptomaines and leucomaines, from
which sanitarj' laws are deduced.

Dr. J. G. Wiltshire, of Baltimore, Md., read
a paper on Aiufsthctics, but retained his manu-
script for some revisions.

DOMESTIC CORRESPONDENCE.

LETTER FROM >rEW TORK.

(FROM OUR OWN CORRESPONDENT. J

Annual Meeting of the New York State Medical
Association — The PresidenV s Address on Tubal
Pregnancv— Laying the Corner Stone of the New
Buildijig for the Academy of Medicine.

The sixth annual meeting of the New York
State Medical Association, which was held at the
Hotel Brunswick, during the last week of Septem-
ber, was, like all its predecessors, successful and
interesting. The well arranged programme pre-
viously published was in the main faithfully' car-
ried out, and, as in former years, the chief features
of interest were the set discussions on topics of
scientific and practical value. This year there
were three of these discu.ssions, the first being on
" Tubal Pregnancy," and opened by the President
of the Association, Dr. Wm. T. Lusk ; the second
on "The Treatment of Hernia," and opened bj-
Dr. Joseph D. Bryant; and the third on "The
New Hypnotics : sulfonal, amyl hydrate, hydro-
bromate of hyoscin, hypnone, paraldehN-de and
urethran," and opened by Dr. Wm. H. Flint.

Among the most noteworthy separate papers
were the Address in Medicine, on "The Bacteri-
ological Test of Drinking-water," by Dr. Edward
K. Dunham, which was a contribution of the
highest scientific merit, and a paper by Dr. H.
D. Didama, of Syracuse, entitled " A Few Fads,"
which was extremely full of the wit and dry hu-
mor so characteristic of its accomplished and ge-
nial author. A case of exceptional interest was
also presented by Dr. Lewis Hall Sayre ; this
being one in which, for the first time on record, a
patient has been enabled to wear an artificial limb
after amputation at the hip-joint. The operation
was performed (b}' Dr. Reginald Sayre) for bone
disease (moUities ossium), in such a way that
flaps were left with a sufficient amount of the
muscles of the thigh to secure a certain amount
of "grip" for the artificial leg; and there can
be little doubt that the case inaugurates a new
era in hip-joint amputations.

In the limits of this correspondence it is mani-
festly impossible to give even a satisfactory out-
line of the work accomplished at the three days'

session of the Association, and the remaining
space at disposal for this .subject will therefore be
devoted to a brief consideration of the able and
brilliant address of the President on "Tubal
Pregnane}';" which, however, can afibrd but a
ver\- inadequate idea of its exhaustive character.

Dr. Lusk first reported two cases of tubal preg-
nancy of his own in which laparotomy was per-
formed after rupture. In the first complete re-
covery followed and since the operation the patient
has enjoyed better health than at any time previ-
ous in her life. In the second case the patient
was affected with Bright's disease, and died from
this cause on the eighth day after the operation.
These two cases, he said, illustrated the ordinarj'
histon.- of tubal pregnane}'. In both, without an-
tecedent symptoms at an early period of gestation
rupture with haemorrhage took place ; in the one
instance the blood primarily making its way be-
tween the folds of the broad ligament, in the
other passing suddenly, without check, directly
into the peritoneal cavity. They were simply
additions to the long list already furnished by Mr.
Lawson Tait, upon which he had based his scheme
of ectopic gestation. In Mr. Tait's belief all cases
of extra-uterine pregnancy were ab initio of tubal
origin. He denied the possibility of a primary
abdominal pregnancy ; while the ovarian form he
regarded as possible, but not proven.

There was no question, Dr. Lusk said, as to the
utility of Mr. Tait's scheme. It was based upon
his exceptional personal experience and had re-
ceived substantial support from the obser\'ations
of others. It had stimulated active inquiry and
given proper direction to pathological study ; but
the subject was .still too new to make it possible
for any scheme to be regarded as a finality. The
most interesting outcome of Mr. Tait's work had
been the change of view as regards the existence
of primar}' abdominal pregnancy, and there was
at present a very general agreement that the re-
ported cases are at least open to grave suspicion.

In regard to the etiology of tubal pregnancy,
Mr. Tait was unquestionabh- right in insisting
upon the importance of the various forms of sal-
pingitis. Owing to the associated loss of epithe-
lium, the dilatation and other changes in the tube
walls, the two active forces which propel the ovum
through the tube, viz.: the ciliated movements
and peristalsis, were weakened or destroyed, while
free ingress was afforded to the spermatozoa. Or,
again, the passage of the ovum might be inter-
fered with by the secondary results of catarrhal
inflammation, such as the production of mucous
polypi, of adhesions, or of sac-like dilatations.
Formerl}- great stress was laid upon the etiologi-
cal importance of flexions and constrictions re-
sulting from old peritoneal adhesions and inflam-
matory bands ; but, curiously enough, in recent
laparotomies for tubal rupture this cause had not
played an important part. Recent obser\'ations

576

DOMESTIC CORRESPONDENCE.

[October 19,

liad also shown that there is a tendencj' of tubal
pregnancy to recur.

The burning question at this moment connected
with tubal pregnancy was that of early diagnosis.
Dr. H. J. Hanks had recently stated his belief
that a diagnosis can be made in 95 per cent, of
the cases we are called upon to attend, Mr. Tait,
on the other hand, thought "he might be excused
for maintaining a somewhat skeptical attitude con-
cerning the correctness of diagnosis of those gen-
tlemen who speak of making a certain diagnosis
before the period of rupture." In the main, Dr.
Lusk said, our dependence must be upon local
symptoms and local changes. The former con-
sisted of the suspension of the menses, often fol-
lowed, after a brief period, by bloody discharge,
of paroxysmal pains, and of the discharge of the
decidua. But the latter was by no means of con-
stant occurrence, while paroxysmal pains were
frequent in other forms of tubal disease, and men-
strual disturbances were common phenomena in
uterine derangements. As a matter of fact, the
occasion for diagnosis must be very exceptional
in the large class in which rupture occurs prima-
rily within the peritoneal cavity. In the intra-
ligamentous form the case was somewhat different.
Here the swelling to the side of the uterus was
easily reached through the vagina, and he be-
lieved in such cases that the chances of error were
slight. He did not understand Mr. Tait to deny
the possibilities of a diagnosis under such condi-
tions. He differed only in regarding all intra-
ligamentous cases as secondary to tubal rupture.
Not much dependence was to be placed upon
uterine changes in the early months ; but after
the third month it was not ordinarily difficult to
determine the existence of the pregnant state. The
distinction of physical signs between the tubal,
the ovarian and the secondary abdominal form
was scarcely practicable so long as trained anato-
mists failed to agree concerning them when the
abdomen has been opened and the organs exposed
to view.

A review of the subject of diagnosis made it
apparent that many cases of ectopic gestation pre-
sent no symptoms previous to rupture. In an-
other class the existence of a suspicious tumor
with few or none of the corroborative signs should
lead to a waiting policy, or, when the .symptoms
were of a threatening character, to an explorative
laparotomy. Upon the fact that in favorable cases
certainty of diagnosis is attainable in the early
stages of ectopic pregnancy rested the entire ar-
gument as to the validity of the treatment by
means of electricity. The only argument against
this treatment, except that the results reported
carried with them the evidences of ignorance and
folly, was that it is likely to cause rupture and
that the retained ovum is liable to excite suppu-
ration. But these eventualities were so rare that
they might be left in case of need to a subsequent

laparotomy. It should be understood that this
means of treatment was only available in the first
three months, and that no one in this country, as
was commonlj' assumed by foreign critics, advo-
cates electro-puncture.

The argument in favor of the early use of gal-
vanism did not in the slightest degree impair the
value of laparotomy, which must always remain
our most important therapeutical resource. Lap-
arotomy not only possessed the advantage of
being the one measure for the treatment of cases
where, as in rupture, death is the common alter-
native, but it enriched our resources in cases of
impending danger. Unlike the employment of
galvanism, it presupposed the equipment neces-
sary for laparotomy and the skill that comes from
experience. It possessed this advantage : it leaves
nothing to chance. All the possibilities are under
the control of human intelligence; and, except for
the question of ethics, it was available both before
and after rupture. The late results with this pro-
cedure left little reason to doubt that when the
anatomical conditions come to be properly realized
human invention will find means to control the
dangers of the so- called primary operation for
extra-uterine pregnancy, and it too will find its
place in the domain of legitimate surgen,-.

The corner-stone of the new building of the
New York Academy of Medicine was laid in the
presence of a large assemblage of physicians and
distinguished men of other professions by the
President of the Academy, Dr. Alfred L. Loomis,
on the afternoon of October 2. On this occasion
the invocation was by Bishop Potter and the prin-
cipal address by Dr. A. Jacobi, ex-President of
the Academy. The feature of chief interest,
however, was an address by ex- President Grover
Cleveland, who followed Dr. Jacobi, and this was
delivered with that clearness, dignity and grace
so characteristic of his public speeches. In the
course of it he said: "To the members of this
organization the corner-stone which we now lay
is an honor, for it is a monument which marks an
important advance in the attainment of the pur-
pose of the Academy as declared in its constitu-
tion, ' the promotion of the science and art of
medicine.' In these extensive foundations is al.so
found proof of the progressive ideas of these ear-
nest men and their constantly enlarging estimate
of what is necessary to meet the purposes to which

their energy is directed I am sure that you

are not inclined to ignore the aid you have re-
ceived in the project you have undertaken from
the laymen among your Fellows. Nor can you
forget that underlying all that you have done and
all that you have received are our free American
institutions, which encourage and give scope to
every worthy effort and which offer fitting rewards
for intelligent and well directed labor in every
condition of life. I hope that when we shall
celebrate here the discovery of our country we

1889.]

BOOK REVIEWS.

577

may point out on this spot, in your completed
building, a splendid monument of the progress
of our medical education, a monument which
shall not only prove to the stranger that our phy-
sicians are proud of their profession, but one which
shall also be a reminder that those who govern
within its walls to not forget in their devotion to
the science and art of medicine the other duties
of citizenship."

It did not perhaps occur to the illustrious
speaker how much more is done for the fostering
of scientific investigation by some of the "effete
monarchies of Europe ' ' than bj- the great and
glorious Government resulting from our free
American institutions. p. b. p.

Tlie Russli Monument Fund.

The attention of the secretaries of county med-
ical societies throughout the United States is
called to the resolution adopted at the meeting of
the American Medical Association at Newport,
" that one member of each county medical so-
ciety in the Union be appointed to solicit funds
for the Rush DIonumcnt,'" and they are requested,
at the next meeting of their several societies, to
ask that such a member be designated for this
purpose, and to send his name and address either
to the undersigned, or to Medical Director Albert
L. Gihon, U. S. N., Chairman of the Rush Monu-
ment Committee, U. S. Naval Hospital, Brook-
lyn, N. Y.

All subscriptions, however, should be remitted
directly to the Treasurer of the Rush Monument
Committee, Dr. DeWitt C. Patterson, 919 T
street, N,W., Washington, D. C.

WiLLi.^M B. Atkinson,
Permanent Secretarj' A. M. A.

1400 Piue street, Philadelphia, Pa.

Unii-siial Liength of Funis.

To the Editor: — I wish to report a case which,
althotigh by no means unique, is, nevertheless,
not without interest. I recently attended a young
woman, 22 years of age, in her first confinement.
She was of slight figure and weighed less than
100 pounds. The child (which was found to
weigh 9' J pounds) was born in a condition of
asphyxia livida. a condition produced by reason
of a coiling of the funis around the neck. There
were five of the.se coils, drawn very tight, not-
withstanding which circumstance there was an
abundance of slack left. The child was resusci-
tated without much difiiculty, and in half an
hour the placenta was delivered by Crede's
method. The latter was of unusual size, being
far larger than any other placenta I ever saw,
although, as usual in such cases, it was by no

means proportionately thick. When expelled it
was rolled up like a scroll. Following the third
stage of labor there was a very considerable flow
of blood, although the uterus contracted fairly
well. This, however, soon stopped after the re-
moval of a large quantity of clots from the vagina
and cervical canal. There was a very apparent
relation between the area of the placental inser-
tion and the amount of blood lost. The cord
measured 48 inches in length and was not espec-
ialh' attenuated. This length, although very
unusual, has no dotibt often been surpassed.
Schneider recorded a funis 120 inches in length
which made six turns around the child's neck ;
Bandelocque reported an instance in which a
cord of 59 inches had seven coils ; Mme. Wald-
wogel mentions a case in which there were eight
coils. Yours truly,

Junius C. Hoag, M.D.
Chicago, October 9, 1SS9.

BOOK REVIEWS.

Catalogue of Sharp & Smith, Importers,
Manufacturers, Wholesale and Retail
Dealers in Surgical Instruments and De-
formity Apparatus. Chicago, 1889; pp. 973.

This is a voluminous and excellent catalogue.
It is very complete and well illustrated. Its
arrangement is convenient. It is to be com-
mended among trade publications.

The Physician's Leisure Library, Series IV.

Syphilis of the Nervol's System, by H. C.

Wood, M.D., LL.D.; pp. 135. 1889. Detroit:

George S. Davis.

The medical public is always glad to hear from
one of its most honored exponents in this coun-
try. Dr. H. C.Wood, and if, therefore, an interest
be awakened by the announcement of a new
brochure bearing the above title, we can assure
our readers that they will find no cause for dis-
appointment in a perusal of the particular volume
in question. There are few physicians who are
in a position to speak more authoritatively upon
this subject than Dr. Wood, who has reached the
conclusions herein set forth from a study of 2,000
cases of nervous disorders as.sociated with syphi-
lis. Among the many points of interest made
bj' the author is this one : That there is a syphi-
litic insanity which exists without obvious
meningeal disease, and is capable of being cured
by antisyphilitic treatment, in support of which
view a table of illustrative cases is given with
regard to the method of antisyphilitic treatment
by the hypodermic injection of the insoluble salts-
of mercury, a method which has been greatly
praised by some European physicians. The

578

MISCELLANY.

[October 19, 1889.

author finds that the dangers of local inflamma-
tion are so great as to overbalance any special
advantage which might thereby be gained. His
first experience in its use resulted so unfortunately
as to discourage its further employment.

MISCELLANY.

The McLean County (III.) Medical Society met
iu the regular session at the office of Dr. C. J. Corley,
October 7, at t, p.m. There were present Drs. H. Park-
hurst, M. Wifson, Wm. Hill, N. F. Jordan, F. J. Park-
hurst, C. J. Corley, S. T. Anderson, C. C. Sater, A. L.
Chapman, F. C. Vander\-oort and M. D. Hull. Dr. C. E.
Ballard, of Saybrook, was elected to membership. Dr.
Wm. Hill w^s elected to fill the vacancy on the Board of
Censors. Dr. F. J. Parkhurst's essay on " Electricity as
a Therapeutical Agency " was very interesting, his ex-
planation of the different kinds of instruments used
showed him to be a man well versed in scientific princi-
ples. A vote of thanks was tendered the doctor for the
excellence of his paper. Dr. D. A. White's essaj- on
" Scarlatina" was attentively listened to by all present.
Drs. M. D. Hull and William Hill were appointed essay-
ists for the December meeting. The Society adjourned
to meet the first Mondav in November.

LETTERS RECEIVED.

Dr. H. Bart Ellis, Los Angeles, Cal., Dr. C. W. Irion,
Rocky Mount, La.; The Subscription News Co.. Chica-
go: Dr. F. E. McKim, IMarietta, O. ; Dr. Wm. Pepper,
Philadelphia; Dr. C. N. Boyd, Butler, Pa.; Dr. G. H.
Grant, Richmond, Ind. ; Syracuse College of Medicine,
Svracuse, N. Y. ; Fairchild Bros. & Foster, New York;
DV. C. S. Pi.xley, Elkhart, Ind.; Publishers' Commercial
Union, Chicago; David Grove, Berlin, Germany; Dr. A.
L. Hummel, Philadelphia; Dr. B. Corbeau, Civet, France;
Dr. .\. P. Brown, Fort Worth, Tex.; Dr. G. H. Eiskamp,
Washington ; Dr. James L. Tavlor, Wheelersburg, O. ; Dr.
T. Delafield, New York; Dr. Chas. W. Dulles, Philadel-
phia; The American and Continental Sanitas Co., New
York; Dr. John O. Roe, Rochester, N. Y.; O. V. Dubia,
Chicago; Dr. J. H. Bryan, Washington; John N. Paton,
Chicago; The Postmaster, Minneapolis, Minn.; Dr. Eu-
gene Grissom. Raleigh, N. C; George Tiemann & Co.,
New York; Lea Bros. & Co., Philadelphia; D. Appleton
& Co., New York; Keystone Watch Co., Philadelphia;
J. H. Bates, New York; Dr. James Tyson, Philadelphia;
Dr. J. k. Borackv, Alma Centre, Wis. ; Medical and Sur-
gical Sanitarium', Battle Creek, Mich.; Dr. G. S. Hall,
Worcester, Mass.; Dr. D. C. Stillians, Chicago; Horlick
Food Co., Racine, Wis.; Dr. Wm. Creighton Woodward,
Philadelphia; Popular Science News Co., Boston; Dr. F.
E. Waxhara, Chicago; Dr. M. A. Bogie, Kansas City,
Mo.; J. H. Chambers cS: Co., St. Louis, JIo.; Dr. R. J.
Dunglison, Philadelphia; Dr. Freudenthal, I. Halden-
stein. New York; Dr. Henry O. Marcy, Boston; Dr. S. C.
Newlin, New Salem, Ind.; Dr. Llewellyn Eliot, Washing-
ton; Ensworth Medical College, St. Joseph, Mo.; Mellier
Drug Co., St. Louis, Mo.; J. B. Lippincott & Co., Phila
delphia; Parke, Davis & Co., Detroit, Mich.; Dr. D. Du
Pr6, Dallas, Tex.; Dr. C. F. Disen, Minneapolis, Minn.
Dr. Wm. Brodie, Detroit, Mich.; The Postmaster, Morti-
mer, Kan.; John Wananiaker, Philadelphia; Dr. H. R.
Storer, Newport, R. I.; College of Physicians and Sur-
geons, Baltimore, Md.; Charles H. Phillips Chemical Co.,
New 'Vork; Dr. E. E. Montgomery, Philadelphia; Dr. M.

Stamm, Fremont, O. ; Dr. J. W. Gleitsmann, New Y'ork;
Dr. M. P. Hatfield, Dr. Jno. A. Robison, Chicago: The
Parmenter Printing Co., Lima, O. ; Rush Medical Col-
lege, Chicago; Dr. Joseph Hoffman, Philadelphia.

Official List of Changes in the Stations and Duties of
Officers Serving in the Medical Department, U. S.
Army, from October 5, i88g, to October 11, i88g.

Lieut.-Col. .\. K. Smth. Surgeon U. S. Army, leave of
absence extended twenty-one days on surgeon's certifi-
cate of disability. Par./, S. O. 234, \. G. O., October
8, 18S9.

Capt. Edward C. Carter, Asst. Surgeon L^. S. .\rmy,
granted leave of absence for twenty days. Par. 6, S.
O. 234, .\. G. O., October S, 18S9.

Capt. Benjamin Munday, .\sst. Surgeon U. S. .\rmy,
granted four months' leave of absence. Par. 2, S. O.
233, .\. G. O., October 7, 1S89.

Asst. Surgeon William P. Kendall, U. S. Army, granted
leave of absence for one mouth. S. O. 93, Dept. of the
Platte, October 2, 1SS9.

Surgeou Wm. S. Tremaine, U. S. .\rmy, relieved from
temporary duty at Ft. Leavenworth, Kan., and will
return to his home (Buffalo, N. Y.). Par. 13, S. O.
230, A. G. O., October 3, 1889.

Surgeon Benjamin F. Pope, U. S. .\rmy, relieved from
duty at Ft. Clark, Texas, and will report for duty to
commanding officer, Whipple Bks. , Ariz. Ter. Par. 11,
S. O. 230, A. G. O., October 3, 1S89.

Surgeon John S. Billings, U. S. Army, detailed as dele-
gate to represent the Medical Department of the Army
at the annual meeting of the .American Public Health
Association to be held at Brooklyn, N. Y., Octo'oer 22,
1SS9. Par. 10, S. O. 230, A. G. 6., October 3, 1SS9.

Official List of Changes in the Medical Corps of the L'. S.

Naxy for the Week Ending October 12, iSSg.
Surgeon G. h.. Bright, detached from temporary duty at
the Naval Academy and placed on waiting orders.

Official List of Changes of Stations and Duties of Medi-
cal Officers of the U. S. Marine-Hospital Service,
for the Six Weeks Ending October 5, jSSg.

Surgeon C. S. D. Fessenden, granted leave of absence for
thirty days. October 3, 18S9.

Surgeon Walter Wyman, granted leave of absence for
thirty- days. September 3 and 21, 18S9.

Surgeou H. W. Sawtelle, granted leave of absence for
seven days. September 26, 1SS9.

Surgeon H. W. Austin, granted leave of absence for thir-
ty days. September 9, 1889.

Surgeon J. M. Gassaway, when relieved at New Orleans,
La., to rejoin station at Cairo, 111. September 30, 1S89.

Surgeou C. B. Goldsborough, leave of absence extended
thirty days on surgeon's certificate of disability. Sep-
tember 16, 1889.

P. A. Surgeon S. T. .\rmstrong, relieved from duty at
New York; ordered to command of Service at Cleve-
land, O. September 17, 1889.

P. A. Surgeon R. P. M. Ames, assigned to duty at New
Orleans, La., upon expiration of leave of absence.
September 30, 1S89.

P. .\. Surgeon J. H. White, leave of absence extended
thirty days on surgeon's certificate of disability. Sep-
tember 21, 1S89.

.'\sst. Surgeon Seaton Norman, granted leave of absence
for thirty days, to take effect when relieved. October
4, 1889. ■

.\sst. Surgeon W. J. Pettus, ordered to Portland, Me.,
for temporary duty. September 26, 1.S89. Granted
le.ive of absence for twenty-six days, to take effect
when relieved. October 3, 18S9.

Asst. Surgeon J. J. Kinyoun, granted leave of absence
for thirty days. September 21, 1SS9.

THE

6 7i

J ournal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.
PUBLISHED WEEKLY.

Vol. XIII.

CHICAGO, OCTOBER 26, 1889.

No. 17.

ORIGINAL ARTICLES.

THE INDUCTION OF PREMATURE LABOR

IN THE BRIGHT'S DISEASE OF

PREGNANCY.

Riad in the Section of Practice of Medicine. Materia Medica and
Physiology, at the Fortieth Annual Meeting of the American Med-
ical Association, /une, iSSo.

BY JAMES TYSON, M.D.,

PROFESSOR OF CLINICAL MEDICINE IN THE TNIVERSITY OF
PENNSYLVANIA.

In reviewing mj- experience with Bright' s dis-
ease associated with pregnancy, either as a conse-
quence or an accidental complication, I have been
led to believe it possible to formulate more pre-
ciselj' than has been done, the conditions under
which premature labor may be induced with a
view to averting the tragic termination so often
met, premising also that I believe that certain
lives now lost might be saved.

I would recommend the induction of premature
labor with a view to saving the life of the patient, ;
first, in casesof Bright's disease complicating preg-
nancy where in a previous pregnancy there has
been puerperal nephritis with grave complications.
Such are illustrated by the following :

Mrs. N. P. A., when pregnant at 25 years of age
with her second child, first noted swelling of her
feet when six months advanced. Thence dropsy
spread over the entire body, including the face.
During this time there were albuminuria and
amaurotic symptoms. At eight months she mis-
carried with a dead foetus. For two or three days
after this she seemed to be doing well, when there
occurred a sudden aggravation of symptoms, inex-
plicably ascribed by the physician in attetidance to
hydro-pericardium. While apparently at the worst
she lay back, in a short time fell asleep and slept ten
hours almost continuously. After this she began
to improve, and the decided symptoms of dimness
of vision which had preceded her labor and had
continued, disappeared suddenly. Four hours
later, however, there occurred complete paralysis
of the right side, with entire loss of speech, but
not of consciousness. There was also some men-
tal hebetude. She did not speak a word for three
weeks, after which she began slowly to improve
in speech, and gradually to acquire the power of
motion. When I was fir.st consulted, June 26,

1885, a year had elapsed since her miscarriage.
She could say almost anything by speaking slow-
ly and she could walk half a mile without appa-
rentlj' dragging her foot, but there did seem to
be some stifihess at the ankle. She could not
open the fingers of her hand, but could close
them ; she could move her arm at the shoulder
better than at the elbow. This history I had
from her husband. I did not see the patient then
or at any time. A specimen of urine, brought to
me at this time, I found strictly normal.

On May 20, 1888, just about three years after
I was consulted, and four j-ears after the concep-
tion alluded to, Mrs. A. again conceived. She
had the usual signs of pregnancy, and up to No-
vember 20 inclusive, being at the beginning of
the seventh month, she was free from any signs
of nephritis, as shown by examinations of the
urine on three separate occasions. '

On the nth of December, three weeks later,
her husband reported that for some time, probably
a month, there had been slight swelling of the
legs, and that this had rather suddenlj' increased
on December i , when it was noted above the shoe
tops. There was also slight puffiness in the hands,
while the swelling was evidently greater in the
hand of the paralyzed (right) side and the leg of
the sound side. A specimen of vuine brought at
this date contained one-fifth its bulk of albumen,
some vaginal epithelium, but no tube casts. On
December 17 the husband reported a decided re-
duction in the twentj^-four hours' urine, while I
found it containing one-half its bulk of albumen
and numerous hyaline tube casts. The patient's
general condition was reported about the same.
A week later, December 24, at the beginning of
the eighth month, while apparently' quite as well
as usual, Mrs. A. fell into a convulsion about 1 1
A.M. from which she never recovered, dying the
same evening.

In this case I had advised putting off interfer-
ence until some more actively dangerous sj'mp-
toms presented themselves, an advice which, in
the light of subsequent events, I believe to have
been bad. The dangerous sj^mptom was the light-
ning's flash which allowed no time for inter\-en-
tion. On the other hand, I think there is every
reason to believe that if premature labor had been
I induced soon after the appearance of decided al-

58o

INDUCTION OF PREMATURE LABOR.

[October 26,

buminuria the patient's life would have beeu
saved. Under the same circumstances I should
strongly advise premature labor. Observe,
however, that it is in view of the fact that we had
in the previous pregnancy of the same patient 1
Bright's disease with symptoms of great gravity,
and this fact I believe to be the turning-point in
cases of this category.

Second. I would advise the induction of prema- \
ture labor with a view to saving the life of the pa-
tient in all primiparoe in whom there is Bright's
disease previous to pregnancj'. So many cases of
this kind have come under m5' notice in which death
terminated a terrific scene at the first confinement
that I have gjown to regard the girl thus afilicted
as walking to her sacrifice as she walks to the altar,
and if the opportunity presents I discourage mar-
riage in the strongest terms. Should it happen,
however, that a girl thus afflicted does marry, she ;
should never be allowed to go to term, but pre-
mature labor should be induced as soon as the
fcEtus is viable. I have often wondered, if the
proper examination of the urine were made in
every case before marriage, how many of those in
whom a fatal puerperal nephritis developed would
have shown albuminuria. I am inclined to believe
the proportion would be surprisingly large.

Third. There remain only to be considered those
cases of puerperal nephritis not included in the
first and second categories, viz. : those in which
we have not the knowledge gained by experience
with a previous occurrence of the disease in the
same patient, and those which are not primiparas
having Bright's disease previous to marriage.
They include, therefore, acquired puerperal neph-
ritis in primiparae, acquired puerperal nephritis
in multiparae present for the first time, and ac-
quired puerperal nephritis in multiparse where a
previous labor has been accomplished without seri-
ous results. These are in fact the cases in which it
is most difficult to decide treatment, because the
data determining action in the other cases are
wanting. It is evident, therefore, that each
case must be decided on its own merits. One
fact of importance in the natural history of these
cases must be emphasized as having an important
bearing on the treatment, and that is that a large
number of them terminate by miscarriage, and
when thejf do so the patient is generally saved.
I did not realize until recently how common this
accident is, and was surprised in looking into the
cases with which I have had to do to .see how
large a number miscarried. These cases, too, ter-
minated favorably in every instance for the moth-
er, but more rarely for the child. The following
is a good illustration of this class : A young
woman of 22, a patient in the Philadelphia Hos-
pital, somewhat past the .seventh month of preg-
nancj', developed ursemic symptoms. She had
an albuminuria ranging from one-twentieth to
one-tenth bulk. At times there were no casts in

the urine, at others were found casts of several
kinds, including granular, hyaline and epithelial,
and even waxy and pus casts. There was undoubt-
edly puerperal nephritis. A consultation decided
on the induction of premature labor, but pending
some further study of the case by myself she mis-
carried, certainly when not more than seven and
one-half months advanced. The child died in
four days, but the woman did well. This fre-
quency of miscarriage in puerperal nephritis I
find generallj' attested by others.

Another verj' similar case was seen with Dr.
Koser, of Shippensburg, Pa., and Dr. Oliver, of
Philadelphia. Mrs. F., set. 26, married about
eighteen months, miscarried with her first child
at about three months, and when I saw her was
six months pregnant with her second child, hav-
ing conceived about the 26th of April, 1888.
After the first miscarriage she had a little dimness
of vision in her left eye, but apparently recovered
completely. In July, 1888, she returned from a
summer trip with severe neuralgia and more than
the usual amount of morning sickness. Early in
October a trace of albumen was found in her
urine. Visual symptoms presenting, she came to
Philadelphia to consult Dr. Oliver, who found
retiyiitis albuminiirica and sent her to me. There
were no other symptoms of Bright's disease, ex-
, cept that she had to rise once at night to pass
water, although this had been her habit as far
back as she could remember. Her urine con-
tained one-twentieth its bulk of albumen, but no
casts. I gave the opinion that she had puerperal
nephritis, but recommended that her bowels and
kidnej's be kept acting, but that no more active
treatment be pursued until some more urgent
symptoms supervened. She returned to her home
and when next I heard from her she had miscar-
ried, November 7, when apparently six and one-
half months advanced. She made a good recovery.
' These two cases go to show not only the ten-
dency to miscarriage, but also the less dangerous
nature of these cases.

That this termination is not invariable and that
a case may progress to full term without accident
is shown by the following case, seen in consulta-
tion with Dr. Parish, of Philadelphia :

Mrs. J., alwaj's delicate, never weighed more
than 100 lbs.; had diphtheria at 19, but there is
no evidence to show she had nephritis before she
married. Four months, however, after concep-
tion, Dr. Parish found albuminuria. On Febru-
ary 19 I was consulted, when the albumen equaled
one-half bulk, and there were hyaline, pale gran-
ular, and epitlielial casts. There was also some
oedema of the face and legs. It was decided to
put her to bed, to eliminate gently by saline ape-
rients and await more serious symptoms. A few
I days later, however, it being supposed she was
nearly at term, it was decided to induce premature
labor on February 27. On going to the house

1889.]

NOTES ON HOANG-NAN.

581

for the purpose, Dr. Parish thought he recognized
some S3'mptoms of labor, and the next morning
he found labor progressing. She was confined
on the morning of March 2 without other com-
plication than extreme exhaustion, from which
she was, however, desperately ill, but ultimatel)'
recovered. The child also lived. Whence too,
we may infer that it is not alwaj's necessary to
induce miscarriage in order to save the patient ;
but note that these cases belong to neither of the
two divisions of the first category.

Reverting to the third categorj^ of cases, it is
plain that no definite course can be laid down.
Each case must be decided on its own merits. In
general, however, it may be said that the super-
vention of urasmic symptoms demands immediate
interference, but, in consequence of the variety
in these and their occasional simulation by symp-
toms due to other causes, great care must be
observed lest an error in diagnosis be made.
So also a marked degree of other symptoms of
Bright's disease, such as interfere with important
and necessary functions, ma}^ justify interference.
As a rule, too, the same symptoms are more seri-
ous in robust women than in the delicate and less
hardy. It is scarcely necessary to say also that ,
Bright's disease acquired in the first pregnancy is
a much more serious complication than in a later
one, and although less .serious than a Bright's
disease previous to marriage on which a pregnan-
cy has supervened, labor is rarely terminated
without grave symptoms, while the patient often
pays the penalty of her life. Under these circum-
stances, therefore, when the sj^mptoms are of a
positive or dangerous character, I should also
favor the induction of premature labor.

' Dr. Atkinson thought the question should be
confined to the consideration of the conditions
which justify the induction of premature labor.
It is just in primiparae that we fear puerperal con-
vulsions. According to his experience the con-
tracted kidney is the most prolific cause of this
trouble. He has had two or three cases that re-
sulted most happily. He did not believe in one
moment's delay after the mildest symptoms are
manifested. Those suffering with other than the
contracted kidnej^ get along better.

Dr. Ch.\mberl.\in thought it best to carry the
case on until the child has become viable. We
often find that a miscarriage will occur while
symptoms of albuminuria are disappearing.

Dr. Carpenter had been fortunate to see the
larger number of such cases recover. He coin-
cides that the contracted kidney was the most
frequent cause of puerperal convulsions. If the
cases be treated vigorously and promptly, we are
often able to carry mother and child safely through
the dangerous period.

Dr. Wilson thought that the prophylactic
measures proposed by Dr. Tyson would not likely
be carried out. But in handling pregnant women
the accoucheur may lay down certain rules, such
as examining the urine every month, and thus be
enabled to early recognize and treat the aflfection.

Dr. Vaughan remarked that certain women
always have uraemic symptoms during pregnancy.
We do not really know of what these symptoms
are due, since it has been found that the urea is
not a very poisonous agent. He agreed with the
author that premature labor should be induced
early in these cases, because if the condition has
manifested itself once or twice it will surely re-
turn, and sometimes very quickly. The speaker
cited a case in illustration. The patient had been
pregnant several times and had convulsions in
each instance. During the last pregnancy, twen-
ty-four hours after an examination showed nor-
mal urine, albumen was found and she passed
into uraemic coma. According to the speaker's
opinion it is the wisest plan not to allow the wo-
men to go to full term. In primiparae, however,
we are not justified in acting so hastily. We
know that the poisonous elements are formed
from the proteids in the food and tissues. The
speaker thought we could accomplish much with
diet. Abstain from proteid food and keep up free
elimination. He had in this way carried his cases
safely through the dangerous period.

NOTES ON HOANG-NAN IN DISEASES
OF THE SKIN.

Read before the Section on Dermatotoi;y, at the Fortieth Annual Meet-
ing of the American Medical Association, June, iSSg.

BY JOHN V. SHOEMAKER, A.M., M.D.,

OF PHILADELPHIA. PA.

Hoang-nan is the native name of a plant which
has been classified as strj'chnos Gautheriana, It
is a climber and belongs to the natural order Lo-
ganiacese. It rises unsupported upon a slender
stem to a considerable height, when it winds
around the branches of tall trees. Its stem is
gray and its leaves dark green. On account of a
I resemblance to the convolvuli it is also known as
tropical bindweed. Its specific title is in honor
of the Roman Catholic missionary, M. Gauthier,
by whom, in 1874, it was introduced to the notice
of French physicians. Its habitat is the moun-
tainous districts of Laos, Anam, Tonquin and
Cambodia. It has been enthu.siastically heralded
as a remarkable remedy in leprosy, rabies, snake
bite and fever. I have been engaged for some
years in a study of its therapeutic virtues, and
regret to say that my experience does not enable
me to endorse the extravagant eulogies of some
of its advocates. More recently, also, laudatory
articles have appeared in the British Medical Jour-
nal and other periodicals, both domestic and for-
eign, with the tenor of which I am unable to con-
cur. Nevertheless, the article has a wide sphere

582

NOTES ON HOANG-NAN.

[October 26,

of applicability and is a valuable addition to our
resources.

Belonging to the genus strj'chnos its bark,
which is the portion used, contains the alkaloids
strychnine and brucine, the latter in larger pro-
portion. Allied thus botanically and chemically,
its medicinal action bears a close resemblance to
that of strychnos nux vomica. In small doses it
quickens and invigorates the heart, accelerates
and deepens the respiration, stimulates secretion
and, consequently, promotes the nutrition of the
organism. Experiments upon frogs, rabbits and
dogs show that in moderately large doses it pro-
duces clonic, succeeded by tonic convulsions. In
excessive doses it causes a rapid and considera-
ble decline of arterial pressure, powerful tetanic
spasms, death occurring from respiratory failure
and probably due to exhaustion of the respiratory
centre. The heart continues to act, in warm-
blooded animals, for a few minutes after respira-
tion has entirely ceased.

In its home it is used in pill form made up with
realgar and alum. In this country a fluid extract
and a tincture have been prepared. I have usu-
ally depended upon the fluid extract, giving it in
doses of from 5 to 30 drops in water three times
a day. It is best given just before meals. It is
promptly absorbed and is eliminated principally
by the kidneys and the bowels, though I believe
that the skin also assists in its removal. It in-
creases intestinal secretion and peristalsis and has,
therefore, a laxative effect. As it sharpens the
appetite and improves digestion it beneficially in-
fluences nutritive processes. From among the
diverse pathological states in which it may be
advantageously prescribed I have selected for con-
sideration before this Section those which concern
the dermatologist.

I have adverted to its influence upon the glands
of the skin. This consists in a stimulant, corrobo-
rant or alterative action upon the cutaneous gland-
ular systems, both perspiratory and sebaceous,
but more particularly the latter. By accelerating
the circulation and by communicating increased
tone to the muscular fibres surrounding the gland
ducts it encourages healthy secretion. Accord-
ingly, I have observed that it exerts a corrective
power upon both the quantity and the quality of
the secretions, increasing those fluids when they
are repressed and checking them when excessive.
This property which hoang-nan possesses renders
it a valuable agent in the treatment of disordered
secretion. I have witnessed marked improvement
follow its use in seborrhoea. As this malady in-
terferes with the growth of the hair, any measure
which cuts .short its progress obviates a tendency
to baldness. In alopecia, likewise, hoang-nan has
proved very .serviceable in my hands. In hyperi-
drosis it is no less beneficial for the same rea.sons.
In anidrosis it will often restore the functions of
the glands, and in bromidrosis will efficiently assist

the action of the local measures employed. Some
obscure defect of nervous energy often lies at the
foundation of these functional troubles. A sub-
stance, therefore, like hoang-nari, which combines
tonic and alterative properties, is eminently calcu-
lated to prove of service. In acne its corrective in-
fluence is often able to effect verj' happy changes in
the morbid process. It softens the sebaceous plug
and favors its discharge and, in consequence, the
subsidence of the resulting folliculitis or perifol-
liculitis. In sycosis, also, which so often depends
upon obvious nutritive failures, this drug has
manifested an excellent remedial quality'. I have
seen marked improvement take place in eczema
pustulosum from the administration of hoang-nan.
As this form of the disease is very prone to occur
in ill-nourished subjects, a remedy which pro-
motes constructive metamorphosis is especially
indicated. Amelioration was particularly ob-
served in cases attacking parts of the body abun-
dantly supplied with sebaceous glands. The
inflammatory process has been abridged in fu-
runculus by the timely use of hoang-nan. I
have observed good results likewise from its use
in carbunculus. Individual cases of purpura
differ so widely in etiology that a wise selection
of curative agents is extremely desirable. I have
met with success in some cases of this affection
treated by means of hoang-nan to the exclusion
of every other remedy, so that the improvement
could be ascribed to it alone, aided only bj- proper
dietetic and hygienic measures. I have made
trial of it in erysipelas, but am unable to report
any decided results. It did not appear to be as
effective as iron and quinine or pilocarpin.

Eeprosy is a disease which, in this part of the
world, the physician is not often called upon to
treat. In one case, however, which was under
my care, I kept the patient upon hoang-nan con-
tinuously for three months. M}' experience failed
to corroborate the very glowing statements which
have been made as to its value in this affection.
Some gain in the constitutional condition may
have resulted, but I cannot sa}- that I was able to
satisfy myself that the slightest effect was pro-
duced upon the local lesions.

Speaking broadly, all conditions of the skin —
and they are many — which are either produced
or are attended by digestive failure, an exhausted
state of the nervo-muscular sj^stem or the imper-
fect function of glandular organs, maj^ be benefited
by the administration of hoang-nan. In this cat-
egory- I would place lichen planus, lichen scrofu-
losus, erythema nodosum, herpes zoster, pemphi-
gus and ecthyma.

Chronic ulcers are often verj' notably improved
by the administration of hoang-nan. The circu-
lation of the diseased tissue is quickened, the
lymphatics stimulated, and the granulations take
on healthy reparative action. While this remark
applies to those ulcers which have assumed a

1889.]

GLANDUIvAR HYPERTROPHY.

583

chronic form owing to unhygienic surroundings,
jBlth, cold, hunger or dissipation, I have had no
reason to believe that hoang-nan is at all more
efficacious in open cancer than the numerous
other remedies which have been tried and found
wanting. But in scrofula it has yielded very ex-
cellent results. Eczema as it occurs in scrofulous
children has often been improved by a resort to
the subject of this paper. It is, however, in the
chronic adenitis characteristic of the disorder and
in the ulcers left after the complete degeneration
and evacuation of glands that I have especially
seen the most favorable influence exerted. In
.sj-philitic lesions likewise I have quite often
availed myself of the tonic properties of the drug
with satisfaction to mj-self and advantage to my
patients. As we all know, there are epochs in
the progress of syphilis when the impoverished
blood, enfeebled appetite and digestion, inactive
liver and swollen spleen — in brief profound dete-
rioration of systemic nutrition — call imperatively
for relief and suggest an addition to or even au
entire suspension of routine antisyphilitic medica-
tion. The fact, as I have said, is sufficiently well
recognized, and yet it appears to be too often over-
looked or neglected in actual practice. Marked
constitutional depression due to the disease may
be obser\'ed at all stages, but is more common in
the later. The initial sclerosis, however, may
take on unhealthy inflammation attended b}' se-
vere constitutional reaction. The stomach be-
comes rebellious, the digestion much enfeebled,
the liver inactive, the bowels capricious. In this
state of affairs the exhibition of mercun,^ or iodine
will frequently prove prejudicial. Either will
aggravate the digestive distress, act as a local ir-
ritant and seem a poison rather than an antidote.
The same process, manifested by the same gen-
eral disturbances, may show itself in the primary
adenopathy. The later cutaneous lesions of -the
secondary stage, the development of gummy tu-
mors and invasion of the viscera during the ter-
tiary period may also, not seldom, be productive
of a general condition in which, for a time, specific
treatment will be of no avail or even work tnis-
chief The later exceptions, also, often occur in
conjunction with a general depraved condition of
fluids and solids. The .seal}- syphiloderm, the
pustular, the ulcerated tubercle, syphilitic ecthy-
ma, rupia, extensive ulcerations of mucous mem-
brane ; each and all of these phases may necessi-
tate the resort to tonic measures and the partial
or complete suspension of specific remedies. When ,
under a tonic regimen, an appetite has returned, ]
when the stomach has regained its power, the '
bowels and the kidneys act with regularity, when
the liver has become capable of performing its
functions, the specific drugs may be resumed with [
advantage. It is needless to dwell upon the cir-
cumstance that these unamenable cases usually de- 1
velop in such persons as have abused their vital |

resources by sexual excess, intemperance, contin-
uous feverish anxiety regarding business matters,
and the many other ways in which modern men
" burn the candle at both ends." When it is judi-
cious to do away with mercurials and iodides I have
found much satisfaction in the employment of ho-
ang-nan. It may be used alone or combined with
iron and quinine or, if need be, cod-liver oil. This
tonic treatment of syphilis is, I believe, too much
neglected. I have not the slightest intention of
detracting from the value and the necessity, in
the vast majority of cases, of the approved mer-
curial or mixed plan of treatment, yet I am firmly
convinced that there are times when this plan is
harmful instead of beneficial, and to recognize
such periods in the progress of the affection is no
less necessary than to make the diagnosis that the
disease is actually present. In fact, the recogni-
tion when to varj' the specific by a tonic course is
a sound evidence of the physician's power of
discrimination.

GLANDULAR HYPERTROPHY AT THE

BASE OF THE TONGUE AND

ITS TREATMENT.

Read in the Section of Laryngology and Otology at the Foitieth An-
nual Meeting of the American Medical Association. June. iSSg.

BY JOHN O. ROE, M.D.,

OF ROCHESTER, N. Y.

It is not unfrequently the case that many of the
minor localized affections that give rise to a va-
riet3^ of disturbances, are not only entirely over-
looked, but remain unsuspected. This has, to a
great extent, been the case with the glandular
hypertrophy which is of frequent occurrence at
the base of the tongue ; and it is not until re-
cently that the importance of this diseased condi-
tion has been full)- recognized.

In the pharynx and naso-pharj-n.x are found
collections of mucous and lymphoid glands which
are aggregated into various masses at certain
points. To these masses have been given the
general name of tonsils. They are, however,
further specialized as follows : the collection be-
tween the pillars of the fauces is termed the "fau-
cial tonsil;" the mass in the vault of the phar3'nx,
the phar>^ngeal, or "Luschka's tonsil ;" while the
mass collected together at the base of the
tongue is termed the "lingual tonsil."

The glands composing these various tonsils are
exactly identical in their structure, and have the
same functions to perform. The chief function
which these glands perform is unquestionably the
secretion of mucus for the purpose of keeping
moist the lower pharj'nx.

The upper pharynx, which constitutes a por-
tion of the respiratorj' passages, is covered with
columnar epithelium, and is abundantly supplied
with muciparous glands for the purpose of modi-

584

GIvANDULAR HYPERTROPHY.

[October 26,

fj'ing the air in its passage to the lungs ; while
the lower pharj-nx, which constitutes a portion
of the food tract, is covered with squamous epi-
thelium and is very scantih' supplied with muci-
parous glands, and hence arises the necessit}' for a
lubricant for the pharj'nx from another source.

In addition to the secretion of mucus, impor-
tant functions are attributed to the h-mphoid tis-
sue found in these masses. These are : first, the
prevention of fluid waste in the economy, b3' re-
absorbing the buccal secretions, particularly in
the inter\^als of deglutition ; secondly, the ab-
sorption from the food bolus in its passage over
them of certain nutritious elements ; and thirdly,
the performance of a certain office in the blood
manufacturing system, acting, as Kingston Fox
expresses it, "as nurseries for young leucocytes
planted by the water side and drawing their sus-
tenance from the nutrient stream." ("The
functions of the Tonsil," Jour. Anat. and
Physiol., London, 1885-6, vol. xx, p. 559.)

This glandular tissue is moderatelj- supplied
with blood vessels, and it is surrounded by a net-
work of these vessels more or less spread out over
the base of the tongue.

Subject as this tissue and these blood vessels
are to all the variations of the temperature of the
fluid and solids that pass over them, and to the di-
rect effect of many of these substances that tend
to irritate the tissue and to cause engorgement of
the blood vessels, it is not surprising that abnor-
mal conditions of these parts are frequentlj- found.

It is, therefore, almost invariably the case that
associated with a hypertrophied condition of this
glandular tissue is an abnormally distended con-
dition of these blood-vessels. And it is the varj--
ing degrees of the distention of the blood-vessels
supplying this glandular tissue and of those sur-
rounding it, which account for the varj-ing de-
grees of enlargement or projection of this glandu-
lar tissue and the different appearances that
these parts present on inspection at different
times. The condition of this tissue and of these
blood-vessels, therefore, not only varies with the
condition of local irritation, but also with ple-
thoric conditions of the general system.

The chronic engorgement of these vessels may
also be, as Mr. Lenox Browne states, "symp-
tomatic of mitral insufiiciency or of severe hepatic
derangement or even of cerebral lesion."' The
veins of this region are frequently found so much
dilated as to be really varicose, and sometimes to
approach a haemorrhoidal condition. The fre-
quent occurrence of the spitting of blood b}' per-
sons having an irritable throat, is due very often
to .small ruptures or leakages of these distended
and weakened vessels.

It is ver)- common to find hypertrophj-.of the
glandular tissue and enlargement of the ves.sels at
the base of the tongue associated with a similar

■ Medical News. Philadelphia, 18S-, Vol. li, p. 443.

condition of the faucial and pharj-ngeal tonsils, and
also with a chronic follicular pharyngitis. The
symptoms of hypertrophj- of the lingual tonsil in
many respects resemble those produced b}' h3per-
trophy of the faucial tonsil. It has a marked in-
terference with phonation, producing a gutteral
intonation, as if an obstruction existed in the
throat. In the effort to overcome this obstruction,
the patient soon experiences the sensation of
vocal fatigue.

The glandular hypertrophy at the base of the
tongue is frequenth- the cause of the great varia-
tions from day to day in the singing voice, and
is the reason why some singers are able to sing
in a clear voice only after a period of rest. I have
obser\^ed this condition to be the cause of a num-
ber of cases of vocal failure in singers, due, as has
been observed bj- Dr. Holbrook Curtis," to direct
mechanical obstruction to the free opening of the
epiglottis or to a reflex action exerted on the mo-
tor laryngeal ner\'es. The epiglottis, in these
cases, is not only greatl}* hindered in its move-
ments, but the irritation of its upper portion I
have observed to be the cause of many cases of
chronic lar}-ngeal hyperasmia and hoarseness, and
also of peculiar spasmodic and persistent coughs,
as has been obsen-ed by Dr. Rice.'

This condition of glandular enlargement is also
sometimes the cause of bronchial irritation and
asthma.

The sensation experienced bj' the patient is
that of fulness, or of a foreign body in the throat,
as for example, some short substance, or a hair ;
some patients liken it to a rag or a piece of thread,
and they are continually trying to get rid of these
apparent obstructions bj- the effort of hawking,
or swallowing.

These glands are also subject to frequent ex-
acerbations of acute or subacute inflammation, as
is the case with the faucial tonsils ; and this con-
dition is the cause of dysphagia and pain in the
throat extending up the sides of the throat to the
ear, as observed by Dr. Glutsmann.*

The condition known as "globus hystericus,"
frequently observed in females, was first demon-
strated by Mr. Lenox Browne to be due to a con-
dition of engorgement of these glands and blood-
vessels at the base of the tongue, which may
become enormouslj- engorged bj- the reflex irrita-
tion of uterine or ovarian disorders. (Compte-
Renau, Congress International de Larj'ngologia,
Milan, 1880, p. 48.)

The diagnosis of these disea.sed conditions is
verj- easily made by drawing the tongue forward
with a napkin and inspecting the base of the
tongue bj- the aid of the larj'ngeal mirror.

In the treatment of this condition we have two
primarj' objects to be accomplished : first, the

= New York Medical Tourual, Nov. 8, 1S&4. Vol. xl. p. 510.

.1 The Mtdicftl Rccor<f. New York, May 1, 18S6, Vol. xxix, p. 493.

4 Medical Record. New York. Dec. 17, 1S87, Vol. xxxii, p. 757.

I889.J

GLANDULAR HYPERTROPHY.

585

removal of all the tissue that has become hyper-
trophied ; and, second, the obliteration of vari-
cosed or distended blood-vessels.

The removal of this tissue is quickly and most
easily accomplished by simple abcision with a
cun'ed knife, or a pair of curved serrated scissors,
cutting it down to its normal level. This opera-
tion is usually attended by ver>' little bleeding,
the tongue heals quickl^^ and with but little sore-
ness. In cases in which the tissue can be readilj'
engaged in the loop of a cold wire snare, this
method of removal I have also found to be very
excellent

The galvanic cauterj' is also very useful in
cases where this enlarged tissue is much flatten-
ed and where it is unusuallj' vascular.

Corrosive substances are also recommended, as
chromic acid, nitric acid, monochloracetic acid,
Vienna paste, fu.sed nitrate of silver, etc. In
conditions of a very moderate amount of h5'per-
trophy, two or more applications of these stronger
caustics may be sufficient to remove all the tissue
desired. But when any great amount of hyper-
tropy is present, their employment is as unad-
visible as they ordinarily are in the same condi-
tion of hypertropy of the faucial tonsils, since
applications of these substances have to be re-
peatedly made in order to produce the desired
amount of destruction of tissue, and the patient
is subjected to an amount of pain and discomfort
that would seem almost unwarrantable when the
tissue can be removed in mass by simply cutting
it away.

In those cases in which it is desirable to remove
the hypertrophy with the galvanic cautery, there
are three methods of doing it. The first is to
destroy the whole growth b}' burning it away
with a flat cautery point from the summit down-
ward ; the second is to cut it off at the base with
an ordinary cautery knife ; the third method is to
transfix the growth through the base, by means
of a very slender cautery point.

For the destruction of the enlarged blood-vessels
or varicose veins, the galvanic cautery point is
the instrument to be employed, and we can ac-
complish the same result by no other method
with so much ease and precision. A slender cau-
tery point should be used, and this should be ap-
plied longitudinally to the trunk of the vessel to
be obliterated. It is desirable in the destruction
of these vessels to obliterate them as near as pos-
sible to the point where they arise ; it is, how-
ever, often nece.ssarj' to obliterate them at difi'er-
ent places for the reason that they so frequently
anastamose with each other.

Before attempting any of these operations, how-
ever, cocaine should be thoroughly applied. It
removes the sensibility of the part, and at the
same time it is a marked haemostatic, as it also is
in operations on the faucial tonsil.

Accompanying the removal of these abnormal

tissues at the base of the tongue, attention should
be directed to the general conditions of the sys-
tem, which may have been the predisposing or
exciting cause of the local disorder.

Dr. J. SoLiS-CoHEN objected to the term tonsil
as applied to collections of lymphoid ti.ssues other
than those existing between the arches of the pal-
ate. He highly approved of the writer's method
of getting rid of large masses with curved ser-
rated scissors. In cases of slight enlargements
he found solutions of creosote in carbolic acid and
iodine in glycerine sufficient topical treatment.
He would state that in the majority of cases seen
by him, and they are counted by hundreds, he
found no abnormal dilatation of the veins except
in cases of very marked hypertrophies.

Dr. Green V. Woolen, of Indianapolis, said :
I am pleased that Dr. Cohen has called attention
to the use of the term tonsil, because it relieves
me from reproach for saying at my home that
there is no such thing anatomically as a tonsil.
When once it is known that such is the case we
will be free from annoyance and opposition when
we desire to remove them. My statistics show
that less than 50 per cent, of diseased throats have
tonsils and frequent observations show them rare
in those not claiming to have diseased ones.

Dr. J. Roe, after the discussion of his paper,
said : If I were the author of the term tonsil, as
applied to the collections of glandular tissue in
the throat, I would gladl}'- comply with Dr.
Cohen's desire to have, the term stricken from our
nomenclature. In my paper I have simply stated
that the collection of glandular tissue at the
base of the tongue is sometimes called the lingual
tonsil because of its identity in function and
structure with the faucial tonsil. The term ton-
sil has doubtless been adopted because it is short
and easy to use, and at the same time designates
the part referred to just as clearly as the longer
and more scientific term.

Regarding the statement made by Dr. Woolen,,
which has already been made by Dr. Bosworth,
that normally there are no tonsils, that the en-
largements we call tonsils are in realitj' abnormal
conditions. This .statement is in the main
true. Normally the collections of glands at these
points are not noticeable on inspection of the
throat, and, therefore, no tonsils appear to exist.
Notwithstanding this the same number of mucous
and Ij-mph glands are found in these regions as
when the tissue composing these glands have be-
come more or less hypertrophied or enlarged by
disease.

The Journ.\i. will be .sent to new .subscribers
from November i, 1889, to January i, 1891, for
$5.00; to July I, 1890, for $2.50.

586

PRESTON RETREAT.

[October 26,

FIVE HUNDRED DELIVERIES WITHOUT
DEATH IN THE PRESTON RETREAT.

Kead in the Section of Obstetrics and the Diseases of Women, at the
fortieth Annual Meeting of the American Medical Associa-
tion, June, 1S89.

BY JOSEPH PRICE, M.D.,

OF PHILADELPHTA.

In making this report I desire to call attention
to the accommodations of the Preston Retreat, and
its routine treatment of puerperal cases, rather than
make a minute analysis of a large number of cases.

The 500 cases reported date from the last death
occurring in the Retreat, more than five years ago,
and include 275 confinements under Dr. Goodell's
care before his resignation as phj-sician in charge.
The series had extended to nearly 600 cases before
the first death occurred, during my serv-ice as phy-
sician in charge. Between these deaths there has
not been a case of puerperal septicemia in the in-
stitution. Both of these deaths being from puer-
peral eclampsia in patients suffering from chronic
Bright' s disease.

The Retreat is a maternity hospital endowed
by the will of Dr. Jonas Preston to furnish ac-
commodations for poor, respectable, married wo-
men during their lying-in period. The building,
standing in an open square of ground, is espe-
cially adapted to its purpose. Lj'ing-in wards
are entirely shut off from the main building ; the
delivery rooms, the closets and bath-rooms. The
bath-rooms and water-closets are placed in towers
at the rear of the building. The plumbing is as
nearly perfect as modem sanitary science can
make it.

Verandas, enclosed in glass, form large, light,
airj' corridors about the sides and rear of the
building, and furnish a distinct circulating at-
mosphere between the house proper, the wards
and the water-closets.

Wide corridors run through the main building
at right angles. This arrangement, together with
that of the flues and heating apparatus, makes the
ventilation of the entire building simply perfect.
The building is heated by the indirect steam
method.

The great success attending the work of this
maternity is due to the strict enforcement of the
law of cleanliness. Cleanliness, water, soap and
pure air are still the best antiseptics. Everything
and everj'body is clean, and jealously kept so.
The routine treatment of patients is as follows :

The patient on entering the house is given a
hot soap bath, dressed in clean clothing and as-
signed a clean bed in the waiting ward. If nec-
essary, a laxative is given and the bowels are
kept .soluble during her waiting period. There-
after until her confinement she is obliged to take
at least two hot soap baths per week and wear
clean clothing. She is allowed to do such light
work about the house as the physician may deem
advisable and is encouraged to take as much open
air exercise as circumstances will permit. Everj'

effort is made bj' the officers and emploj^es of the
institution to make it as cheerful and homelike
as possible. When ready for the deliver^' room,
the patient is again given a hot soap bath, also
an enema and vaginal injection of a i to 2,000
solution of bichloride of mercurj- in distilled
water. She is clothed in a clean night-robe and
drawers and placed upon a new, clean delivery-
bed. Scrupulous cleanliness is observed in all
manipulations of the patient, and after delivery
a second vaginal injection is given and a vaginal
: suppository- of iodoform is introduced.

The patient's person is carefully cleaned, all
soiled clothing removed, the binder and pad ap-
plied, a clean set of night clothes put on, and the
patient is put in a new, clean bed in the ward.
All soiled articles are immediately removed from
the delivery room and a new bed made up for the
next patient.

The patients in the ward are carefully observed
bj- the nurses, but no unnecessar}- handling or in-
terference permitted; they remain m the ward un-
til they are able to be up, when they are removed
to the convalescent ward. As the ward is emp-
tied, the beds are burned and all bedding most
carefully cleaned.

No soiled linen (as draw-sheets, diapers, nap-
kins or other articles) is allowed to remain in the
ward ; but when soiled is immediately placed in
a covered receptacle and removed from the build-
ing. No sponges, wash-rags or absorbent cotton
are used in the house. Corrosive jute supplies
the place of these articles, being clean, soft, re-
markablj- absorbent and cheap. It is destroyed
immediately after being used. The pads to ab-
sorb the lochia are also of jute and likewise de-
stroyed. The beds in the ward are of fresh rye
straw and are burned after ten days. All dis-
charges from the delivery room are immediately
burned ; all bedding soiled beyond cleansing or
contaminated by purulent or specific discharges
is likewise burned. In short, every effort is made
to keep the house perfectly pure and sweet.

The anangement of the building permits of
rotation in the use of the wards, so that a ward
once emptied is not again used until three others
have been filled. In the meantime it is most
carefully cleaned and thrown open to the atmos-
phere. A similar system is pursued in the con-
valescent wards and deliver},- rooms.

In the 500 labors reported, there were 200 pri-
miparous mothers. The complications were as
follows: There were 52 forceps deliveries, most
of them for contracted pelves and large, hard
heads ; 3 induced labors ; 3 cases in which podalic
version was performed ; 2 cases of mi.s.sed labor ;
I case of congenital absence of the right leg of
the mother {a. normal delivery) ; i case of pla-
centa pnevia ; 12 still births; 3 twin labors; 5
breech presentations and i face presentation.
Other statistics are omitted purposelj-.

1889.]

TUBERCULOSIS OF BONES AND JOINTS.

587

TUBERCULOSIS OF BONES AND JOINTS.

Read before the Chicago Medical Society,

BY CHRISTIAN FENGER, M.D.,

OF CHICAGO, ILL.

History. — The tuberculosis of bones and joints
form anatomically and clinically a unit, because
the tuberculosis of the bones usually extends to
the joints, and derives from the affections of the
latter the main clinical features.

Our knowledge of this branch of tuberculosis
is only twenty years old, commencing at the time
when Karl Kiister called attention to the frequent
occurrence of miliary tubercles in the fungous
granulations of the disease then known as white
swelling. Soon afterwards Friedliinder, Hueter,
and especially Volkmann and Konig, not only
verified Ktister's statements, but carefully studied
anatomicall^^ clinically and experimentally this
form of local tuberculosis. This naturally at-
tracted the universal attention of the profession,
so that an extensive literature of the subject
■quickly sprang up — so quickly, indeed, that even
before Koch's discovery of the bacillus tubercu-
losis, in 188 1, the tuberculosis of bones and joints
was already well established as a distinct form of
disease. So much was this the case that Volk-
mann, at the German Surgical Congress in 1885,
was able to state that all cases of the hitherto so-
called paidarthrocacis, spina-ventosa, tumor al-
bus, fungous and strumous arthritis, etc., be-
longed to tuberculosis.

Etiology. — Tuberculosis of bones and joints is
evidently always a secondary invasion ; that is,
the place of primary invasion of the bacillus must
be elsewhere in the body, and one or more depots
must exist in the lungs or lymph glands before
so deep-seated localities as the bones and joints
can be invaded. When, therefore, authors speak
of primar}- tuberculosis of the bones and joints, it
is only a clinical term and means that clinical
examination, or even the autopsy, fails to reveal
the place of invasion, the primary depots. As a
clinical distinction its importance lies in the fact
that if tuberculosis is practically localized to a
joint, the patient's life is not in danger from de-
posits in other organs, and the total removal
might prove efficient to extinguish the disease.

In this sense a primary, or, to use the more
correct expression, a localized articular and osse-
ous tuberculosis, is, according to Kiimmer, found
in about 40 per cent, of the cases. In the remain-
ing 60 per cent., depots are found at the same
time in other organs of the body. The lungs
come first with 25 per cent.; other joints, 10 per
cent.; bones, 10 per cent.; glands, 10 per cent.;
peritoneum, 3 per cent.; pleura, 2 per cent.

The presence of the bacillus of tuberculosis in
a body is the condition sine qua non, and may be
aided by other etiological elements, the most im-
portant of which is traumatism. Max Schiiller

proved experimentally in animals infected with
tuberculosis (for instance through the respirator}^
tract) that a slight traumatism to a joint would
determine the localization of the bacillus tubercu-
losis, by way of the circulation, to the place of
traumatism, and that a tuberculous .synovitis or
panarthritis would follow.

Clinically the tuberculosis of joints has been
traced in 56 per cent, of the cases to traumatism,
by a direct blow to a joint, or distortion, or over-
exertion. It is characteristic that the traumatism
is always slight ; a severe trauma, causing intra-
articular fracture, is very rarely followed by
tuberculosis.

As a general characteristic of the articular and
osseous tuberculosis it must be stated that it be-
longs to the benignant chronic forms of disease ;
that is, it lasts for years and years, has a tendency
to spontaneous recovery, little tendency to gen-
eralization and, consequently, to the destruction
of life, as compared with the acute forms of tuber-
culosis of the internal organs, or even the experi-
mental inoculated tuberculosis.

An explanation of this clinical fact is given by
Baumgarten, who distinguishes between three
forms of miliar}' tubercles :

1. The lymphoid-celled tubercle, Virchow's
small-celled tubercle, which is rich in bacilli, ex-
tremely malignant, and is found in tuberculosis
miliaris acutissima, for instance in the lungs.

2. The mixed tubercle of lymphoid cells and
epithelioid cells, which contains fewer bacilli, is
less benignant, and is found in the more chronic
forms of general miliary tuberculosis.

3. The epithelioid and giant-celled tubercle,
with no lymphoid cells, containing comparatively
few bacilli, more benignant, and found in the
benign forms of localized tuberculosis, joints,
bones, lupus and lymph glands.

That this benignancy of the tubercle can be
dependent upon lessened vitality in the tubercle
bacillus has been proven experimentally by the
inoculation of artificially weakened cultures,
which were seen to produce localized tuberculosis
in the nearest lymph glands only, with no gen-
eralization (Baumgarten). Kiimmer found he-
redity as an element in 37 per cent, of the cases.

Anatomy. — Tuberculosis has a distinct predi-
lection for the medullary tissue of the bones ;
thus it is correct to speak of the tuberculous
osteo -myelitis as a first effect of the arrest of ba-
cilli in some place of the medulla. The anatom-
ical condition of the vessels in this tissue, thin
walls, slight contractility and sluggish circula-
tion, favor the implantation on the vessel wall,
in the same way as pus microbes are localized in
acute osteo-myelitis.

Embolism from foci in the lungs opening into
the pulmonary veins may cause a tuberculous in-
farction of the bone. The interesting experi-
ments of Miiller, who injected pus from a tuber-

588

TUBERCULOSIS OF BONES AND JOINTS.

[October 26,

culous. abscess into the nutrient artery of the
long bones of goats and rabbits, have proven that
this is a possible origin of local osteo- tuberculosis.

The seat of the tuberculosis in bones is usually
in the cancellous substance of the epiphysis of
the long boues, the short and flat bones, and verj-
seldom, the medulla of the shafts. The only ex-
ceptions to this are the shafts of the phalanges of
the fingers and toes, and the metacarpal and
metatarsal bones in children, where the tubercu-
lous osteo-myelitis gives rise to the well-known
spina-ventosa of the old authors.

The frequencj' of the localization in the differ-
ent bones of the body is given b}' Schmallfuss, as
follows :

BiUroth.

Jaffe.

Per cent.

Schmallfuss.

Per cent.

Vertebra

Vertebra

26

Knee

23

Knee

Foot

21

Foot

19

Cranium

Hip

13

Hip

16

Face

Knee

10

Elbow

g

Hip

Hand

9

Hand

s

Sternum-Ribs

Elbow

4

Vertebra

7-5

Foot

Pelvis

Tibia

4

Elbow

Cranium

3

Cranium

4

Pelvis

Pelvis

3-6

Tibia and Fib-

Sternum, Clav-

ula

icle and Ribs

3

Sternum, etc.

3-6

Femur

Shoulder

2

Femur

••9

Shoulder

Femur

r

Shoulder

'■5

Humerus

Tibia

I

Ulna

1.4

Ulna

Fibula

I

Humerus

I

Radius

Humerus

I

Radius

0.7

Scapula

Scapula

0.6

Fibula

0.5

Ulna

0.6

Patella

0.1

The gross appearances of the osteo-tuberculosis
as it is found in the articular extremities of the
long bones are well described by Konig under
the three following forms : (i) The granulating
focus ; (2) the tubercular necrosis, and (3) the
tuberculous infarct, the diffuse tuberculous osteo-
myelitis.

I. The granulating foais is found as single or
multiple, round or cylindrical cavities, from the
size of a millet seed to that of a pea or hazelnut,
and contains either grayish-red, soft, living gran-
ulation tissue, or, if coagulation necrosis has
taken place, yellowish-graj' cheesy matter or
liquid tuberculous pus. Fine spicula of bone
may be felt with the finger, or when smaller,
seen with the microscope in the contents.

The granulation tissue contains epithelioid and
giant-celled tubercles and bacilli. The wall of
the cavity is either soft, when rarefying osteo-
myelitis has taken place, significant of destruction
and extension; or sclerotic when an osteo-plastic
osteo-myelitis surrounds the focus, showing a
tendency to localization and cicatrization. As
little as this form of osteo-myelitis has in com-
mon with the usual form of acute osteo-myelitis
due to pus microbes, with its extensive area of
inflammation and large sequestra, still it may be
difficult to distinguish it from the more rare form
of sub-acute multiple osteo-myelitis of the epi-
physis, in which multiple foci of similar form are
found. But the infectious osteo-myelitis has thin

3'ellow pus and flabby granulations without tu-
bercles, and the pus contains pus microbes.

2. The tubercular necrosis. When the area of
the tuberculous osteo-myelitis is larger than a
hazelnut, the bone is usualh^ not absorbed, but
remains as a sequestrum in the cavitj-. This
sequestrum is sometimes osteo-sclerotic, some-
times osteo- porotic, sometimes like the .surround-
ing bone, according to the character of the osteo-
myelitis previous to the interruption of nutrition.
It is yellowish-white or grayish-red, according to
the contents of the Haversian canals or medullar}'
spaces of dead or living tuberculous tissue. It
majf be separated from the wall of the cavit)- b}'
a layer of tuberculous granulation tissue, or drj-
cheesj- matter, or tuberculous pus. If separated
by a layer of granulation tissue, this may be so
thin that the sequestrum fits the cavit}' exactly,
and, if its shape is irregular, fits in so immovablj-
that it takes a good deal of force to pry it out by
the gouge and chisel.

J. The tuberculous infarct has the character-
istic conical shape of infarcts in other parts of the
bod}-, with the apex in a proximal and the base
in a distal direction. It represents the territorj-
of an arterj^ and suggests embolism. Large in-
farcts, then, must require either a larger embolus,
or, in addition to the embolus, arterial throm-
bosis, from the place of arrest of the embolus.
Their seat is usually a little inside of the cortical
substance of the bone ; thus, they maj- be over-
looked if the bone is not sawn through. If, as
in the specimen here presented, the base takes in
the articular surface of the joint, this surface will
be ground off and polished, signifying instanta-
neous death of the infarct at the time of the em-
bolism.

The line of demarcation forms slowly as a fur-
row surrounding the dead area, the central por-
tion of which may remain in connection with the
living bone for a long time, a year or more, even
in a joint apparently on the way to recover}-.

The smallest sequestra, in the dry- forms of
tuberculosis with a tendency to cicatrization, may
heal in or be imbedded in the non-tuberculous
cicatricial tissue, remaining after the tuberculosis
has come to an end and incomplete recover}'
taken place, without perceptibly disturbing the
futiction.

The fate of the osteo-tuberculous foci varies
according to the activity of the microbe and the
size of the focus. The smaller granulation foci
in the dry forms of tuberculosis may result in
either complete recover}- by removal of the tuber-
culous elements by absorption and filling up the
cavity with cicatricial ti.ssue, or in incomplete re-
cover}-, in which part of the focus is transformed
into cicatricial tissue, in part of which dormant
bacilli remain. The.se are apt to be revived under
favorable circumstances, of which a fresh culture
fluid from a traumatism is the only one known.

1889.]

TUBERCULOSIS OF BONES AND JOINTS.

589

In the joints, however, this is a very common oc-
currence, as we shall see later on. This accounts
for the local relapses so frequent in tuberculosis as
to make a permanent recovery almost impossible.

Small sequestra may, as stated above, disap-
pear by absorption, or be included in the cicatri-
cial tissue. Large sequestra will, of course,
neither be absorbed nor be included in a cicatrix.
Moreover, they furnish an inexhaustible depot of
bacilli and keep up the local tuberculosis on its
progressive wa)^ to further destruction,

We have hitherto considered the osteo-tuber-
culosis at its place of origin in the bone, where it
is of comparatively little importance, since so
long as it is confined to the bone it gives rise to
little or no functional disturbance. We shall
now follow it on its extension beyond the bone,
and then distinguish between its extension to the
periosteum and the soft tissues on the one hand,
and to the joints on the other. It is not until
the tuberculosis has extended to one of the places
named, that its symptoms become manifest and
the grave consequences to the patient's welfare
take place.

I. Extension to the periosteum outside of the
joints. — It is characteristic of tuberculosis that
the periosteum, on the whole, is rarely affected
to any great extent. We do not find, as in acute
osteo-myelitis, a diffuse infiltration of the perios-
teum and the formation of extensive masses of
bone. Tuberculosis of the periosteum is local-
ized in the joint in the same way as in tubercular
osteo-myelitis, and the place of perforation lim-
ited to a small area surrounded by normal peri-
osteum, with little or no thickening or enlarge-
ment of the bone affected. When the dry granu-
lating form of tuberculosis reaches the periosteum
a small, soft, elastic, limited granulation tumor
forms, first under the periosteum, then outside of
it. It is characterized by slow growth, compara-
tively little pain, slight tenderness, and a ten-
dency to remain stationary for a long time. It
is different with the soft suppurating tuberculosis,
which, although it also breaks through the peri-
osteum in a limited space, acts in an entirely dif-
ferent way as soon as it has reached the para-
periosteal loose, connective-tissue spaces. Here
it has a tendency to extend rapidly and to form
large abscesses, the so-called cold abscesses,
traveling, like all other abscesses in connective
tissues, in the direction of least resistance. On
its way from the deep para-periosteal tissues out
toward the skin, it forms large or small abscess
cavities and finally breaks through to the sur-
face, after having transformed the skin into
tuberculous tissue, which sometimes presents the
appearance of lupus at the place of perforation.
No conclusion can be drawn from the size or
acuteness of the abscess as to the extent of the
osteo- tuberculosis. A large abscess may come
from a small focus in the bone, and vice versa.

The question has arisen whether the rapid
formation of tuberculous abscesses is not the con-
sequence of a mixed infection from auto-infection
of pus microbes. It must be said that such auto-
infection is rare, as the pus in these abscesses is
found on microscopical examination and culture
in culture substances, not only not to contain pus
microbes, but its inoculation in the camera an-
terior of the eye, or the abdominal cavity of ani-
mals, produces an unmixed tuberculous invasion
and no suppuration.

Diffuse tuberculous osteo-myelitis. — This form is
rare. On the cut surface of the bone we find
large, irregular, often multiple areas and islands,
with no tendency to definition, of a yellowish-
white infiltration, containing small multiple foci
of liquid pus. Here is no tendency to limitation
or the formation of sequestra, but rather a ten-
dency to spread indefinitely and to invade even
the medullary tissue of the shafts. This form
has in common with the acute diffuse osteo-mye-
litis that it will spread through the Haversian
canals diffusely to the periosteum and cause a
diffuse plastic periostitis with irregular diffuse
masses of bone formed on the outside of the cor-
tical substance. Consequently it resembles, in
its clinical features, acute osteo-myelitis. Locally
and generally it is a severe form : locally it forms
an extensive tuberculous depot, from which ab-
scesses may form indefinitely; generally, patients
with this form are exposed to the dangers of a
fatal general tuberculosis if the whole depot is
not removed in time. In operating it is impor-
tant to recognize this form, since it requires more
radical measures, either amputation or very ex-
tensive excision. As a rule, the mere removal of
the periosteal tuberculous masses and the dis-
eased medullary tissue is insuflScient, and the
whole continuity of the bone must be taken away,
as in the specimen here presented. Fortunately
this form is extremely rare.

Tuberculous abscess.— In addition to what has
already been stated about the tuberculous abscess
I shall here briefly call attention to the main
characteristics of its wall, which is formed of a
thinner or thicker layer of tuberculous granula-
tion tissue thickly studded with the characteristic
miliary tubercles of the benignant type, with
relatively few bacilli. This tuberculous pyo-
genetic membrane, as it was called by the old
authors, is only very loosely connected with the
surrounding tissues and organs, in the spaces be-
tween which it is located. So loose is the con-
nection that, when the abscess is opened, the
whole membrane can be wiped off the wall with
a sponge, or, when more firmly attached, easily
removed with a sharp spoon, leaving the walls
so healthy as to readily unite by first intention
when brought together ; hence the modern treat-
ment of these abscesses by incision of the whole
length, removal of the wall, and reunion. In

590

TUBERCULOSIS OF BONES AND JOINTS.

[October 26,

rare instances, however, a fascia, for instance the
fascia lata of the femur, may be diffusely infil-
trated, even to such a degree as to cause diffuse
necrosis, presenting the appearance of diffuse
phlegmonous inflammation. In such cases care-
ful removal, by the knife and scissors, of the
whole area involved is required.

At this place I will call attention to the latest
step in the conserv'ative treatment of large tuber-
culous abscesses, especially the large psoas ab-
scesses from tuberculosis of the vertebral column
from Pott's disease. It is well known that the
opening of these abscesses in prse-antiseptic times
was almost always followed by a fatal septic in-
fection from without. The modem opening and
drainage under antiseptic precautions, so much
praised in the beginning, has been proven not to
be without danger, inasmuch as, in many cases,
late infection has taken place when, after months,
the inclosed fistulous openings have been guarded
with less stringency in the application of anti-
septic dressings.

Thus, two years ago, Bruns, in Tiibingen, pro-
posed a return to the older subcutaneous method,
namely aspiration ; but, in addition to this, injec-
tion into the emptied abscess cavitj' of a 10 per
cent, iodoform emulsion in equal parts of glycer-
ine and alcohol, this procedure to be repeated
every four to six weeks. Usually, after three or
four aspirations, the formation of pus in the ab-
scess cavity ceases, the fever stops, and the pa-
tient regains health and strength. No iodoform
poisoning from this treatment has yet been re-
ported.

2. Extensio7i into the joints. — The osteo-tuber-
culous foci in the epiphyses of the long bones are
situated so near to the surface of the joint that,
when thej' come to the surface, in an overwhelm-
ing majorit}' of the cases, they will be inside of
the articular cavity ; the bacilli of tuberculosis
are consequently poured into the joint, and a
tuberculous synovitis or arthritis is the result.

Tuberculosis of joints is bj' far the most com-
mon joint disease, so much so that Konig states
that, in the surgical clinics, the surgeon will
have 100 cases of tuberculosis of the joints to
deal with to one of the other classes of inflamma-
tion, such as gonorrhoeal, sj-philitic, septic, osteo-
myelitic, rheumatic, or the metastatic inflamma-
tions subsequent to acute infectious disea.se. Al-
though the statement may seem to the general
practitioner to be carried to the extreme, still the
authority of Konig is .sufficient warrant for the
statement that tuberculosis as a cause of joint
disease far exceeds all others, and that the tuber-
cular arthritides are the everydaj' cases of the
surgeon.

We di.stinguish, as to origin, between primary
synovial and primary osteal tuberculosis of the
joints. Max Scliiiller stated, as a result of ex-
periments, that a slight injury to a joint in a per-

son who had bacilli floating in his blood would
determine localization, commonly in the form of
a synovial tuberculosis. It may be said here
that, as to the relative frequency of the two forms,
it has been shown that the primary osteal tuber-
culosis occurs two or three times as often as the
primary' Synovial. As far as the course and de-
velopment of the articular tuberculosis is con-
cerned, the difference in origin makes little or no
difference — so little, indeed, that we are unable
to make a differential diagnosis, even from the
symptoms.

As to the primarj- osteal tuberculosis of the
joints, we have already seen that an osteo-tuber-
culous infarct is located in the joint from its very
beginning, while the smaller granulation foci
open into the joint secondarily. When located
close to the articular cartilage, this must be de-
stroyed before the joint is invaded, the cartilage
forming a barrier which may sometimes prove
sufficient to resist invasion. A small drj' granu-
lation focus may heal up before perforation takes
place.

When located at the surface of the joint, where
the bone is not covered with articular cartilage,
the thin periosteum and the serous membrane
covering it are more easil}' opened through. An
important complication is when an osteo-tuber-
culous focus is placed right at the insertion of
the capsule of the joint. It ma}' then open in
and outside of the joint simultaneously, or the
one or the other, the saving of the joint depend-
ing upon the few lines of difference. When the
tubercle bacillus invades a joint and tuberculosis
of the joint ensues, all the constituent parts of
the joint will be successivel}' affected, namelj',
the synovial membrane, para-sj'uovial tissue,
ligaments and peri-sj'novial tissues, the articular
cartilage, and finally the articular surface of the
bone.

It is a question whether so light a form of in-
flammation as a simple sj'novitis (whatever that
may be), as mentioned by Kiimmer, can set in as
an effect of either ptomaines alone, from a near
focus, or from extremely weakened tubercle ba-
cilli. A simple serous synovitis of entirelj' be-
nignant character, if it exist, is of extremely
rare occurrence.

Commonh' the presence of the tubercle bacillus
in the joint produces one of the following forms :
I. A pannous hj'perplastic synovitis. 2. A tu-
berous hyperplastic sjniovitis or papillamatous
plastic synovitis. 3. A granular or fungous hy-
perplastic synovitis (Hueter) ; and, 4. The tuber-
culous articular empj-ema (Konig).

I. The pannojis hypcrplasiie synovitis {Hueter').
— The synovial membrane is moderately thick-
ened. From the border of the cartilage a thin
vascular layer of graimlation ti.s.sue creeps in-
over the .surface of the latter, so much so as ta
sometimes cover the larger part of the surface

1889.]

TUBERCULOSIS OF BONES AND JOINTS.

591

and unite with the cartilage, which gradually be-
comes transformed into connective tissue. The
tubercles are usualh' not visible to the naked eye.

2. The tuberous plastic synovitis, or circumscribed
nodular (uberailosis of the synovial membrane . —
The tubercular fibroma is characterized bj^ the
development of a subserous tumor the size of a
walnut or larger, protruding into the joint and
filling, for example, the supra-patellar recess of
the knee-joint, with simple synovitis or pannous
sj'uovitis in the rest of the cavit3^ Such a local
tuberculosis is amenable to extirpation of the
tuberculous tumor followed by recovery. The
papillomatous plastic sj-novitis is a diffuse form
of hj-perplastic tuberculosis, and, as shown in the
specimen, we find the whole inner surface of the
sj'novial membrane covered with sessile or pe-
dunculated papillomatous growths, small and
rather uniform in size, some of which may be-
come detached and constitute the so-called rice
bodies.

J. Diffuse granulating synovial tuberculosis. —
Here the synovial membrane is considerabh'
thickened, hyperaemic, with or without visible
tubercles, always accompanied by invasion of the
para-articular tissue and the ligaments of the
joint. Thus is formed the thick cedematous mass
of tissue, usuallj' of a gelatinous appearance, in
which coagulation necrosis will cause, in the
more drj' forms, islands of cheesj- matter ; m the
more liquid forms, islands of pus, that is, small
multiple abscesses.

Any of the above named forms of synovitis
may give ri.se to the exudation of serous or sero-
fibrinous fluid in the joint, the tuberculous hy-
drops of Konig. A considerable hydrops is
most commonl}^ associated with a diffu.se synovial
tuberculosis, with little thickening of the capsule.
Less commonly it is found in the tuberous and
papillomatous synovitis ; most rarely in the fun-
gous or granulating synovitis. The fluid is clear
in the lighter forms; slightly milky from migratory
corpuscles, or mixed with shreds of fibrin in the
severer forms. So-called rice corpuscles may be
found and derived either from islands of fibrin or
from loosened papillomata. Their presence indi-
cates tuberculosis (Reidel).

4. Empyema artiadationis tuberailosum. Cold
abscess of the joint {Kdnig). — The inside of the
capsule is covered with loosely adherent tubercu-
lous membrane similar to that in tuberculous
abscesses, so loosely connected with the capsule
as to permit of its being scraped off. The re-
maining synovial membrane is diffusely' infiltrated
with miliarj- tubercles, but onlj- slightly thick-
ened, if at all, because of the non- invasion of the
para-.synovial tissues.

The articular cartilage plays, as a rule, only a
passive part in tuberculosis of the joint, as its
fate is destruction or absorption. The cartilage
covering a large sequestrum dies off and is me-

chanically detached from the bone in smaller or
larger pieces. An osteo- tuberculous focus, when
reaching the cartilage, will cause gradual local
absorption, and a local, usually round defect,
through which red granulation tissue or cheesy
matter protrudes. The surrounding cartilage
may be entirely normal and efiicient for the func-
tion of the joint. A primarj- synovial tubercu-
losis has a tendency to develop most intensely in
the region of the capsule at the circumference of
the articular cartilage. From here it has an
easier way down into the vascular bone than into
the non-vascular cartilage, and extends down be-
tween the bone and the cartilage as a tuberculous
osteo-myelitis, creating a layer of tuberculous
granulation tissue that will detach the cartilage
from the bone. Local hyperplastic foci in this
granulation tissue may perforate the cartilage in
many places, just the same as a primary osteo-
tuberculous focus, so that the cartilage presents
the appearance of a sieve. Finally either the
whole cartilage or shreds of it are found loose in
the cavit}' of the joint.

In the pannous synovitis and the dry forms of
fungous synovitis an apparently direct transfor-
mation of cartilage into connective tissue takes
place.

The articular surfaces of the bone, after the
disappearance of the cartilage, present the follow-
ing appearance : In the drj' form, a layer of not
very vascular connective tissue covers the surface
and connects it with the opposite similarlj- trans-
formed surface. In the more moist and suppu-
rating forms, a layer of miliarj' tuberculous tissue
covers the bone with visible, yellow miliary tu-
bercles, extending usually only a short distance
down from the surface. Thus the whole head of
the femur, the acetabulum, etc., is gradually de-
stroyed.

SYMPTOMS.

I. Tuberculous Hydrops, as we have stated, is
common in the diffuse synovial tuberculosis with
little swelling of the capsule, also in the papillo-
matous diffuse synovitis or local tuberous syno-
vitis, but is seldom found in the granulating fun-
gous sj'uovitis. It is characterized by the usual
symptoms of a painless intra-articular accumula-
tion of fluid which usually reaccumulates when
removed, and sooner or later, the tuberculosis
going on, shows some thickening of the capsule
after removal of the fluid.

The prognosis is relatively good because there
is little tendency to destruction of the joint or to
suppuration. Some cases recover after puncture
and rest. Rice bodies, when present, can be felt
to give a peculiar friction sound when moved
from one point of the joint to another. The joint
remains for a long time in relatively good func-
tion which only ceases when, later on, thickening
of the capsule and destruction of the joint sets in.

592

TUBERCULOSIS OF BONES AND JOINTS.

[October 26,

A tubercular fibroma can be felt after the aspira-
tion of the joint as a sessile, more or less movable
tumor, simulating floating cartilage. Simple
arthrotomy and extirpation may prove efifectual.
The tuberculous hydrops is never accompanied
by fever. As above stated, the lighter forms may
recover by aspiration and immobilization. More
obstinate forms require opening of the joint, ex-
cision of the local tumors if found, a partial ex-
cision of portions of the capsule with iodoformi-
zation and drainage. Konig has opened the
knee-joint on both sides of the patella, excised
large slices of the capsule, and seen perfect recov-
ery. However, the result is always uncertain, and
the tuberculosis may in spite of initial, more
conservative treatment, go on to the severe and
more destructive forms, and require more radical
operative measures.

II. Fungous Arthritis, Granulating Synovial
Tuberculosis, White Sivelling, Tumor Aldus, This
is by far the most common form of tuberculosis
of the joints, whether primarj' osteal or primarj'
synovial. No symptoms enable us to make a
distinct diagnosis between a primary osteal and a
primary S3'novial tuberculosis of the joint, but as
we stated in the discussion of tuberculosis of the
bones, the primary osteal form is the most common.
In the knee, the proportion of the pri-
mary osteal to the primary synovial form
is as three to one ; in the hip, four to
one ; in the elbow, four to one (Konig).
As to age, the proportion is in children below 15,
two to one ; above 15, three to one. If it were
possible to know that a large osteo- tuberculous
focus was to be found in a given case of articular
tuberculosis, this knowledge would determine an
immediate operation, and no time would be lost
by conservative treatment. But unfortunately, as
yet the diagnosis is almost impossible.

The fungous arthritis is much more more fre-
quent in the lower than in the upper extremities.
According to Albrecht, out of 325 cases, of which
he gives the statistics, 91 were found in the
joints of the upper extremity, and 234 in those of
the lower extremity. The granulating synovitis
or fungous arthritis presents a great variety of
clinical forms, according to the acuteness of the
onset and the course ; slowness or rapidity of de-
struction, and extent of the infiltration of
the synovial tissues. It is especially the
degree of peri-articular infiltration, its almost
entire absence, or presence, in abundance,
that makes the clinical distinction between
the dry and soft forms so characteristic that
Volkmann has called attention to the former
as a distinct class of cases.

/. The dry granulating tuberculosis, the atro-
phic form, plastic synovitis) Kiimmer'), caries
sicca of Volkmann, so common in the shoulder-
joint is characterized bj' the tendency of the tu-
berculous tissue to cicatrization, and slight ten-

dency to extensive destruction of cartilage and
bone. Absence of invasion of para-articular
tissues results in only a slight or in no swelling
in the region of the joint, which may even be
found atrophic, as in the shoulder-joint from
atrophy of the muscles, or in the hip-joint in
young individuals (Konig) ; more rarely in the
knee. In the shoulder-joint there may be con-
siderable atrophy, and still so much mobility that
the disease may simulate a neurosis resulting in
atrophy of the muscles of the joint. A careful
examination iii narcosis, revealing restriction of
mobility from cicatricial contraction of the tu-
berculous capsule, will enable us to make an
early diagnosis, which is confirmed later on when
peri-articular abscesses form. In a majority of
cases, however, this form has a tendency to come
to an end without the formation of abscesses, ter-
minating simply in a more or less restricted mo-
bility of the joint. Tiry caries of the shoulder-
joint is found not infrequently in young women
(Konig).

2. Fmigoiis arthritis, tumor albus, synovitis
fungosa sive granulosa, is probably the most com-
mon of all the forms of articular tuberculosis. It
is characterized by the softer condition of the tu-
berculous granulation tissue, with tendency to
destructive invasion of all the elements of the
joint, coagulation necrosis and liquefaction. The
invasion of the para- articular tissues causes con-
siderable swelling in the region of the joint, giv-
ing to the latter the characteristic spindle-shape
so frequently found in the knee, elbow and ankle-
i joints ; the swelling being so much the more ap-
parent when atrophy of the muscles above and be-
low has taken place. Extension of the infiltration
from the para-articular tissues out towards the
subcutaneous tissues finally causes the swollen
joint to be covered with a whitish, immovable,
dense skin, giving the joint the appearance from
which the time-honored name of white swelling
is derived. In the beginning of the disease a
slight degree of hydrops is found in a few cases ;
most often the cavity of the joint contains no
fluid, or not a sufficient amount to be recognized
by palpation. Later in the disea.se liquefaction
in the islands of coagulation necrosis in the
islands of soft granulation tissue gives rise to the
presence of tuberculous pus. This may be found
as small foci in the soft granulating capsule,
small abscesses inside of the granulation tissue,
or as pus from the cavity of the joint. At this
stage of the disease, especially in the .softer form
of tuberculosis, the peri-articular abscess is
formed. Most commonly a local destruction of
the tuberculous capsule facilitates the invasion of
the peri -articular inter-mu.scular spaces by the
tuberculous pus already contained in the joint ;
and a more or less rapid increase in size of the
ab.sce.ss cavity in the direction of least resistance,
causes the formation of more or less distant ab-

1889.]

TUBERCUI.OSIS OF BONES AND JOINTS.

593

scess cavities, which of course, alwaj's lead into
the ca\'ity of the joint. More rarel}-, peri-articu-
lar abscesses form directl}- from an osteal focus
b}^ the extension of a ma.ss of tuberculous granu-
lation tissue, extending through the capsule out
into the peri-articular tissue, as a primar}^ mass of
solid granulation tissue in which liquefaction
takes place secondarily. A peri- articular abscess
originating in this way may attain the same size
as that previously mentioned, but owing to its
original form a local osteo-tuberculous focus is of
less prognostic importance, inasmuch as it does
not necessarily indicate suppurative destruction
of the cavity of the joint. This latter form of
abscess may be opened and evacuated and may
then close up with or without the removal of the
osteo-tuberculous focus and still leave the joint in
a more or less unimpaired condition; while on the
other hand, the peri-articular abscess communi-
cating directly with the destroyed joint cavity
has no tendency to come to a close, but leaves
fistulous openings which keep open permanently,
and only too often, when not protected bj^ anti-
septic dressings, sooner or later, furnish a place
of invasion for pus microbes, adding acute sup-
puration or sepsis to the tuberculosis, and giving
rise to a rapid increase in the destruction of the
articular surface.

A fungous arthritis, when limited toasinglejoint,
will rarelj- cause any rise in temperature. High tem- \
perature is always indicative of a mixed infection |
with pus microbes, or what is very rarely met
with, general acute tuberculosis. Bj- far the
most common is the mixed infection which comes
from without, the pus microbes entering the open
and unprotected peri-articular abscess. It is very
exceptional that auto-infection, that is, invasion
of a closed tuberculous joint by floating pus mi-
crobes from a distant place of invasion, takes
place. A slight rise in temperature, remittent or
intermittent, however, commonlj' accompanies the
formation of tubercular peri-articular abscesses.
A temperature of 100° to 101° in the evening
with normal morning temperature is indicative of
this complication, and this, as first pointed out
b}- Konig, is an important diagnostic symptom.

Contractions, lateral deviations or other abnor-
mal positions of the articular surfaces, usually
signify destruction of the articular ligaments and
articular surfaces. Thej' are thus not seen in the
articular hydrops, or the lighter forms of syno-
■ vial tuberculosis, while we find them in tumor
albus, or the destructive forms of para-arthritis.
Konig ver>- properly uses the term "destructions-
contractur" (contraction by destruction), for
these displacements, in preference to the usual
term of spontanieous dislocations, and employs the
latter expression to signif\- the condition when
through muscular contraction or a slight injury
to the joint, whose strengthening ligaments are
destroyed, a sudden, very painful and often con-

siderable displacement takes place. This is es-
pecially common in the hip-joint. The clinical
importance of any of these displacements lies in
the fact that they signify a certain amount of de-
struction of the joint, thus often indicating surgi-
cal interference.

Pain as a symptom accompanying tuberculosis
of the joint, although always present, is of ex-
tremely variable intensity ; two patients with an
apparenth' similar degree or form of tuberculosis in
the knee-joint may diflTer so much as far as pain is
concerned that the one maj- be able to walk almost
without pain, while in the other, the slightest
movement will cause intense suffering. Although
the intensity of the pain does not give any abso-
lutely certain information as to the extent of de-
struction of the joint, it may be said that in gen-
eral, the more acute destructive forms of tubercu-
losis are the more painful, and further, that in-
tense pain on movement may mean large intra-
articular osteal foci, and extensive intra-articular
destruction ; while slight pain would indicate
that the articular cartilage was as yet compara-
tively intact. A sudden attack of intense pain
sometimes means that perforation of an osteal
focus into the yet intact joint cavitj' has taken
place. It is of more practical importance when
we find a local painful spot on the articular ex-
tremit}^ of the bone, especialfy when it is outside
of the usual line of the swollen and tender cap-
sule. Inasmuch as this may indicate an osteal
focus if the tender spot shows some localized soft-
ness or swelling, it is of even more significance
in this direction, and indicates a local operation
which may save an as yet comparatively intact
joint.

J. Cold Abscess, the Pyarthrous Tiibeiadosis, is
rare. Its most typical form is found in diffuse
miliarj^ tuberculosis, and a less typical form, that
is, less fluid in the joint, in the soft forms of
granulating tuberculosis. The onset is usually
acute, often with considerable pain accompanied
by fever, so as even to simulate suppurative syno-
vitis. There is a tendencj- to destruction of the
capsule and the early formation of large peri- ar-
ticular and inter-muscular abscesses. The symp-
toms of general acute tuberculosis are likely to
set in sooner or later.

DIAGNOSIS.

As a rule there is no difficultj- in the diagno-
sis of tuberculosis of the joints when the history,
course and symptoms of the disease are taken
into consideration, as above stated ; but, as
Konig justl)' remarks, it is well to remember that
an articular tuberculosis even of the large joints,
is practically a local disease, and has for a long
time little or no influence on the general health
of the patient. Thus we may find patients ap-
parently strong and healthj'-looking suffering
from articular tuberculosis.

594

TUBERCULOSIS OF BONES AND JOINTS.

[October 26,

The hydrops tuberculosis is distinguished from
a "common articular hydrops," whatever that
may mean, traumatic, for instance, by its persis-
tency and tendency to relapse as soon as the
joint is put to use again. Flocculi of fibrin or
rice bodies indicate tuberculosis.

The tubercular fibromas might be mistaken for
lipoma arborescens or gummata. The diagnosis
of the latter will be cleared up by anti-specific
treatment, which should always be tried in cases
of doubt.

Cold abscess is distinguished from the suppu-
rating synovitis by less pain, some swelling of
the capsule, and the frequent presence of tuber-
culosis in other organs.

The fungous synovitis or pan-arthritis rarely
causes any diflSculties in diagnosis. The elastic
swelling, comparatively painless abscesses or
fistulous openings with fungous granulation tis-
sue protruding are characteri.stic. It can be dis-
tinguished from acute multiple osteo-myelitis of
the articular surfaces b}^ its slow and compara-
tively painless onset, and the slight tendency to
anchylosis as compared with the latter.

The caries sicca of Volkmann, ordr}- cicatricial
atrophic tuberculosis, especially as found in the
shoulder-joint, might be mistaken for a neurosis
with atrophy of the muscles covering the joint.
An examination in narcosis will reveal some loss
of mobilit}' in the tuberculosis as compared with
the absolutely free mobility in neurosis. Exact
measurement may reveal some shortening, that
is, articular destruction in the tuberculosis.

PROGNOSIS.

It is almost impossible in any given case of
articular tuberculosis to state the future fate of
the joint, inasmuch as the course of the tubercu-
losis is in the highest degree atypical. Konig
states that all forms and cases of tuberculosis of
bones and joints are capable of spontaneous re-
covery with more or less loss of function ; but it
may be stated as a general rule that the softer
and more acute the tuberculosis, the larger the
osteal foci, the earlier the suppuration and the
less careful the early treatment, the more grave is
the prognosis. An apparent recover}^ is always
uncertain as to its duration, inasmuch as relapse
or rekindling of the tuberculosis is likely to take
place at any time. The articular tuberculosis
usually extends over man}' years, especiall)' the
fungous pan-arthritis. The caries sicca may, ac-
cording to Konig, come to an end in two or
three years with some loss of mobility. Lighter
forms of .synovial tuberculosis or articular hy-
drops may disappear by proper treatment in a
much shorter time.

As to the question when it can be said that re-
covery or disappearance of the tuberculosis has
taken place, we may be guided by complete dis-
appearance of the pain and swelling, and by the

painlessness of what mobility has been left in the
joint. As has been stated before, complete an-
chylosis is rare, but when it takes place it gives
this advantage, that the pain disappears, even
when the tuberculous foci are left in the capsule
or the bones.

As to the prognosis in difierent ages, it may be
said in general that children will more easilj' re-
cover even from a severe articular tuberculosis
than adults — a fact that permits of more exten-
sive conservatism in the treatment of tuberculo-
sis in early age. This is an important fact, as
the articular ends, as is well known, play an im-
portant part in the growth of the extremities, and
destructive operations in children are apt to leave
useless limbs from lack of growth.

The danger to life from articular tuberculosis
presents the following points for consideration :

1. Sepsis, a secondary invasion of the pus
microbes into the joint and peri-articular ab-
scesses, is not uncommon. The pus microbes in-
vade, not by auto-infection, but through careless
or rather non-antiseptic treatment of spontaneous
or artificial openings leading to peri-articular
abscesses, It may thus be said that although
practically this complication is not an uncom-
mon one, it can be prevented bj' careful, system-
atic, antiseptic treatment. The difficulty is that
the fistulous openings into tuberculous joints re-
main open for months and years, attendants and
patients grow careless in course of time, and late
septic invasion takes place.

2. General tuberculosis, acute or chronic, is
much more grave, since it is impossible to pre-
vent it. In the course of years a number of pa-
tients succumb to this complication. Billroth
states that in sixteen j'ears 27 per cent, were lost
in this way. Konig, from a table of 117 opera-
tions for tuberculosis, found that after four years
16 per cent, had died from general tuberculosis.

3. It has recently been pointed out by various
authors, especially Konig, Wartmanu, and Al-
brecht that operations on tuberculous joints maj'

' cause immediate infection, the so-called opera-
tion tuberculosis. This complication is not very
I common ; Konig in his extensive experience has
I seen only sixteen cases, and Wartmann, from a
collection of excisions amounting to 837 cases
I with 225 deaths, found only twenty-six cases of
I operation tuberculosis. It sets in, as Konig de-
'' scribes it, seven to ten daj's after an operation,
which may be aseptic and heal by first intention,
either as acute tuberculosis of the lungs or tuber-
I cular meningitis, terminating in death three to
I four weeks after the operation. Sometimes in
cases where the operation is followed by suppu-
ration and secondary operations become neces-
sary, it follows these.

4. A number of patients in the course of
! years succumb to amyloid degeneration of the
i spleen, the liver and especially the kidneys, with

1889.]

TUBERCULOSIS OF BONES AND JOINTS.

595

its accompanying dropsy, which takes away some
of the survivors.

I shall say nothing as to the treatment of the
articular tuberculosis, inasmuch as this question
belongs to special surgery, and would be alto-
gether too extensive to be taken up in the time
allotted by this Society to the discussion of the
question of tuberculosis.

However, before leaving the field of tuberculo-
sis I want to call the attention of the Society to a
comparatively rare localization of the tubercle
bacillus, and to an affection that has only been
recently recognized as such, namely,

TENDON TUBERCULOSIS.

Tendon tuberculosis is a necessary appendix of
tuberculosis of the joints. I do not mean tuber-
culosis of the tendons where the tuberculosis
creeps out along the tendons from a tuberculous
joint, as 3'ou find it around the tendo Achillis
from the ankle joint, or the flexor tendons of the
arm from a tuberculous wrist-joint ; but I mean
primary tendon tuberculosis, which is on an
equal footing with any other primary synovial
tuberculosis. The subject of tendon tuberculo-
sis is a new one. French authors more than
thirty years ago called attention to a so-called
fungous tendon synovitis, describing it, as far as
gross appearances go, very well, but of course
they did not come to an understanding about its
pathology any more than about that of the so-
called synovitis of the joints. Nothing was done
until 1875 when Volkmann' gave a masterly de-
scription of the tendon tuberculosis, but without
recognizing it as a tuberculosis. Then came
Riedel, Konig's assistant, who showed that the
rice bodies so commonly found in the so-called
fibrinous hydrops of the tendon sheaths, or hy-
gromas of the flexor tendons of the hand always
indicate a synovial tuberculosis.

I wish only to say a few words about the
pathology of this form of tuberculosis, because
as far as it needs treatment, it is a synovial tuber-
culosis— a fungous synovitis. It is a tuberculosis
with an enormous development of tuberculous tis-
sue in the sheath of the tendon and on the ten-
don itself In the sheath of the tendon it forms
a layer of from one to four lines in thickness, of
the usual well-known gelatinous tuberculous tis-
sue. On the tendon it forms a similar laj-er
usually smaller and with that important anatomi-
cal feature that this granulation tissue creeps
down between the bundles of the tendon and
separates them until finally it makes a perfect
brush out of them ; then atrophy of these sepa-
rate bundles of the tendon takes place and the
tendon ruptures — a spontaneous rupture in the
same sense as a spontaneous fracture, that is, that
with a very slight movement the tendon tears. If
left alone this tendon tuberculosis has the same

' Beitriige zur Chirurgie.

fate as tuberculosis of the same character in other
parts of the body ; it goes on to liquefaction of the
tubercles and the .surrounding tissue, and pus, if
we may so call it, tuberculous pus without the
pus microbes, forms. This abscess is opened or
breaks spontaneously, leaving tuberculous fistulae
with no tendency to heal, just the same as fistu-
lae leading into tuberculous joints. The same
fate, as with all other tuberculous tissue, will be
the result of the opening, namely, that if septic
invasion from without takes place, that is, if the
tuberculosis is not removed at that time, or anti-
septic precautions taken, then sepsis sets in and
finds a congenial soil in the tuberculous tissue,
an excellent culture soil for the common pus mi-
crobe ; just the same as in tuberculous abscess
from Pott's disease, or tuberculosis of the verte-
bral column, in which the opening is, in the large
majority of cases, the beginning of the end. Ten-
don tuberculosis most commonlj^ attacks the
flexor tendons of the hand ; then we have the so-
called hygroma of the hand with its swelling in
the palm and above. These are undoubtedly
always tuberculous ; further we find isolated ten-
don tuberculosis in the extensor tendons of the
hand, more rarely in the tendons of the lower ex-
tremity, as the patellar ligaments, of which I have
seen one case.

I wish to present a patient to-night who has
kindly consented to come down and show his
hand. The history is as follows :

John Harrington, laborer, aged 35. Family
history good. The present trouble commenced
about three years ago when the patient noticed a
slight painless swelling on the dorsum of his
hand. A watery fluid collected which was re-
moved but collected again ; the increased swell-
ing gave rise to severe pain and inabilitj^ to flex
the fingers. After a few months the swelling
broke spontaneously, and there was a sero-puru-
lent discharge. This discharge continued for
about two years, the swelling increasing slightly,
until October 27, 1888, when the patient came to
my clinic at the College of Physicians and Sur-
geons.

Examination revealed a swelling about five
inches long in the median line of the dorsum of
the hand extending from about one and one-half
inches from the metacarpo-phalangeal articulation
to beyond the wrist-joint.

Diagnosis : Tendon tuberculosis of the exten-
sor tendons of the hand. An incision was made
extending from within half an inch of the meta-
carpo-phalangeal articulation, seven inches up the
forearm in the median line, over the .swelling.
The incision was made down to the mu.scles and
tendons and a quantity of rice bodies removed ;
these were also found inclosed in the sheaths of
each of the tendons when opened. The sheaths
of the extensor tendons were removed and each
and every tendon was thoroughly scraped to re-

596

MEDICAL PROGRESS.

[October 26,

move the tuberculous material. The extensor
tendon of the thvimb was divided, it being impos-
sible to separate the tuberculous tissue without
this. The tendon was united to one of the other
extensor tendons. The integument was sutured
with silk and the hand and forearm dressed anti-
septically. One week after the operation the
wound had united, and the sutures were re-
moved and the hand dressed. Two weeks after
the operation there was good union. Four weeks
after the operation flexion and extension of the
fingers was regained. There was no sign of
return of the disease.

When this man came for operation, one of the
tendons, the short extensor of the thumb, was
destroyed ; the others could be separated from
the tuberculous tissue. This dissection of the
tendons from the tuberculous tissue takes a long
time. It has to be done with the utmost care be-
cause the tuberculous tissue that runs down be-
tween the fibres of the tendons is adherent ; there
is no short way of rubbing it ofiF the tendons, it
must be dissected ofi" carefullj^ particle by par-
ticle, and then the whole sheath of the tendon
dissected ofi" with scissors and forceps, just as
carefully as in the joints, particle by particle, and
this law holds good in all operations for tubercu-
losis. Then come the difiiculties of dressing. It
has been found that in dressing with drainage
tubes, antiseptic washes, etc. , the results are not
as good as if the wound is left to heal by the or-
ganization of an aseptic clot, as L,ister called it.
But this healing without drainage implies that
the wound shall be filled with blood. No exact
union of the wound is made, but a couple of
spaces are left between the sutures so that the
surface blood can get out. Schede recommends
this method, having found that the connective
tissue formed in the nidus of the clot was more
pliant than the connective tissue formed when
there was drainage. That method was used in
this case, and the consequence is that much more
extension than before is possible. This patient
also shows a tuberculosis of a metacarpo-phalan-
geal joint.

The prognosis as to the future functions of the
tendons depends upon perfect asepsis (if there is
not perfect asepsis then the result is lost) ; sup-
puration must not take place after the operation.
It further makes a great difference as to the
future function of the hand whether the tubercu-
losis is on the dorsal or on the palmar side. On
the palmar .side of the hand where we have to
open from the palm up to the middle of the fore-
arm, the palmar ligament may be divided and re-
united with sutures, and it may be necessary to
to do this so as to dissect out the wall of the com-
mon tendon sheath. Tuberculosis in the palm
of the hand gives much less satisfactory results
after operation for removal of the tuberculous
sheath from the tendon, than on the dorsal side

of the hand. Another point is that when the
tuberculosis has reached the upper end of the
tendons it creeps up the muscles not only in the
loose connective tissue, but up between the
bundles of the muscular fibers. This we can rec-
ognize with the naked eye bj- the color and con-
sistency of the muscle. The invaded muscle be-
comes hard and grayish and is not shining as the
normal muscle tissue. Of course all this tissue
has to be cut away carefully, because it is one of
the modern improvements of our technique in
operating for tuberculosis that everj' part of the
diseased tissue is carefully removed from the
joints by scissors and forceps, so as to leave, if
possible, no tuberculous tissue at all. This
makes a verj' different operation from the one
where the bones are sawed off" from the joints,
for instance, and the abscess drained, no care
being taken either of the walls of the abscess or
the cartilage, the consequence being that the tu-
berculosis very often grows right out again and
there is greater liabilit}^ to sepsis setting in.
These operations are long and tedious, but if per-
fect asepsis is secured we may expect the results
to be locall}^ permanent. Tendon tuberculosis is
a rare disease; it exists only in i or 2 per cent, of
the cases in the statistics of tuberculosis.

MEDICAL PROGRESS.

Intussusception and the Use of Injec-
tions.— (By "W. E. Forest, M.D., of New York.)
In the Medical Record for August 3, is reported a
case of intussusception in a child relieved by the
use of sulphuretted hj^drogen gas from a Bergeon
apparatus. It is stated that this is the first case,
as far as known, where the Bergeon apparatus
has been used for this purpose in this State.

However admirable this method maj- be in the
treatment of the condition in question, if another
method can be shown to be as eff"ective and more
safe, more simple, and more scientific, the former
should give way to the latter.

Without further introduction, I will suggest to
Dr. Rodenhurst and the profession in general, a
method that will meet the requirements men-
tioned.

In using injections of either gas or liquid to
overcome intestinal obstruction, one ought, if
possible, to know two things, namely : i. How
much force (approximatehO the intestine will
stand without danger of rupture. 2. How much
force one is using at an}- moment in giving the
injection.

As to the first point, a series of experiments made
by me and detailed in a paper read before the New
York Academy of Medicine, and published in the
Journal of Obstetrics in 1886, would seem to show

1889.]

MEDICAI, PROGRESS.

597

that it is not safe to use an injection with a
pressure exceeding fifteen pounds to the square
inch in a case of intussusception, and this only in
adults. In infants the pressure should not ex-
ceed six or eight pounds to the square inch (see
fou7nal of Obstetrics. )

Now, with the Bergeon apparatus a greater
pressure than the above might be used, I sup-
pose. With the Davison syringe I have shown
that a pressure of from thirty to seventy pounds
to the square inch ma}- be exerted on the in-
testine, and hence a verj- dangerous pressure.

The objection to the Bergeon apparatus, aside
from the fact that one cannot measure and regu-
late the pressure accurately, is its cost and cum-
bersomeness as compared with the apparatus I
have suggested in the article referred to.

In order to measure the pressure used in an
injection, it is onlj' necessary- to remember that
one atmosphere, or fifteen pounds to the square j
inch, supports a column of water thirty-three j
feet high ; hence a column of water thirty-three j
feet high will make a pressure of fifteen pounds
upon e\'er}' square inch of surface at the base of i
the column.

Now, if this column of water be held in a rub-
ber tube of ordiuarj- size, after allowing for fric-
tion of the water in the tube, it will be accurate
enough to say that ever}^ two feet of the column
represents a pressure of one pound to the square
inch ; hence a rubber tube six feet long, filled
with water and held vertical, will cause a pres-
sure of three pounds to the square inch at its
base ; and a tube twelve feet long will exert a
pressure of six pounds to the square inch at its
base ; and so on.

Now, apply this principle to a case of in-
tussusception in a child, for instance. The sur-
geon, instead of sending to the nearest cit}- for a
consultant and a Bergeon apparatus, goes to the
drug store or hardware store and gets a rubber
tube twelve to twenty feet in length. Into one
end is inserted a funnel ; into the other a nozzle '
of a Davison syringe. In order that the injected j
fluid may be retained, a shoulder may be made |
on the nozzle about one inch from the end, by
winding a roller-bandage around. This shoulder |
will retain everj' drop of the injection when
pressed against the sphincter. Now a pitcher of
warm salt-water completes the apparatus, and
the father of the child is the assistant surgeon.
The patient is taken into the hallwaj' of the
house, so that the requisite elevation may be
gained, the child is etherized, the surgeon in-
serts the nozzle of the syringe and holds it in the
rectum with one hand, while with the other he
manipulates the walls of the child's abdomen.
The assistant pours the water into the funnel and
slowly raises it, mounting the stairs at the time
if necessary. When the funnel has been raised
twelve feet above the level of the child's body.

great care should be exercised, as the pressure is
now about six pounds on everj' square inch of
colon below the obstruction. It is seldom that a
greater pressure than this will be needed to re-
duce a recent invagination. The pressure should
be increased verj- slowly, as time is an important
element in reducing an invagination.

If in any case the pressure mentioned above
does not bring about the end aimed at, the pres-
sure may be increased up to ten pounds to the
square inch.

For further details as to the method and when
to employ it, as well as for a simple and cheap
method for generating gas and its use in reducing
an intu-ssusception, I must refer to the article in
the AmaicaJi Journal of Obstetrics for 1886.

In that article are the histories of two cases of
intussusception successfully reduced by gaseous
and fluid enemata introduced from a syphon of
Vichy water.

Since publishing the method for the use of a
column of water. Dr. A. S. Hunter, of this city,
has used the method successfully in a case of in-
vagination in a child. — Medical Record,

Medical Treatment of the Intestines. —
In concluding an article on the subject of intes-
tinal obstruction {Medical Press) Prof. H. Noth-
NAGEL says :

"I may briefly state in one sentence all the
treatment I can recommend as an hospital con-
sultant : Absolute abstinence from food ; induce
the peristaltic action from below ; still it from
above ; and above all, avoid purgative medicines.
Further I know of nothing to add for the guid-
ance of others.

' ' As regards other methods of treatment, very
little can be said, but there are one or two forms
of recent origin which I cannot pass without a
remark. Washing out the stomach was intro-
duced by Kussmaul as a remedy, but past expe-
rience of this form of treatment has nothing par-
ticular to commend itself, and has been of very
little use. One advantage in using it is that it is
a harmless application, and there is not an}- dan-
ger attending its use. The clyster I can alwaj-s
recommend as a most effectual remed}- in all forms
of faecal accumulations, but it is not suitable for
faecal vomiting where there are inflammatory- con-
ditions. The object of a large clyster is to break
up large faecal masses, but this is to be avoided
where there is a tender bowel. Electricity is an-
other remed}' which has come into recent favor,
and is not without merit. When using this agent
it is recommended that both poles be placed over
the tender or painful part of the bowel, or one pole
introduced into the bowel. The successful cases
from this treatment are so few that no opinion
can be vouchsafed. There are other drugs, like
belladonna, nicotine, and others that might be
named, but there is one regularly prescribed drug

598

MEDICAL PROGRESS.

[October 26,

that might be noticed. There was a time when
every stoppage of the bowel must be drugged with
mercury, but the greater number of the observers
of this treatment have spoken very adversely of
it. No doubt an individual case has arisen where
success may be attributed to the drug, but these
are very few, and leave us in grave doubt when it
should be used at all. If the tradition of this
drug tempts you to its use in any form of vomit-
ing, I beg to consign it to your charge with care,
and trust that you will carefully use your own
judgment in applying the drug where the least
danger exists. In concluding my observations on
the medical treatment of the bowel, I felt it my
duty to say that the most severe cases that we
meet in our daily practice are frequently beyond
the reach of our medicines, when arising from
locking of the bowel, and properly belong to the
region of operative surgery for their relief." —
The Canada Lancet.

A Case of Abdominal Gestation. — Dr. H.
Kreutzmann, of San Francisco, reports a case
of this description with the following interesting
details : The patient, aet. 37 years, had borne
two children and had twice miscarried. In Feb-
ruary, 1888, she believed herself to be again preg-
nant. The last menstruation was on January 20.
Two months later she had a haemorrhage from
the genitals — this was regarded as a miscarriage.
From that time a sero-sanguinolent discharge took
place, and repeatedly during the next two months
fleshy masses were removed from the vagina. In
the meantime the usual signs of pregnancy were
apparent, in addition to which there was acute
acute abdominal pain. Later on fcetal mov^ements
occasioned great pain. There was much vomit-
ing. At about the period of her expected con-
finement she experienced excruciating pain of a
bearing down character, then the pains suddenly
ceased. Attempts were made to deliver the wo-
man/(jr vias natiirales. From this time on the
patient's condition became much worse and she
sank rapidly from fever and exhaustion. The
patient was first seen by the reporter November
26, at which time she was extremely feeble; pulse
120, temp. 102°; abdomen very tense and tender.
An examination under ansesthesia revealed a tu-
mor filling lower abdomen and reaching as far as
the umbilicus, above which there was tympanites.
The OS externum was slightly dilated and the pos-
terior cul-de-sac was filled with a hard mass. The
OS uteri was then dilated by instruments and the
cavura uteri found empty. Corpus uteri was pal-
pable. Extra-uterine pregnancy was diagnosti-
cated. Seven weeks after death of the fcetus lap-
arotomy was performed by Dr. Fred Hund. Upon
opening the peritoneum there was an escape of
fetid fluid and gas. A full grown macerated fetus
was extracted. The ovisac was everywhere ad-
herent. The posterior cul-de-sac was occupied

by the placenta, which was left in situ. The pa-
tient did well at first but finally died of inanition
on the seventeenth day. The autopsy revealed
extensive adhesions of the ovisac to the intestines.
Death was due to ichoraemia. The reporter be-
lieves that in every case of extra-uterine preg-
nancy up to sixth month laparotomy should at
once be resorted to — the same holding good in all
cases, regardless of time, where the fcetus is dead.
Cases which have reached the sixth month, with
the foetus living, and which are distinctly abdom-
inal ones, should be operated upon at term to re-
cover a living child. The aim should be to remove
the entire ovisac and its contents at once. — Pacific
Med. Jour., September, 1889.

Tuberculosis of the Sacro-Iliac Joint. —
Dr. Ludwig Hektoen, of Chicago, gives a
very complete and interesting account of such a
case, together with a complete and careful anal-
ysis of the post-mortem findings. He also gives
brief reports of five other recent cases of similar
character, one of which is notable as being the
sole authentic instance on record of a primary
synovial tuberculosis of the sacro-iliac joint. In-
corporating these cases with the 55 collected by
Van Hook he gives the following tabulated exhi-
bit of the locality of the abscesses in the entire
group :

Pointing posteriorly, 20 abscesses (i. e..,
immediately over the joint.

Dissecting upward (pointing in gluteal
region), 2 abscesses.

Dissecting downward (pointing in glu-

Extra-pelvic, 25, or 41 per
cent.

r

Intra - pel-
vic, 36, or
59 per ct.

Dissecting upward
to lumbar reg'n, 1
^ abscesses.

Dissecting outw'rd
and forward.

teal region), 3 abscesses.

r Under periosteum, i abscess.
I r Without finishing

exit anteriorly, 7
Under the 1 abscesses.

ileo-psoas. 1 Toward insertion of
I the ileo-psoas, it
( abscesses.

Dissecting directly

downward.

I. One thro'
scia t i c
notch.

Through gluteus, 5

abscesses.
Downward to thigh,

3 abscesses.

I. Inward f Rectum, 2 abscesses,
toward the |

ischio -rec-l Perineum or anus, 3
[ tal fossa. (. abscesses.

— North Am. Practitioner^ Oct., 1889.

To Prevent Abortion. — Dr. Q. C. Smith
suggests the following :

Fluid extract of ergot.
Fluid extract of black haw,
Tr. belladoiiua,

Tr. ipecac, aa f ^5 j. "J!.

Sig. — A small teaspoouful, t. d., after meals.

It is said to be especially suited to the preven-
tion of habitual abortion, caused by deranged
constitutions, and is also very effective for allay-
ing uterine irritabilit}'^ resulting from traumatism
or external violence. Of course the bowels
should be kept comfortably open regularly. Op-
ium is not admissible in this class of cases, un-
less it is desired to terminate pregnancy without
delay. — Nashville Journal Med. and Surg,

1889.]

EDITORIAI^.

599

Journal of the American Medical Association

PUBLISHED WEEKLY.

Subscription Price. Including Postage.

Per annum, in Advance $5.00

Single Copies 10 cents.

Subscription may begin at any time. The safest mode of remit-
tance is by bank check or postal money order, drawn to the order
of The Journal. When neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
letters.
Address
JOURNAI, OF THE AMERICAN MKDICAI, ASSOCIATION,
No. 68 Wabash Ave.,

Chicago, Illinois.
All members of the Association should send their Annual Dues
to the Treasurer, Richard J. Dunglison, M.D., Lock Box 1274, Phila
delphia, Pa.

London Office, 57 and 59 Ludgate Hill.

SATURDAY, OCTOBER 26, 1889.

MEDICAL SOCIETIES AND ORGANIZATIONS.

Organization and division of labor is a theme
that is of practical everyday interest to all think-
ing men. It engages the attention of statesmen,
politicians, philosophers and financiers, as well
as of the laborer, artisan, manufacturer, merchant
and professional worker.

In the struggle for existence and rivalry for
supremacj', effective, congenial organization is
the very first act for consideration. It precedes
all forms of government, and antedates all corpo-
rate existence. Corporate organization keeps
step in the most beautiful manner with the de-
velopment paces of the scientific investigator.

Without the invention of the lamp chimney the
Standard Oil Company would never have breathed
the breath of life, in the form of an organization
that within a score of j'ears has built a number
of colossal fortunes, and moulded the acts of pow-
erful State Legislatures as if thej- were clay in
the hands of the potter. One man, even with
kingly authority, could not have done this, but
an eifective, congenial organization was equal to
the occasion.

In the last century the East India Company
became more powerful and wealthy than the
crown of England, and it is very questionable
to-day whether organized corporate power is not
greater in this country- than the political power.
We are quite sure it would be the greatest if our
form of government were any other than republi-
can. Men of all occupations recognize the power
and necessity of corporate organization, in order

to the accomplishment of any specific purpose of
magnitude.

In our profession as practitioners of the healing
art, whether engaged in making bedside observa-
tions, or delving in the unknown, with or without
the aid of instruments of precision, that may be
fitly spoken of as supplying a third hand and eye;
division of labor and society organizations are an
absolute necessity. The results of the labor of
any one man are usually small, but as an integral
part of the labors of a whole profession that has
an effective organization, his value may be com-
pared to that of the pinion wheel in a watch ;
without which the entire remainder is entirely
valueless as a timekeeper.

Hence, the necessity and use of professional
organizations, where every member will be a liv-
ing factor, properly adjusted and in the place
where he will fill his mission in doing the great-
est possible amount of good to himself and his
fellow men.

The village and city, county and State, district
and National societies all have their place, and as
every member of the most obscure society has his
definite place in that organization, so should all
organized medical societies be brought together
in order to become and form one unified, composite
body, complete in all its parts, and embracing
within its folds every reputable member 'of the
medical profession in this wonderland of ours.

Through the medium of a perfected system of
organization, the results of all observations,
thoughts and investigations, may be deftly placed
in their proper niche for utilization for the com-
mon good.

For lack of necessarj' facilities for presentation
to and through some society organization, many
a valuable discovery has literally been lost, not
only to the medical profession, but its benefits for
an indefinite time have been withheld from the
entire world.

Not infrequently the reading of an elaborate
paper brings out in discussion a greater and more
valuable fund of information than the author was
able to obtain through weeks of labor in scanning
all the books and journals at his command.

The frictions of all society meetings have their
beneficial effects. The conscious or unconscious
ego that is apt to be a part of every educated
man, is often rasped, filed, sandpapered and final-
ly rubbed down to a polish that is always more

6oo

HOME TREATMENT OF CONSUMPTIVES.

[October 26,

becoming to an accomplished and well-bred phy-
sician, than the rough jewel he was before the
process was undertaken.

With a marvelous growth of population, medi-
cal science has kept abreast of the times. Rapid
transit by means of steam and electric motors ;
cheap and practically instantaneous intercommu-
nication have absolutely revolutionized commer-
cial methods of business, and singularly enough
they have in like manner influenced the ways of
the medical practitioner. He is summoned by
telephone or telegraph and often imparts the most
important and vital directions through the same
instrumentality.

The physician of the period has ceased taking
and looking ' to a cumbrous quarterly or half
yearly medical magazine for his current literature,
and nothing short of a weekly meets his arbitrary
and hungrj' demands, while the doctor who has
prepared a paper for publication and does not
want it printed and sent on its mission within a
week, is a rare man; his family are suffering from
a mortality that will only remind us of those sad-
dest words of tongue or pen — "what might have
been."*:

The local medical society is a most important
factor in our professional organization. Every
such society fitlj' represents a cog in the great
driving wheel of progress.

Noting the scientific value 01 society organiza-
tion and the incalculable benefits to be derived
from the accumulated wisdom unfolded and un-
bidden at the meetings, we are not to forget that
one of the great benefits conferred, is the oppor-
tunity furnished by the occasion for a cultivation
of peace, amity and goodwill. The people and
practitioners alike are benefited in promoting in-
clinations for consultations, and in this manner
demonstrate to the world the brotherhood of man
as exemplified in our profession, and the cosmo-
politan character of our art. |

Professional activity has already accomplished
a world of good in organizing and fostering the
growth of medical societies, and now there is no
more important question open for discussion than
the comprehensive one as to what are the best
methods to be u.sed, in order to bring abont a
complete unification of the entire medical profes-
sion in their society organizations. In a recent
issue of The Journal, we endeavored to indicate
a feasible plan for bringing about a unification of

the entire medical profession of this countrj',
through the organization and incorporation of
district and other kindred societies as actual
branches of the American Medical Association.

The comments directly received and borne to
us have been of a favorable and gratifying char-
acter. It is our desire that the subject, which we
regard as a very vital one to the Association it-
self, as well as to the entire medical profession,
shall have the widest possible attention and dis-
cussion.

Organization means power and influence. The
more thorough and complete it is made, within
the most liberal bounds, correspondingl}' will the
power and influence be great for the welfare of
science, the entire membership of our profession,
and that of the people.

THE HOME TREATMENT OF CONSUMPTIVES.

Sad indeed is the outlook for the consumptive
who is unable to seek a change of climate when
that of his home is not suited to life out of doors.
So uncertain are all means directed to the local
treatment of pulmonarj' tuberculosis, even Wei-
gert's hot air inhalations, that the greatest hope
of arresting the disease lies still in its proper cli-
matic management. By far the largest number
of consumptives, however, is compelled to forego
this chance of recovery and rel}- upon the phy-
sician and nurse. In only too man)' instances the
former falls into a drearj' routine born of hopeless-
ness, while the nurse is but too often an ignorant,
inexperienced, though loving member of the
family. This is deplorable. If for good and suf-
ficient reasons the doctor does not resort to ex-
pensive local measures, but is satisfied if he can
merely ameliorate the patient's condition and
prolong life, he should at least manage the case
intelligentl}^ and conscientiously. It is safe,
probably, to assert that the average practitioner
employs means to mitigate symptoms which in
the end defeat the object aimed at. For example
take the cough. This is often most harassing
and the cause of the sufferer's chief complaint.
What is usually given to relieve it ? A cough
mixture, generally a cough syrup containing
opium or one of its alkaloids. The cough is
mitigated, but at the expense of the stomach.
The best and safest measure addressed to the
relief of the cough of phthisis in its later stages

1889.]

EDITORIAL NOTES.

601

consists in the use of respirators charged with
volatile substances. R. Douglas Poweli. states it
forcibly when he says : ' ' The effect of such in-
halations is to relieve cough and to lessen expec-
toration, and there can be no doubt that, as I
believe to be the opinion of Dr. Coghill, who has
so ablj^ advocated their use, one of their chief
functions is to do away with cough mixtures ;
for certainly the cough linctus treatment of this
eliminative period of phthisis, by lulling cough
and deranging the stomach, is the very worst
that could be devised." In the early stages,
when inflammation is active, Jaccoud insists on
the benefit to cough to be derived from persistent
counter-irritation over the affected parts. At all
events it should be a rule to avoid the adminis-
tration of opiates except, it may be, in cases of
suffering from laryngeal complications.

Another routine prescription is that of atropine
for night sweats. This is all right when they
are exhausting and cannot be controlled bj^ sim-
pler or more agreeable means ; but it so often
produces so much sleeplessness and restlessness,
and the sweating is so often less than is repre-
sented, that a little thought on the part of the
doctor will discover some efiBcient and more de-
sirable remedy.

How now is it with the nursing of the con-
sumptive ? Alas ! In most cases, the attention
bestowed by mother or sister is fraught with such
a degree of solicitude as defeats its own ends.
More intelligent nursing and firm enforcement of
salutary orders, with less enen'ating coddling,
would be far better for the invalid.

The principle of treatment of all consump-
tives should be, the least medicine possible and
the greatest possible nourishment. Both phy-
sician and nurse should comprehend this and
work together for its accomplishment. The con-
sumptive's stomach is sensitive already' and
loathes the very thought of ingesta of any kind.
Then why increase it by drugs and particularly
opium ?

The wisest treatment of the phthisical sufferer
is to be found in his simplest and most natural
management. The physician should bestow his
thought upon the most suitable kinds of nourish-
ment, modifying these as the state of the case
varies. He must not content himself with issuing
the vague instruction to give anything the pa-
tient can eat. Thought is necessary. At first

force upon the system all the nitrogenous food it
can be made to assimilate by help of fresh air
and judicious exercise. But when hectic is con-
suming the frame and the supply of oxygen is
small by reason of extensive structural loss as
well as inability to exercise, then to overload the
system with such food is but to heap fuel on the
flames. At such a time a readily oxidizable non-
nitrogenous dietary is indicated. While the
physician is thus thoughtfully superintending
the character of the food, the nurse should be
studying how to successfully tempt the capricious
invalid to take the nourishment. In the skilful
preparation and dainty serving of the viands
there is ample room for the nurse's ingenuity.
In all other matters pertaining to the art of nurs-
ing, in short in the hygiene both of the patient's
person and surroundings, intelligence even more
than affectionate solicitude will minister to the
comfort and prolong the life of the consumptive.

Meantime the welfare of the home circle should
not be sacrificed to the care of the invalid.
Strict antiseptic and prophylactic measures should
be carried out. The health of the well members
of the family' is of no less importance than the
care of the sick !

It is beyond the scope of this article to detail
the proper management of consumption, its aim
is only to emphasize the fact that, although med-
ical skill has not yet found a means of success-
fully coping with consumption, much can never-
theless be done by a wise, not by a routine,
direction of the home-treatment of phthisical
patients.

EDITORIAL NOTES.

HOME.

The Tri-State Medical Society. — The
meeting for the organization of this Society, was
held at Chattanooga, Tenn., on the 15th inst.,
and was in session for two days. A special cor-
respondent says that in every particular it was a
complete success, and promises to embrace the
best working body of medical men in the South.
The membership numbers over eighty. The
papers were abundant and of good quality, and
the discussions far above the average in ability
and interest. All in all, the outlook for the new
Society is most promising. We shall have oc-
casion to refer to its proceedings in a later issue.

602

EDITORIAL NOTES.

[October 26,

Wabash Surgical Association. — The an-
nual meeting of this Association will be held at
Toledo, O., on the first Tuesday in November.

Management of Garbage in Large Cities.
— Dr. Oscar C. De Wolf, ex-Health officer of
Chicago, contributes an excellent article on this
subject in the Sanitary News of October 12.
He says that thirty-five years ago preventive
medicine consisted in trying to keep out disease
by quarantine methods ; now it consists chiefly
in removing the conditions favorable to its ex-
istence and spread. The country is constantly
pouring into the city the organic matter necessary
to sustain the city's life. From the prairies of
the jWest, from the fields and gardens of the
South, from foreign lands, and from the seas
loaded trains and freighted ships are constantly
arriving and discharging the provision for the or-
ganic wants of the population. This provision
is not all consumed, but a large residue remains,
effete, putrefiable, dangerous, which, if not
speedily cast out beyond the borders, or other-
wise properly disposed of, is sure to produce a
poison by its decomposition which not only di-
rectly affects the health of the community, but
indirectly supplies a breeding place for the
specific germs of disease and stimulates them to
great activity of development.

In the country vegetable growth makes use of
this effete matter as a stimulant to other growth,
reorganizing it into other nutritious substances.
In the city this source of putrification is wanting;
small accumulations from each family result
finally in immense quantities from many families,
which impregnate the soil, vitiate the air, and
cling in putrid films to the walls of dwellings
and to all exposed surfaces. Unless, therefore, a
city is provided with the proper means to care for
this refuse in a sanitary manner, the accumula-
tion will work a steady and sure vitiation of all
the avenues of life ; and one of the great ad-
vances of sanitarj' science in the later years,
along the lines of disease prevention, has been
the successful effort to remove this filth from all
its hiding places in alley and street, area and
comer, and the indispensable provision to care
for it and dispose of it by sanitary methods.

The custom of using garbage for filling low
lots and old water courses within the limits of a
city — and which were to be used as sites for

dwellings — or feeding it to swine, was long con-
tinued, and is even now permitted in some lo-
calities, although such methods can receive noth-
ing but the most emphatic condemnation from
sanitarians

Rats are the peculiar vermin which swarm
about kitchen garbage in all our cities, and if a
man may harbor 100,000,000 of these trichinae
parasites — as Cobbold says he may — then a rat
may pcssibly be infected with 1,000,000, which
at a certain period of evolution of the parasite
are lying free in the intestines of the rodent, and
which may be freely discharged from the bowels
with the .faeces. Is it strange, therefore, that
hogs fed on city garbage are peculiarly liable to
this dangerous infection, and are regarded with
suspicion by sanitarians as food for man when
thus fed?

The feeding of garbage to milch cows is also
very objectionable from the sanitary stand-point.
It diminishes the vigor of the animal and vitiates
the secretion of milk.

The Medical Mirror is the title of a new
journal to appear in January, under the editor-
ship and management of Dr. I. N. Love, of St.
Louis.

. foreign.

An Anglo-American Medical Association
\ IN Germany. — Some English and American
physicians have resolved to found in Vienna a
society to be called the Anglo-American Vienna
Medical Association, with a view to giving infor-
mation and moral support to the English and
American doctors and students of medicine who
come to the Vienna University. As a rule, there
are but few students of medicine from England
and America, but a great number of doctors of
medicine. In the last half year 103 American
doctors were on the books.

A Hospital for Students. — The Associa-
tion for the care of sick students in Vienna is
about to purchase, at a cost of $22,000, a building
suitable for a hospital, in which forty patients
can be cared for. The annual cost of supporting
the hospital is estimated at $6,000.

Dr. Protheroe Smith, the founder of the
Hospital for Women, Soho Square, London, died j
September 28, aged 80 years. j

Prof. Bardeleben has been elected Dean of I
the Medical Faculty of the University of Berlin.

1889.]

TOPICS OF THE WEEK.

603

TOPICS OF THE WEEK.

LAPAROTOMY DURING MENSTRUATION.

We quote the following paragraph from the President's
address, delivered at the fourteenth annual meeting of
the American Gynecological Society, held in Boston,
September, i88g, by Dr. H. P. C. Wil^ON, of Baltimore :

But, gentlemen, before closing this address, which you
have required me to deliver, and which is more trj-ing to
me than man}- laparotomies, I must present you with
one question : Shall we perform laparotomy immediate-
ly preceding or during menstruation ?

This is a question which frequently embarrassed me in
my earlier professional experience. Books were searched
and authorities consulted for its elucidation, but I found
nothing to enlighten me on the subject. The medical
friends with whom I consulted advised against such a
procedure. In addition to this came the paper of Dr.
Horatio R. Storer, read at the first meeting of this So-
ciet}', in 1876, in which he concluded "that for pelvic
operations, all things being equal, it is better to select
the week immediately following the cessation of the
catamenia " for all such operations.

Operations per vaginam may require the selection of
the uterine ebb, where such choice can be made, as the
dressings and attention necessary afterward maj- be em-
barassed by menstruation; but for laparotomies involving
the peUnc organs ray experience t-eaches me to select the
uterine flood, rather than the uterine ebb. During the
uterine flood the circulation and innervation are in a
state of tonic excitement. During the uterine ebb they
are in a state of relaxation and depression; and patients
thus are more liable to passive haemorrhages, the absorp-
tion of septic poison, the deadly influence of shock, than
when the system is under the stimulus of the uterine
flood.

It may be said that inflammatory troubles are more
apt to be set up during the uterine flood. I would ask
the Fellows how many of their laparotomies have been
lost by inflammation other than septic. I cannot recall
one in my own experience. Shock, hsemorrhage and
blood-poison have been the causes of death in all cases,
and blood-poison oftener than all other causes together.
— Boston Medical and Surgical Journal.

and both physical and intellectual exhaustion. Contrary
to the treatment a colt receives at the hands of its owner,
human society, or the State, permits or directs that the
powers of a child should be rendered unfit for its future
functions, physical, mental and moral, for these three
are indelibly interwoven. It requires physical and meti-
tal education to fertilize the soil for the evolution of
morals. Thus the physician, and especially he who
makes paediatrics his special study, is a pedagogue by
profession. The question of school-house building and
school-room furniture, the structure of bench and table,
the paper and the type in the books, the number of
school hours for the average child and the individual
pupil, the number and length of recesses, the hours and
duration of intervening meals, the alternation of mental
and physical training, the age at which the average and
the individual child should be first sent, have been too
long decided by school boards consisting of coal mer-
chants, carpenters, cheap printers, and under-taught and
over-aged school mistresses; not, however, of physicians.
The health and vigor of the American child in early years-
seem, according to Bowditch, superior to those of the
European; why is the youth and maiden, particularlj- the
latter, so inferior? Why is it that anaemia and neuroses
eat the marrow of the land and undermine the future of
the country by degenerating both the workers and the
thinkers of the community, and the future mothers ? If
there is a country in the world with a great destiny and a
grave responsibility, it is ours. Its self-assumed destiny
is to raise humanitarian and social development to a
higher plane by amalgamating, humanizing and civil-
izing the scum of all the inferior races and nationalities
which are congregating under the folds of our flag. Un-
less the education and the care of the young is carried
on according to the principles of a sound and scientific
physical and mental hj-giene, neither the aim of our po-
litical institutions will ever be reached, nor the United
States fulfil its true manifest destiny. That destiny is
not so much the political one of excluding Europeans
from our continent. North or South — for indeed the par-
ticipation of European civilization in the gradual work
of removing barbarism ought to be very welcome— but of
raising the standard of physical and mental health to
possible perfection, and thereby contributing to the wel-
fare and happiness of the people."

PEDIATRICS AND PUBLIC HYGIENE.

At the recent meeting of the American Paedriatic So-
ciety, the President, Dr. A. Jacobi, in his annual ad-
dress, makes reference to this important subject as fol-
lows :

" The most vital questions of public hygiene are most
intimately connected with paediatrics. It is mainly two
subjects that attract the attention of those who take an
interest in children. I allude to the school and to con-
stitutional diseases. My remarks to-day can be but frag-
mentary, but still I must not, both in the interest of our
science and human society, omit to emphasize the fact
that it still appears that our schools were establishments
organized to produce nearsightedness, scoliosis, anaemia,

THE ARTIFICIAL FEEDING OF INFANTS.

At the first annual meeting of the American Pediatric
Society, held in Washington, D. C, September 20 and
21, 1889, Dr. a. V. Meigs, of Philadelphia, read a paper
upon this subject, a report of which we copy from The
Medical Record:

The author said that, after a long experience, he had
seen no reason for making any radical change in the ar-
tificial food which he had previously recommended. He
had found that mother's milk never contained more than
I per cent, of casein. This food was based upon the di-
lution of cow's milk, for the reason that it contains too
much casein; the further need of the addition of cream
because, in diluting, the fat was reduced to too small an

6o4

TOPICS OF THE WEEK.

[October 26,

amount; the addition of sugar, to make it equal to the
amount contained in human milk; aud of lime-water, to
change it from being an acid to an alkaline fluid. How-
ever, he had fallen upon several improvements to render
it easier to get together the required amounts of the dif-
ferent constituents, and thus simplifying the work of the
nurses. He directs that instead of taking cream and
milk in the proportion, respectively, of two and one in
eight, three parts of a weak cream be used, which is ob-
tained as follows: One quart of good ordinary milk is
obtained and placed in a high vessel, and allowed to
stand in a cool place for three hours. Then one pint is
poured slowly from this, care being taken that the vessel
is not agitated, the object being to obtain the upper layer
of fluid, rich in fat, and leave the lower comparatively
poor portion behind. When the child is to be fed, there
is taken of this weak cream 3 tablespoonfuls, of lime-
water 2 tablespoonfuls, and of sugar-water 3 tablespoon-
fuls. The sugar-water is to be made in the proportion
of 18 drachms of milk-sugar to i pint of water. This is
an improvement upon the food recommended previously
by the author, because it is more economical (cream
being expensive) and the food is less likely to ferment.

THE TREATMENT OF GASTRIC DIGESTION.

In cases where there is reason to believe that gastric
digestion is imperfect, common salt should be used in
increased amount in the food, so that the quantity of
hydrochloric acid may be increased. If, however, there
is reason to believe that lactic acid is present in too small
a quantity to split up this salt, then hydrochloric acid
must itself be used, and where it is employed given
freely in order not only to act thorough!}' itself, but also
to perform an equallj- important function, namely, the
conversion of pepsinogen into the active body pepsin.
In other words, deficiency of pepsin in the juice is to
be corrected not by a prescription containing much
pepsin aud little acid, but rather the reverse, for the
pepsin in the prescription is after all an extraneous pro-
duct, while the pepsin brought into being by the acid is
a normal secretion. Of course the quantity of pepsin
must depend on a normal formation of pepsinogen, but
it should not be forgotten, on the other hand, that as
pepsin acts by catalysis, and is a most powerful ferment,
onlv very small quantities of it are absolutely necessary,
while large amounts of hydrochloric acid, comparatively
speaking, are essential.

In an article recently published in the Revue Medicate
de la Suisse Romande Bourget has enunciated some
thoughts which are so completely in accord with the
views here expressed as to be worthy of quotation. He
believes, as does the writer, that the hydrochloric acid is
generally the secretion which is lacking in amount, and
recommends its free employment as the most important
part of the treatment of gastric indigestion. He does
not seem to do this because he believes it to increase the
pepsin, but only because he thinks the acid secretion is
more apt to be deranged than is that of the ferment.
According to my own practical experience and the much
more reliable information gained by experimental re-
search, it is to be concluded, therefore, that pepsin is to

occupy the least prominent position in a prescription for
gastric disturbance, and that the acid is to be freely
used. Indeed, I am so surely convinced of the impor-
tance of the acid in its double sphere that I fear I am
sometimes inclined to give almost no pepsin at all. —
Med. Analectic. — Mass. Med. Journal.

THE MEDICAL PROFESSION AND THE WORLD'S F.AIR.

Under the above caption the Medical Record deplores
the fact that the Ma3or of New York has not as yet
placed a representation of the profession on the World's
Fair Committee. It is not so in Chicago, where there is
a regular organization of the profession working with
the general committee to raise Jio,ooo,ooo towards secur-
ing the World's Fair for this new Metropolis of the
United States. The editor very sensibly remarks that "as
the purposes of the Fair have so far been outlined, there
will surely be a field for medical and surgical displays of
various kinds. There should be historical exhibits to
show the progress in the care of the sick, and in their
surgical and medical treatment, with displays illustrating
the old hospitals and the new, the old surgical instru-
ments and mechanical appliances and the new. There
should be illustrations also of the development of the
specialties, with displays of all new apparatus and in-
struments of precision in every field. The development
of bacteriology, the improvements in methods of teach-
ing, historical accounts of medical progress, and of the
growth of sanitary science, all would have a fitting
place. It is easy to see that a medical aud surgical ex-
hibit might be made which would have great intrinsic
interest, and would be of immense educational value,
not only to the medical profession, but to the laity."

We would add to this a suggestion that whichever
city is selected there should be held the meetings of the
American Medical Association, and the various National
Societies of Specialists in 1S92. This is not only desira-
ble from the standpoint of economy, but will ensure a
larger attendance at the meetings, and enable the mem-
bers to " take in " the medical and surgical exhibit so
ably advocated by the Medical Record.

A DOG WITHOUT A BRAIN.

At the last meeting of German neurologists, held in
Baden-Baden, Prof. Goltz, of Strasburg, reported a
most remarkable experiment. He cut out, in two opera-
tions, almost the entire cerebrum of a dog, leaving only
the cerebellum and a small portion of the base of the
cerebrum. The animal lived for fifty-one days after the
last operation and then died of pneumonia. The re-
markable part of the experiment was the influence it had
on the dog, who, a few hours after the operation, raised
himself on his hind legs, put his paws over the side of
his box, and looked inquiringly around. He could walk,
eat, and drink, and would chew any food that was placed
in his mouth. Waking and sleeping alternated natur-
ally. He was restless before feeding, but afterward
would become quiet and sleep. .■V slight touch would
awaken him from sleep. Durnig urination and defeca-
tion the animal .assumed the normal position. Hearing,
taste, and smell were, of course, absent — Wiener Med-
ical Presse.

1889.3

PRACTICAL NOTES.

605

PRACTICAL NOTES.

CURE OF FISTULA IN ANO AND H.5;mORRHOIDS BY
ELECTRICITY.

Dr. Shotwell, of Grand Rapids, Mich., claims
complete success from the following methods of
treatment : In fistula he first passes a probe

were in the hospital. They forget that the ma-
jority of these patients were suffering from incur-
able disease. — Braithwaite' s Retrospect. — Medical
Age.

MALE FERN AND CALOMEL FOR TAPE-WORM.

In the treatment of taenia Dr. Duchesne strong-
ly recommends male fern combined with calomel,
with an eye point from the external opening into according to the following formula :
the rectum. He then introduces a lance-pointed ' Eth. extract male feru 2 draclims.

probe (having likewise an eye near the end), ,,'-^i°'?^'' ■ ■ ■ ■ ,■ •;.■,• • • ; ■ 12 grams.

, • ., ■ 4. r ■ „„_^.•^ i,„„t tt -^-uii. M. Make 16 capsules, which are eiven two at a tune

making the point of insertion about three-eighths . .^^rv teu minutes until all are takeS.

of an inch further from the anus, and pushes it
in through the solid structures, parallel with the
fistulous track, till its eye is seen within the rec-
tum. The eyes of both probes are then threaded
with the ends of a No. 24 platinum wire about
10 inches in length, and both probes are with-
drawn, leaving the wire in the form of a loop.
The ends of the loop are now attached to a bat-

tery, an electrolytic current turned on and the

loop drawn through the partition in its passage s";VerDuche"sne his yet

The great advantage of this preparation is that
the patient has nothing to drink, and that the
purgative is taken along with the worm-medicine.
For some people, especially women, capsules are
difficult to take, in which case the medicine is
perhaps best taken with molasses. Sometimes
the capsules provoke colicky pains, but these can
be avoided by taking 20 grs. of antipyrin fifteen
minutes before the capsules. With these cap-

,-..., , f • it. £ .. f -NT -5"'vo i^uv.ucouc iia=) vcL to experieucc his first
destroying the membrane lining the fistula. No r-\ a \, x. \ a j 4.u ■ -u

, .-' .» 1 i iv 1 1 i ,j . failure, and he has already used them in hun-
dressing is necessary, but the bowels should not j„j r ht 1 r • ^u 1 a

, *.,, , . -" r , TT • , , dreds of cases. Male fern is the only remedy

that will successfully expel the bothriocephalus.

be permitted to move for one week. Union takes
place by first intention. The Shotwell rectoscope
is employed and the patient requires to be anaes-
thetized during the operation. Haemorrhoidal
tumors are similarly removed and without the
occurrence of haemorrhage. — New Orleans Med.
and Surg. Journal.

-THE INITIAL

HYPODERMIC USE OF MORPHIA
DOSE.

Great diversity of opinion exists as to what
constitutes a safe initial dose in a person unac-
customed to its use. This should not exceed for
an adult female one-eighth grain, for an adult
male one-sixth grain. I have myself seen death
follow upon the injection of one-quarter grain in
an adult male, and Ringer says "a larger quan-
tity than one-sixth grain sometimes produces ;rupefies"Ihe wo'rm

serious consequences. There are, I think, two i/^^,v^/ p^^^t-^

reasons for the large quantities given : (i) The
maximum officinal dose of half a grain is much
too high. This is evident when we consider that
the maximum hypodermic dose, and that for ad-
mini.stratiou by the mouth, is fixed at the same
quantity, namely half a grain. All authorities
are, I believe, agreed that morphia injected hypo-
dermically is at least twice as potent as morphia
given by the mouth. The maximum hypodermic
dose ought, therefore, to have been fixed at one

The treatment of taenia in children is a difficult
matter, but he has been regularlj' successful with
the following plan : After fasting twelve hours,
administer the following preparation to a child
of 5 j^ears :

Eth. extract of male fern i drachm.

Calomel 6 grains.

Sugar 2 drachms.

Gelatin, q. s. to make a jelly of ordinary consistence

The patient should be told to take an injection
of salt water when the worm appears at the anus,
and then sit over a vessel of warm water to float
the worm and prevent it breaking from its own
weight. The one point always to be remem-
bered, on which success depends, whatever the
vermifuge used, is the necessity of administering
the purgative soon after the substance which
77^1? Weekly Medical Review.

Medical Record.

OBSERVATIONS ON THE USE OF GLYCERINE
ENEMATA IN CHILDREN.

During a period of four months glycerine ene-
mata were used at the Evelina Hospital for the
treatment of constipation, to the exclusion of
purgatives. The children were not allowed to
pass more than two da5's without an action of the
bowels. A carefull}- prepared table is submitted.

quarter grain instead of half a grain, and we showing the result of 214 injections in sixty-three
have, I am afraid, the British Pharmacopoeia to children. One drachm of glycerine was given in
thank for many fatal results that have occurred. 156 cases, one drachm and a half in forty-eight,
(2) Many of the younger members of the profes- - and two drachms or more in but nine,
sion have taken their standard of an ordinary In 154 instances the injection was followed by
dose from the quantities they were ordered, when normal motions, in twenty^six they were loose,
clerks or dre.ssers, to inject during the time they , and in twenty-four of more than normal con-

6o6

PRACTICAL NOTES.

[October 26,

sistency or composed of scybala. In ten only
did the enema fail to act. In no instance were
there unpleasant symptoms, either local or con-
stitutional. Xo child was found whose bowels
failed to respond to the glycerine stimulation at
one time or another.

As regards the time of action, ninety-five in-
jections were followed by motions within five
minutes, ninety within thirteen minutes, while
with the remainder the time varied from thirty-
five minutes to eleven hours. The failures or
cases of delayed action were in tubercular pa-
tients or those who had undergone operation and
were therefore restrained from exercise or move-
ment.

After a brief summary of the action of various
cathartics in common use among children, the
author expresses himself as very favorablj- im-
pressed with glycerine enemata, which are easy
of application, unattended by pain, quick and
natural in action, and followed by but few
failures. — Epitome. — Mass. Med. Journal.

cannot too closely contemplate. Some, like the
bacteria of tuberculosis and glanders, propagate
themselves slowly ; but the great majority of the
bacteria causing animal plagues will, in favora-
ble cases, double their numbers hourly. — Prof.
Law, in The Pharmaceutical Era.

PHENACETINE IN WHOOPING-COUGH.

Dr. Heimann, of London, writing in the
Miinchener Med. Wochenschrift, states that he
was induced to trj^ the effect of phenacetine in
whooping-cough, as he had been very much dis-
appointed with antipyrin. Although he has
given children of 3 and 4 j-ears old a few doses
of 15 grains each of phenacetine, he has never
found any ill effects from its use, and the results,
he says, have been uniformly satisfactory- —
London Lancet.

FOR CHAPPED NIPPLES.

Says the St. Louis Medical and Sjirgical Jour-
nal: MiTROPOLSKY, of Moscow, recommends chlo-
ral as an excellent local means for fissured and ex-
coriated nipples. The latter should be kept covered
with compresses (soft linen soaked in a solution
of '2 drachm of chloral in 3 ozs, of water). The
compresses should be changed every two and a
half or three hours. When a prolonged applica-
tion is necessary, it is advisable to use a weaker
lotion {}2 drachm to 6 ozs.) The solution leaves
a thin, whitish, firmly adherent film over the dis-
eased surface, which does not disappear by suck-
ling. Pain and tenderness are said to be strik-
ingh' relieved almost immediately, the lesions
rapidl}' healing. The chloral compresses do not
produce anj' bad effects on nurslings. — The Can-
ada Lancet.

A VEHICLE FOR IODIDE OF POTASSIUM.

Milk as a vehicle for iodide of potassium com-
pletely masks the taste, and does not apparentlj-
interfere with the therapeutic qualities. Patients
who could not tolerate 10 grains when admin-
istered in water could soon take 40 grains in
milk with no symptoms of nausea. — Cincinnati
Lancet- Clinic.

THE MULTIPLICATION OF BACTERIA.

As regards the reproduction of the bacteria,
many of them can double their numbers everj-
hour when placed in the best conditions for their
activity. In such circumstances then, a single
bacterium would in twenty-four hours produce
no less than 16,777,220. At the end of forty-
eight hours the offspring would amount to 281,-
500,000,000, and would fill a half pint mea.sure —
all produced in two days from a single germ
measuring xTTiViTrTr of an inch. Fortunately, how-
ever, bacteria can rarely so propagate themselves,
they meet with all sorts of drawbacks, and thus
in spite of their enormous fertility the survivors
are in a general way only enough to keep up a
fair balance in nature. The diseases producing
bacteria, however, have no claim upon our for-
bearance, and in these the enormous fecundity we

THEINE IN NEURALGIA.

Prof. J. K. B.\ndv, of St. Louis, finds in the
hypodermic injection of theine a specific for some
forms of neuralgia. The dose is from ){ to ^^
gr. ; the point of the needle should be brought in
as close contact with the sheath of the affected
nerve as possible.

explosive MEDICAMENTS.

Prof. Robert calls attention to the following
explosive mixtures : Chlorate of potash mixed
with charcoal dentifrice powder may explode, even
in the mouth. Chlorate of potash mixed with
catechu, or with tannin, explodes with friction,
even if glycerin is added. Chlorate of potash and
phosphate of sodium explodes while mixing the J
powder. One part of chromic acid mixed with 1
two parts of glj-cerin explodes immediatel}'. Io-
dine and ammonium should never be mixed to-
gether, as it is extremely apt to explode. Bromine
and alcohol, forming the bromide of ethyl, often
explodes. Picric acid reduced to powder ex-
plodes, when mixed with any other substance. —
Gazette de (iynccolo^^ie. — 'The Times and Ke^ister.

PRESERVE your INSTRUMENTS.

You can preser\''e your instruments from rust-
ing by immersing them in a solution of carbonate
of potash for a few minutes. They will not rust
for years, even when exposed to a damp atmos-
phere.

1889.]

SOCIETY PROCEEDINGS.

607

SOCIETY PROCEEDINGS.

American Ortliopedic Association.

Proceedmgs of the Third Annual I\Icdi7ig, held in
Bostoti, Mass., Sept. ij, /S, and /p.

First Day — Morning Session.

The Association was called to order by the
President, Dr. E. H. Bradford, of Boston, who
delivered an address of welcome.

Dr. V. P. GiBNEY, of New York, read a pa-
per on

THE TYPHOID SPINE.

He drew attention to a group of sj-mptoms per-
taining to the spinal column, as sequelae of this
fever, and as an anatomical designation used
the term pcn'spondylitis, meaning an acute in-
flammation of the periosteum and the fibrous
structures which hold the spinal column together.
He reported three cases. Careful search of text-
books has failed to reveal any cases of like na-
ture. He alluded to a similar condition in which
the hip was afi'ected.

Dr. Iv. A. Weigel, of Rochester, N. Y., con-
tributed a paper on The Relation of the Thoracic
and Abdominal Walls to the Spinal Column con-
sidered with Reference to the Treatment of Antero-
posterior Curvature.

Dr. Dillon Brown, of New York, read a pa-
per on

PSOAS CONTRACTION AS A SYMPTOM.

He referred to the various diseases in which
this condition may be found, and gave their diag-
nostic points, emphasizing the phenomena by
means of which each disease could be excluded.

Dr. a. B. Judson, of New York, read a pa-
per on

THE PREVENTION OF THE SHORT LEG OF HIP

DISEASE.

He said the deformities of hip disease are
caused by the patient's efforts to so place the
limb that it shall be the least disturbed by, and
afford him the most convenience in, his custom-
ary attitudes and movements. They are (i) ab-
duction ; (2 ) adduction ; and (3 ) extreme adduc-
tion and flexion. The second position is practi-
cally by far the most important.

Dr. C. C. Foster, of Cambridge, Mass., re-
ported a

CASE OF CARIES OF THE ANKLE TREATED
CONSERVATIVELY.

He gave a detailed account of the case and its
treatment. He showed the patient and plaster
casts of the foot before and after treatment. He
held that such treatment is not so quick and easj'
as a successful resection, but that the final result
is far superior.

Dr. C. L. Scudder, of Boston, read

A REPORT OF CASES OF CARIES OF THE ANKLE
TREATED BY EXCISION,

exhibiting patients.

He drew the following conclusions :

1 . Excision is safe, and the mortality not great.

2. The convalescence and time of after-treat-
ment are short.

3. The disease in the foot is ended ; and the
prognosis is sure.

4. Profuse suppuration and its consequences
are avoided.

5. The likelihood of septic infection is at a
minimum.

6. The partial operation of curetting is of verj-
little value.

7. There is no mutilation of the foot.

8. Its usefulness is verj- great after excision.

Q. The question of tubercular infection from
operative influence is yet unsettled.

ID. Excision of all the diseased bone should
be resorted to earlier in the treatment of chronic
ankle joint and tarsal disease.

Dr. John Ridlon, of New York, reported a

CASE OF CONGENITAL DISLOCATION AT THE HIP.

The patient, a female, aged lo^^ years, came
under his obser^-ation Feb. 16, 1888. The right
great trochanter was 2'j inches above Nelaton's
line, and it required a blocking under the foot of
three inches to make her stand fairly erect.

The old pattern of the Taylor extension hip
splint was applied, and the leg elevated on an
inclined plane. For one j'ear the child did not
leave her bed, and so relaxation of the traction
was for once permitted. At the end of this time
it was possible to locate the head of the femur,
which was found to be displaced upwards and
forwards, lying almost directly below the anterior
iliac spine, and the difference in the length of the
legs was found to be reduced to one-half inch.
A jointed splint was applied on Feb. i, 1889, and
the patient was allowed to get up.

Drs. R. W. Lovett and J. E. Goldthwaite,
of Boston, contributed a paper entitled

abscesses in hip disease, their prevention,
significance and treatment.

Three hundred and twenty cases of hip disease
from the Children's Hospital were anal5'zed with
reference to the number of abscesses occurring
and the effect of treatment.

In the 320 cases 75 abscesses occurred, a per-
centage of 23, which very small percentage is
attributed to long continued treatment with the
long traction splint and by fixation in bed and
traction in the line of deformity whenever de-
formity or sensitiveness occurred. The operation
is not attended with the ri.sk of septicaemia, nor
does it prevent the occurrence of tubercular me-
ningitis or amj'loid degeneration, and finally it

6o8

SOCIETY PROCEEDINGS.

[October 26,

maj' be said that thorough operation is followed,
in a fair proportion of all cases, by speedy and
permanent closure of the abscesses.

Second Day.

The following papers were read : The Princi-
ples of Treatment of Hip Disease, bj^ Dr. N. M.
Shaffer, of New York ; The Early Local Treat-
nietit of Hip Disease, by Dr. A. j. Steele, of St.
Louis; The Operative Treatment of Hip Disease,
by Dr. DeF. Willard, of Philadelphia, and The
Immediate Disyrgard of Malposition of the Thigh
in the Treatment of Hip Disease, by Dr. Barton,
of Buffalo.

Dr. E. G. Brackett, of Boston, read a paper
entitled An Experimental Study of Distraction of
the Hip Joint, ^vhich was followed bj' one on A71
Analysis of Twenty-one Cases of Hip Disease
Treated by the Thomas Splint bj' Mr. John H.
Huddleston, of Boston.

Dr. John Ridlon, of New York, read a paper
on Fixation and Traction in the Treatment of Hip
Joint Disease, followed by one on Excision, by
Dr. R. H. Sayre, of New York, after which a
general discussion ensued.

Third D.\y.

Dr. G. W. Ryan, of Cincinnati, read a paper
entitled When Shall Treatment be Dispensed With
in Spondylitis} The following were also read :
A Contribution to the Study of Flat Foot, bj- Dr.
V. P. Gibney, of New York ; Traumatism of the
Hip, Simulating Thyroid Dislocation, by Dr. T.
H. Meyers, of New York.

OFFICERS FOR 189O.

President, Dr. DeForest Willard, of Philadel-
phia; Vice-Presidents, Drs. A. J. Steele, of St.
Louis, and A. B. Judson, of New York ; Record-
ing Secretar>', Dr. G. W. Ryan, of Cincinnati ;
Corresponding Secretary, Dr. Samuel Ketch, of
New York.

Next place of meeting, Philadelphia, third
Tuesda}' in September, 1890,

Jlecllcal Society of the Disti-ict of Coliiinbia.

Stated Meeting, March, 20, i88g.

The President, Charles E. Hagner, M.D.,
IN the Chair.

Dr. J. Ford Thompson reported the following
cases :

I. EXCISION OF the KNEE-JOINT (PATIENT

exhibitedV

C. A. C, aet. 23, white, American, and a car-
penter by trade. Was struck on the inner side of
the right knee with an adze, making an incised

wound involving the knee-joint. Inflammation
ensued. He was treated by another physician
for some time but kept getting worse and losing
flesh and strength. When I first saw him the leg
was flexed at right angles, there were several
suppurating sinuses and the knee felt soft and
boggy. On the nth of December, 1888, I sent
him to the Garfield Memorial Hospital, where I
operated on the 13th.

The flap was made on the anterior surface and
dissected back ; the patella was removed, the dis-
eased ends of the bones sawed off, and the dis-
eased soft tissues removed. During the operation
a stream of antiseptic fluid was constantly flowing
over the wound. The ends of the femur and
tibia were fixed by nails. The knee was then
dressed antiseptically, and plaster dressing.

December 21. The dressing was changed and
the wound looked well. December 23. The
dressing was again removed on account of a
slight elevation of temperature. From this time
the recovery- was steady and not marked by any
untoward S3'mptom. There was no pus in this
case except where the nails were introduced, and
these were removed in the third and fourth week.
Januarj^ 28. Discharged cured. Walking on
crutches. March 20. He is present and walks
with a cane.

About a 3^ear ago I reported to this Society a
case of erasiou of the knee-joint in a little girl 10
years old, in which recoverj- took place in five
weeks. After the operation there was not any pus
except along the line of the nails. In this case
it was not properly an excision, as onl}- diseased
soft tissues and ends of the bones had been re-
moved. I have never tried to get motion after
erasion, although several cases have been recent-
ly reported in which motion was secured. I
could not hope for motion in mj- cases and I ques-
tion whether it would be proper to attempt mo-
tion. The operation of erasion is an improvement
over the older practice of waiting until the tis-
sues are so much diseased that excision is neces-
sary. Excision is especially unsatisfactory in
children, since if the ends of the bones are re-
moved the limb will not grow. In an adult this
will make ver>- little difference, but in the child
one leg would grow while the other did not, so
that by the time the bone was through growing
the shortening will be verj' marked. Erasion
does not interfere with the growth of the bone.

About the time of the operation on the patient
presented to-night I performed it upon a colored
girl for tubercular disease of the knee-joint. She
did not do ver>- well, and as there were several
sinu.ses I opened the joint a second time and
spooned out all the diseased tissue that I could
could find. She is now up and about, but is in
a hectic condition and does not get well. I think
an amputation would have been better in the be-
giiniing, and it may be necessary yet.

1889.]

SOCIETY PROCEEDINGS.

609

2. INCISED WOUND OF THE ABDOMEN.

S. H., male, colored, aet. 28, Arlington, Va.
"This man was cut about 9:30 p.m. of May 7, 1888,
and was brought to Emergency Hospital in a
milk wagou from Arlington, Va,, a distance of
six miles, arriving at 12:30 a.m. of May 8, about
three hours after receipt of injury.

I saw him within an hour after admission. He
had been cut with a knife in a fight, the wound
made being about 2 inches in length, extending
obliquely downwards and outwards to the left,
beginning just below the ensiform cartilage and
the lower part extending nearly through the left
cartilaginous border of the epigastric region. The
patient, who was pulseless from shock, had been
cared for by the house physician by application of
hot bottles, hypodermatic injections of ether and
arom. spt, of ammonia. Over the epigastric ^nd
umbilical region there was a large mass of abdom-
inal contents, which upon examination proved to
be the entire stomach with great omentum, and
all of the transverse colon, the mass being tightly
constricted at the Vv'ound, as in strangulated her-
nia, and covered with dirt. The protrusion was
carefully Vv^ashed with bichloride solution i to
2,500, and thoroughly examined for wounds, but
none being found, a blunt-pointed bistoury was
insinuated beneath the protrusion and the incision
enlarged downwards for an inch or more, after
which the parts were reduced by taxis.

I found it very difficult to close the wound
nicely at its deeper part on account of its extend-
ing into the cartilages. I brought the peritoneum
together first with catgut sutures, and then closed
the wound with sutures passed as deeply as was
practicable. Antiseptic dressing was used.

May 8. Temp. 100°; pulse 100; resp. 20.

Maj- 9. Temp. 102.2°; pulse 114; quite tym-
panitic. Coil was applied, and enema given,
which produced good stool. Temp, was reduced
by evening to 99.8°; pulse 98.

May 10. Temp. 100°; pulse 99.

May 13, evening. Sutures removed; pus oozed
from suture wounds, and about 2 ozs, during
night from wound. Milk diet and antiseptic
dressing throughout. Recovery uninterrupted.

3. PERFORATIVE APPENDICITIS.

I was asked by Dr. J. W. Dunn to see this case
at 8 P.M., February 21, 1889. There was a his-
tor>' of intestinal obstruction ; he was very low
and hiccough was incessant. I stated that it was
a clear case demanding operative interference,
but concluded to postpone it until next morning.

February 2 2d the patient was in about the
same condition and I had the family advised of
the extreme gravity of the case and advised im-
mediate laparotomy. The patient was then
ansesthetized and an incision in the median line
was made. Upon opening the peritoneum a
milky fluid escaped and I thought the intestines

had been opened. The incision was then en-
larged and about a quart of this fluid escaped.
The pelvis cavity was filled with it. The incision
was now lengthened upwards and the intestines
were found to be adherent, of a blackish color,
and looked gangrenous. They were gently
manipulated. They were quite distended, and
four punctures were made to draw off the fluids
and gases ; the punctures were closed with the
Lembert catgut suture. In the csecal region an
abscess cavity broke and about five or six ounces
of pure pus escaped. This cavity was then
washed with a warm carbolized solution. At the
caput coli the intestine looked healthy, but about
two feet of the ileum seemed almost gangrenous,
with numerous black, soft and leatherj^ spots.
In the abscess cavity a concretion like a coffee-
grain was found, which I believed to be calcar-
eous. The appendix and surrounding tissues
having a gangrenous appearance, I thought it
best to remove the appendix above the deeply
congested part and establish an artificial anus,
because I did not think the intestine could stand
the pressure of the gases and contents. I also
thought that if the patient survived the operation
the artificial anus could be operated on success-
fully. He seemed to stand the operation very
well, but died three hours after of shock.

I had never seen such a condition of the intes-
tines. I did not know how the fluid got into the
man's pelvis, nor its nature. It looked like the
fluid injected into the rectum, but how did it get
into the peritoneal and pelvic cavities? It did
not pass through the abscess, as its walls were
perfect. The case had been managed by one of
the most capable female nurses I have ever seen,
and she gave the enemata with the Davidson
syringe, and not the long tube of other syringes,
which is usually passed into the intestine while
the operator is in ignorance where it is going.
He suspected rupture in some portion of the in-
testine below the disease, but it could not be ex-
amined satisfactorily, and a post-mortem was not
allowed to confirm the .suspicion. The disease of
the intestine was beyond all I had ever seen, and
I do not know what caused it. In appendicitis
there is no reason for the disease extending to
such an extent.

If the man had had vitality enough to have
survived the immediate effects of the operation,
the artificial anus would have relieved the weak-
ened bowel and he might have been cured by a
subsequent operation.

I preferred the median operation because I sup-
posed the trouble was obstruction, but it was for-
tunate that it was made under such a supposi-
tion, because it proved very advantageous. In
appendicitis I perform the right inguinal opera-
tion. The diagnosis in such cases is very diffi-
cult and the best diagnosticians frequently fail.

I am impressed with the importance of the

6io

SOCIETY PROCEEDINGS.

[October 26,

early operation, and believe that it is too fre-
quently delayed until the vitality of the patient
is too much exhausted to resist the shock of
laparotomy'. In man}' cases the trouble is merely
suspected and the phj'sician waits for positive
proof, which comes too late to save life. In all
cases exhibiting peritoneal symptoms combined
with those of obstruction the operation is impera-
tive.

The case reported by Dr. McArdle, upon which
I operated, has entirely' recovered.

The history by Dr. J. W. Dunn, of this case,
is briefly as follows : C. D., aet. 21 years, sent
for me between 6 and 7 o'clock, on the evening
of Feb. II, 1889. I called about 8 o'clock, and
elicited the following account of his illness :
The daj' before (Sunday) had walked to Rock
Creek cemetery and back again without fatigue.
Upon his return had eaten a good dinner and en-
joyed it. Monday morning about 10 o'clock was
seized with a pain at the pit of the stomach,
which was severe and lasted until he arrived
home and had vomited his breakfast, which con-
sisted of two soft boiled eggs, some bread and a
saucer of preserved peaches with cream. The
violent pain then disappeared. Vomited bile and
mucus several times during the afternoon. Was
given crushed ice and brandy, and when I ar-
rived had not vomited for nearly two hours.
Upon examination detected nothing abnormal,
with the exception of a feeling of soreness over
the region of the stomach. Said he was not ill
but his bowels had not moved. I then ordered i
grain of calomel in eight powders. One every
two hours. Said he would send for me if he had
further trouble. Temperature 98.6° ; pulse 74.

Did not hear from him again until Friday, the
15th. Found him in bed, but had been up and
around the house, and had eaten three meals a
day. Said the soreness over the .stomach had
not gone away. Only felt it when erect, not
when lying down. Was perfectly horizontal and
free from pain. No pain on pressure over caecum
or in iliac region ; thigh not flexed on pelvis ;
could extend leg freely and easily ; no hardness ;
and abdomen uniformly tympanitic. Had not
had nausea. Temperature 98. °6 taken in the
mouth ; pulse 76. The calomel had not oper-
ated, and his mother had given him a dose of
castor oil, which had moved the bowels three
times freely. Gave .sulphate of quinine 2 grains
every 4 hours, and ordered turpentine stunes
over bowels.

From this time until Monday the i8th, his
condition remained about the same. Had two or
three light colored and offensive movements daily.
Abdomen tympanitic and slightly swollen.
Tongue of a natural color, and white fur on pos-
terior portion. On this date ( iSth), seven or eight
dark red spots appeared over the lower portion of
the chest, disappearing in twenty-four hours.

Highest temperature recorded 101.4°; pulse never
over 96 per minute. Made diagnosis of "mild
case of typhoid fever."

19th. Complained in the morning of nausea ;
bowels had not moved since evening before.
Gave drachm doses of granulated effervescing
citrate of magnesia, to be repeated every hour.
This quieted the nausea, and at 9:15 p.m., pro-
duced a slight movement with quantities of
offensive gas. At 10 p.m., the nurse gave an
enema of one quart of warm water with soap-
suds, which did not come away, and was repeated
in one hour. 12:15 a.m., enema came awa}-,
bringing two hard pieces each, about three inches
long. The nausea returned at this time.

20th, 2:30 A.M. Had severe pain in right side,
came on suddenly' and rapidly, subsided with ap-
plications of hot water and turpentine. Said the
milk made him sick and vomited it with some
greenish material and mucus three times during
the day, viz.: at 11:45, 4:35, and 7 p.m. No
movement during the day; 7 p.m., enema one
quart, came away in thirty minutes, bringing four
brown pieces and about two inches in length.
The milk was withdrawn, and he did not vomit
again. Pain in side did not return. Abdomen
only moderately distended. No evidence of
typhlitis or of perityphlitis. Was moderately
tender on pressure on both sides. Principal sore-
ness just below ensiform appendix. Tempera-
ture 101.2°, pulse 104.

2ist, 2 a.m. Small movement, about 2 oz. of
yellow fluid ; 6:15 a.m., some yellow movement
of about 4 oz.; 7 A.M., vomited about one pint of
greenish material ; after this seemed much better;
10:15, enema; slight movement with four small
pieces; 4:30 p.m., vomited about 4 oz. of suspici-
ous looking material, yellow in color. Had no
marked faecal odor ; 5:50 p.m., large enema (two
quarts), came away hardly stained. Nurse stated
that he had hiccough during the afternoon ; 9:15
P.M., enema of one quart of infusion senna ;
came away in one hour, one small yellow piece.
Abdomen swelled rapidly on 21, and was much
distended by 6 p.m. Enemata with exception of
a few small pieces, were hardly stained. Tem-
perature 101.8°; pulse 108.

Treatment consisted of 2 grains of quinine
every four hours for three days, after which no
medicine but the magnesia was given by mouth.
Suppositories of morphine '4 grain were given
occasionally to procure sleep. Hot applications
over bowels constantly'. Diet consisted of milk
and liquid beef peptonoids.

4. TWO CASES OF STRANGULTED FEMORAI,
HERNIA.

Case r . — I was asked by Dr. Busey to see Mrs.
B., who had a strangulated femoral hernia of the
right side, of several days duration. I examined
her on Feb. 10, 1S89, and found a small tumor>

1889.]

FOREIGN CORRESPONDENCE.

611

resembling a gland, just below Poupart's liga-
ment, and I advised an immediate operation.
Upon opening the sac I found a small knuckle of
intestine, so verj^ much congested that it looked
at first to be in condition of gangrene ; but after
irrigation with warm water its appearance im-
proved and it was returned. The sac was dis-
sected off and tied with double catgut ligature as
high up as possible in the ring. A drainage tube
was inserted into the peritoneal cavity through
stump of sac. Patient recovered with bad s^mip-
toms. The wound healed by granulation. The
patient had no fever, and she was given an ene-
ma on the third day, which brought away faeces.

I think drainage is necessary in such cases as
this for the radical cure of herniae, and I expect
a radical cure in those cases in which the sac is
removed. In the following case also the sac was
dissected out and the wound allowed to heal by
granulation.

Case 2. — March i Dr. Koones asked me to see
Mrs. G., white, aged 37, the mother of one child
14 years old. She stated that she had been rup-
tured about six j^ears previously, but that it had
never caused her any trouble until about three
days previous, when lifting a heav)' barrel she
felt a sharp pain in the right inguinal region, and
that she had been vomiting for the past two days.
On examination Dr. Koones found a large fem-
oral hernia, inflamed and irreducible. March i,
the operation described above was performed.
March 2, temp. 100°, pulse 96 ; abdomen slightly
tympanitic, and pain in right iliac region. March
4, temp. 96.6", pulse 95. Had a natural stool.
March 6, discharged cured.

In these cases the strangulated knuckle of in-
testine was enclosed hy an omental sac. After
relieving constriction the intestine was returned,
the omentum transfixed and tied with catgut lig-
ature high up in canal, and this large mass cut
away. The sac was then dissected out, tied and
cut off as in previous case. Drainage tube was
inserted and antiseptic dressing applied.

Recovery' without bad symptoms.

The concretion removed from the case of per-
forative appendicitis was referred to the Commit-
tee on Microscopy.

Dr. Kober : In the after-treatment, did Dr.
Thompson desire to secure bony or fibrous an-
chylosis ?

Dr. Thompson : The operation is not com-
plete unless there is bony union, as in case of
fracture.

The President : Some time ago he had seen
a case of fracture of the patella by direct violence,
in which there was subsequent union. Some time
afterwards this patient, in an effort to break a
fall, fractured the other patella, and union took
place in it, making both limbs alike. He walks
very well since the second accident.

Dr. Kober simplj' desired to direct attention to

the different results obtained so far as the mor-
tality was concerned, when excision was per-
formed for traumatic causes and when performed
for disease. Of 1 16 cases of excision of the knee-
joint, collected by Gurlt, there were 21 recoveries
and 95 deaths, or 81.89 per cent. Whilst of 431
cases collected by Penieres, operated on for dis-
ease, 300 recovered and 131, or 30.4 per cent.,
died, showing a difference of 50 per cent, in favor
of the cases operated on for disease.

Dr. Thompson : Conclusions drawn from sta-
tistics of several years ago are of little surgical
value nowadays. There has been such a revolu-
tion in surgery that the results now attained are
far better than those for the same operations a
few years ago. The ca.se reported was traumatic,
and still it got well without a bad symptom.

FOREIGN CORRESPONDENCE.

LETTER FROM PARIS.

(FROM OUR REGULAR CORRESPONDENT.)

Dr. Gut'niot on the Causes and Treat)ne7it of the
severe or obstmate Vomiting of Pregnajicy — Dr.
Marc See on Congenital Hypertrophy of the Right
Loicer Extremity — Prof. Gayet on the Wearing of
Celluloid Artificial Eyes — Antipyrin in the Treat-
ment of Eiiuresis — The Incompatibilitv of certain
Antiseptic S2(5sta/iccs.

At a recent meeting of the Academy of Medi-
cine Dr. Gueniot read a memoir on the causes
and treatment of the severe or obstinate vomiting
of pregnancy. According to the author there are
three principal factors concerned in the etiology-
of this form of vomiting, viz.: the uterus, the
nervous system and the stomach, consequently it
is against the alteration of one of these organs
that the treatment should be directed. Thus, as
regards the uterus, there maj' be ulceration of its
neck, or a flexion of its body on the neck may
be a source of irritation which reflects on the ner-
vous system and the stomach and thus produces
obstinate vomiting. On the other hand, it is pos-
sible that diseases of the ovum ma)' cause the
vomiting. The author had seen a patient who
was the subject of a hydatiform pregnancy who
was affected with obstinate vomiting. Some irri-
tability of the nervous system might also reflect
on the stomach. Finally, the stomach itself may
be diseased, which would singularly predispose
to vomiting. These etiological considerations
should guide the physician in the treatment to be
adopted. It is thus that in rectifying a flexion
or deviation of the uterus, the raising of the hip
combined with the lowering of the trunk is some-
times sufficient to arrest these persistent vomit-
ings, and the application of a suitable pessary
sometimes gives good results. If there be ulcer-

6l2

DOMESTIC CORRESPONDENCE.

[October 26,

ation of the neck, topical remedies and even cau-
terization maj- be employed without fear of pro-
voking abortion. If there is a tumor, it must be
excised. If there is vaginismus, it must be com-
bated b}' prolonged baths and the application of
an ointment of cocaine. Even when an examina-
tion discovers no lesion on the side of the uterus,
dilatation of the neck practised with the finger
in multiparse, with laminaria or a dilating instru-
ment in primiparae, would often arrest the vomit-
ing. If there is irritabilit}' of the nervous system,
enemata of the bromide of potassium or of chloral
should be employed. The application of Chap-
man's ice bag to the dorso-lumbar regions of the
spine, also gives good results. The ether spray
to the spine and to the stomach, practiced just
before meals, is often sufficient to check the vom-
iting. Inhalations of oxygen are also beneficial.
If there be, disease of the stomach, the patient
must be subjected to a rigorous diet, all acidulous
and alcoholic drinks must be suppressed. Ice,
Vals or Vichy water, milk or beef tea to be taken
often, but in small quantities at a time, maj' be
allowed.

At the same meeting Dr. Marc See read a re-
port on a case of congenital hypertrophy of the
right lower extremit}' related by Dr. Duploriy at
the meeting of the 20th of August last. Dr.
Marc See is of opinion that before practicing dis-
articulation of the thigh, the surgeon should try
ligature of the artery, and he would strongly rec-
ommend the application of elastic compression,
from which he had obtained excellent results in
a similar ca.se.

Prof. Gayet, of Lyons, reports that he had
lately observed several cases in which the wearing
of artificial ej^es made of celluloid was attended
with some inconveniences. Artificial eyes made
of this substance have not the brilliancy nor the
lifelike appearance of eyes made of glass or en-
amel, but they do not break, are easily adapted
to the hollows and projections of the orbital cav-
ity which has been modified, thej' are much cheap-
er. Patients may even, when granulations or
adhesions are formed in the orbital cavity, cut
the piece in such a manner that it will continue
to well adapt it.self to the orbital cavity. Thus
it will be .seen that these pieces in celluloid have
certain advantages, but they have the great in-
convenience of not being tolerated more than
three or four months. At that time their chemi-
cal composition is probably modified by the liq- j
uids of the eyelids and of the orbital cavity, as !
well as by the tears which keep them constantly |
wet, .so that the stump becomes red, granulating,
painful, and gives rise to an abundant purulent
secretion which compels the patient to abandon
his artificial eye. Antiseptic washings may give ,
some relief but there remain the vegetations, j
which must be cauterized or exci.sed. A cure is j
effected, but if the patient reapplies the artificial |

eye of celluloid he soon returns for the same treat-
ment. The author does not know where these
artificial eyes are manufactured, but believes that
they come from Germany. Thej' are composed
of two distinct parts. The sclerotic is of cellu-
loid and contains at its anterior part a cavity in
which is implanted a piece similar to that of eyes
of glass forming the iris and the cornea. When
the sclerotic becomes altered, at the end of three
or four months, it sometimes acquires an odor of
an extraordinarj' fetidity. This odor recalls that
of bromine, and it is no wonder, as celluloid is
made of the mono-bromide of camphor. It is
therefore possible that the bromine at a certain
moment is set free, and gives rise to this odor.
Under the influence of the heat the sclerotic be-
comes altered and softened, the central piece (the
iris and the cornea) becomes somewhat movable
in its cavity, and there results a cutting edge on
which rub the posterior surfaces of the eyelids.

Starting from the idea that enuresis is due to a
spasm of the fibres which preside the expulsion
of the urine, Drs. Perret and Devic treated two
cases of essential nocturnal incontinence of urine,
the one aged 1 1 3'ears and the other 1 2 years, to
whom he administered from 2 to 3 grams of an-
tip5'rin per da}'. The first case, which was that
of a boy, was cured in ten days after treatment,
and the second, a girl, was cured in fourteen
days. Even after the suppression of antipyrin
the enuresis was not reproduced.

The Archives dc Pharmacic points out the in-
compatibility of the following antiseptic sub-
stances : Corrosive sublimate and iodine, corro-
sive sublimate and soap, carbolic acid and iodine,
carbolic acid and the permanganate of pota.sh,
iodine and .soap, salicylic acid and the permanga-
nate of potash, permanganate of potash and oil.
soap and glycerine. A. b.

DOMESTIC CORRESPONDENCE.

Snake Bites— A Correction.

To the Editor: — In the issue of The Journal
for September 28th I notice the following item,
clipped from The Southern Practitioner, which is
calculated to make a very false impression, at
least in the minds of your northern readers, and
to do our section of the State of Te.xas great in-
justice :

Dr. L. G. Lincecum, of Lampasas, Texas, reports that
he has treated more than one hunilred cases of bites in-
flicted by poisonous reptiles, and that he has never seen
a case result fatally that was treated by the hypodermic
.idministration of permanganate of potassium and the
administration of chloroform locally and by means of
inhalation. He gives the permanganate in i and 2 grain
doses.

I have now practiced medicine in Texas eight

6i3

DOMESTIC CORRESPONDENCE.

[October 26,

years, part of the time in the northwest portion
of the State known as the Panhandle, and the
last five and one-half j'ears in Lampasas. I have
treated four cases of bites from poisonous reptiles.
My practice and acquaintance extend over a re-
gion of from fifteen to twenty miles in either di-
rection from town. Two of my cases were in the
Panhandle, the other two in this vicinity. I am
in position to know of the occurrence of snake
bites in au)^ part of the county. I have heard of
but two or three cases besides my two cases.

Dr. Lincecum has practiced medicine here for
fourteen or fifteen years. If he has treated one
case a year here it is far more than anybody here
knows anything about in the practice of all the
other physicians here. If he has treated ''over
one hundred cases," it certainly must have oc-
curred before he came here — probably whilst he
practiced in the city of Austin.

We do not deny but that there are venomous
reptiles and insects in the State of Texas, but
they are not as numerous as many are led to sup-
pose, and bites and stings from them are of rare
occurrence. There are physicians in Texas who
have never seen a case of rattlesnake bite in a
practice of years. Others, in certain localities,
might treat two or three cases a year. There is
no question in regard to the success of the per-
manganate of potassium treatment in these cases.

Respectfully, J. D. Carhart, M.D.,
Member of Texas State Medical Association ; of

the American Medical Association ; delegate

to Ninth International Medical Congress.

I 5. That the virus from all varieties of ery-
sipelas should be considered dangerous to the
parturient, regarding the intensity of the inflam-
mation and time of development of the virus as
greater factors for evil than the variety and situa-
tion of the erysipelas.

i Seeing that mj' conclusions were incorrectly
stated in an important publication of wide circu-
lation, and desiring to further investigate the
subject, this communication is sent for publi-
cation.

Wishing to see if a larger collection of cases
will further establish the above conclusions,
any of the readers of The Journal having had
cases of erysipelas complicating pregnancy, are

1 respectfully requested to report them to the
writer according to the outline given below.
Only cases of erj'sipelas occurring in the preg-
nant from the time of conception to commence-

' ment of labor are wanted, and not those cases of
septic infection occurring after delivery.

Form. — I. Period of pregnancy at which ery-
sipelas occurred. 2. Variety and situation of
erj^sipelas. 3. Time of delivery as to stage of
erysipelas and period of pregnancy. 4. Result
as to death or recover}^ of mother. 6. Did
mother have puerperal peritonitis or septicaemia ?
To any one reporting cases due credit will be
given, and a reprint of the article on the above
subject will be sent to them if requested. Please
send reports to, Yours respectfully,

R. R. KiME, M.D.
Petersburg, Ind., Oct. 12, 1889.

Erysipelas Complicatingr Pregnancy.

To the Editor: — In a paper read before the
Indiana State Medical Society, June 6, 1888, on
"Erj'sipelas Complicating Pregnancy," the fol-
lowing conclusions were based on an analysis of
thirty-seven cases:

1. The nearer to full term the attack of ery-
sipelas, the less danger of death and greater
certainty of abortion or premature delivery.

2. That nearlj' all cases complicated by puer-
peral peritonitis die, while those not thus com-
plicated get well.

3. That there is less danger of death to the
pregnant in the later months of pregnancy suSer-
ing with erysipelas than to the parturient to
whom erysipelatous virus has been conveyed,
producing puerperal peritonitis.

4. That the dangers to the pregnant or parturi-
ent are greatest in the active invasive stage of
erysipelas ; that puerperal septicaemia is not so
likely to follow those cases of abortion or prema-
ture deliver}' occurring in the retrogressive stage
of the erysipelatous inflammation, and that the
dangers grow less as the inflammation subsides,
provided the system is not left in a condition
favorable to a return of the erysipelas.

"Etiologrj^ of Tetanus.

To the Editor: — Recent articles and communi-
cations in The Journal on the contagion or mi-
crobe of tetanus, and its relation to the oSal of
animals, have added interest, in view of the oc-
currence of a case of tetanus which, during the
week past, has in this city reached a fatal termi-
nation. The victim was a woman of advanced
age, but of notabl}- vigorous health. About two
weeks previous to her death she had occasion to
step into a poultry coop or enclosure, when a
nail, concealed by dirt and offal of the poultry,
penetrated the plantar surface of the instep. In
a few days stiffness of the cervical tissues ap-
peared, with the result stated. As many medical
men in a lifetime of active practice fail to meet a
case of this kind, so rare is the disease outside of
hospitals, albeit rusty nail wounds of the feet are
sufficiently frequent, the special circumstances of
the etiology of this case are significant, as veri-
fying the recent view of a microbe origin. The
writer was not medically in the case, but is accu-
rately informed of the above facts, and would re-
gard their burial with the victim with disfavor.
Yours respectfully,

H. C. Markham, M.D. -
Independence, la., October 11, 1889.

6i4

MISCELLANY.

[October 26, 1889.

NECROLOGY.

Dr. Charles W. Haddock.

Dr. Chas. W. Haddock, a well-known phy-
sician of Beverly, died Oct. 10, 1889. He was
born at Hanover, N. H., sixty-seven years ago.
His father was a clergyman and a professor in
Dartmouth College, in which university the fu-
ture physician was graduated. In 1847 he went
to Beverly, where he won a high reputation. He
was a member of the Massachusetts and Essex
South District Medical Societies. He was sur-
geon of the 8th Regiment Ma.ssachusetts Infantry
during its nine month's campaign in the Caro-
linas, and was surgeon of the 2d Corps of Cadets
for several years. He had been medical exam-
iner for the Beverly district since the office was
created, and was chairman of the Board of United
States Pensioner Examiners, having been recently
appointed. His wife and one son. Dr. Charles
W. Haddock, survive him.

MISCELLANY.

Epidemic Disease in Belfa.st.— At a meeting of the
Belfast Dispensary Committee on October 7, the reports
from the various medical officers showed the existence
of a large amount of typhoid and typhus fevers in the
city. The outbreak of typhoid was attributed to the heat
and drought of the early summer, succeeded by the wet
weather of August. There is reason for thinking that a
conjunction of circumstances of this kind does tend to
have this effect. Happily, the epidemic is not of a se-
vere type, and the mortality has been very moderate.
Dr. Woodhouse, Local Government Board Inspector,
stated his opinion that 10 per cent, of the death-rate was
due to diarrhoea in infants, of which the causes were
mainly two — wrong feeding and imperfect sanitation. —
British Med. Jour., Oct. 12, 1889.

Veer, Albany, N. Y.; Battle & Co., St. Louis, Mo.; Lov
ell Washer Co., Erie, Pa.; George F. Lasher, Philadel-
phia ; Galvano-Faradic Manufacturing Co., New York;
Dr. Benj. Lee, Philadelphia; Henry Schwindt, New York;
Dr. George W. Ryan, Cincinnati, O. ; Lehn & Fink, New
York; Anthony S'.Werielf, Chicago; G. P. Putnam&Cc,
New York; Dr. E. H. M. Sell, Allentown, Pa.; Dr. C. C.
Hunt, Dixon. 111.; Dr. Augustin A. Goelet, New York;
Dr. Joseph H. Hoifman, St. Mary's, Pa.; Dr. W. L. Linn,
Bowen, 111.; Dr. George W. Stoner, Detroit, Mich.; Dr.
H. L. Getz, Marshalltown, la.; Dr. M. Blumenthal, New
York; Dr. Robert T. Morris, Lutz & Movius, New York;
Dr. F. B. Davidson, Fleetville, Pa.; Dr. Chaill^, New Or-
leans, La.; Dios Chemical Co., St. Louis, Mo.; Wm. R.
Warner & Co., Philadelphia ; The Zymoticine Chemical
Co., Springfield, O.; Dr. W. Freudenthal, New York; Dr.
Jonathan Wright, Brooklyn, N. Y.; W. P. Clears-, New
York; Dr. A. R. Baker, Cleveland, C; Dr. A. S. Mvgatt,
Rolfe, la.; Dr. Samuel Hart, Marietta, O.; Dr. W. N.
Yates, Fayetteville, Ark. ; Dr. Thomas F. Rumbold, St.
Louis, Mo.; Dr. Irving D. Wiltrout, Hudson, Wis.

LETTERS RECEIVED.

Dr. John ."V. Larrabee, Louisville, Ky. ; Dr. A. B. New-
kirk, Falls City, Neb.; Thomas F. Goode, Buffalo Lithia
Springs, Va.; F. W. Koch, New York; Georgetown Med-
ical College. Washington; Eli Lilly & Co., Indianapolis,
Ind.; Upjohn Pill and Granule Co., Kalamazoo, Mich.;
W. H. Moore, Brockport, N. Y.; Dr. George O. Mead,
London, Eng. ; Doliber, Goodale & Co., Boston; The
American News Co , New York; Northwestern Ohio
Medical College, Toledo, O.; Chicago Polyclinic, Chicago;
Dr. J. Wright, Brooklyn, N. Y.; Dr. Robert Tilley, Chi-
cago; Dr. J. H. Bryan, Washington; Dr. C. S. Curry, New-
ark, N. Y.; Dr. James Ty.son, Philadelphia; Dr. Hermann
Goldenberg, New York; Gladstone Lamp Co., New York;
Lambert Pharmacal Co., St. Louis, Mo.; Lea Bros. & Co.,
Philadelphia; S. H. Parvin's Sons, Cincinnati, O.; I. Hal-
denstein. New York; Dr. John V. Shoemaker, Philadel-
phia; Dr. W. H. Atkinson, New York; Oneita Springs
Co., Utica, N. Y.; Dr. S. F. Cook, New York; Parmenter
Printing Co., Lima, O.; John Wanamaker, Philadelphia;
Dr. J. A. Webb, Voluntown, Conn.; Dr. R. Harvey Reed,
Mansfield, O.; Malted Milk Co., Racine, Wis.; The Mar-
lin Fire Arms Co., New Haven, Conn.; Dr. A. Vander-

Official List of Changes in the Stations and Duties of
Officers Serving in the Medical Department, U. S.
Army, from October iz, iSSg, to October 18, i88g.

Capt. Louis Brechemin, Asst. Surgeon U. S. Army, re-
lieved from duty at Ft. Laramie, Wyo. Ter., and or-
dered to Ft. Apache, Ariz. Ter. Par. 2, S. O. 241, A.
G. O., October 16, 1S89.

First Lieut. Alfred E. Bradlej-, Asst. Surgeon U. S. Ar-
my, relieved from duty at David's Island, New York
Harbor, and ordered to Ft. Omaha, Neb. Par. 2, S. O.
214, A. G. O., October 16, 1889.

First Lieut. H. S. T. Harris, Asst. Surgeon U. S. Army,
relieved from duty at San Antonio, Tex., and ordered
to Ft. Keogh, Mont. Par. 2, S. O. 241, A. G. O., Octo-
ber 16, 1889.

Capt. Edward Everts, Asst. Surgeon U. S. Army, relieved
from duty at Ft. .Apache, .\riz., and ordered to David's
Island, New York Harbor. Par. 2, S. O. 241, .•V. G. O.,
October 16, 1889. |

Capt. W. R. Steinmetz, Asst. Surgeon U. S. .\rmy, or- \
dered for examination for promotion. Par. 3, S. O.
236, A. G. O., October 10, 1889.

Capt. Louis Brechemin, Asst. Surgeon U. S. .\rmy, grant-
ed leave of absence for one month. Par. i, S. O. 98,
Hdqrs. Dept. of the Platte, October 12, 1S89.

Capt. George W. Adair, A.sst. Surgeon U. S. Army, leave
of absence extended for fifteen days. Par. 15, S. O.
238, A. G. O., October 12, 1S89.

Capt. Valery Havard, Asst. Surgeon U. S. Army, leave of
absence extended one month. Par. 3, S. O. 240, A. G.
O., Octoberi5, 1889.

Major L. Y. Loring, Surgeon V- S. Army, sick leave of
absence extended two months on surgeon's certificate
of disability. Par. 16, S. O. 241, A. G. O., October 16,
1889.

Lieut. -Col. Anthony Heger, Surgeon U. S. Army, re-
lieved from duty in Div. of the Atlantic, and ordered
for duty as attending .surgeon, Washington, D. C. Par.
2, S. O.' 241, A. G. O;, October 16, 1889.

Major Robert M. O'Reilly, Surgeon U. S. Army, granted
leave of absence for six months, with permission to
leave the United States. Par. 3, S. O. 241, A. G. O.,
October 16, 1889.

Official List of Changes in the Medical Corps of the U. S.
Navy for the Week Ending October ig, rSSg.

Surgeon D. W. Bertolette, detached from the "Frank
lin," and ordered to duty at Naval Hospital, Philadel-
phia.

P. A. Surgeon N. H. Rush, detached from Naval Hospi-
tal, Philadelphia, and ordered to the "Saratoga."

P. A. Surgeon C. T. Hibbett, ordered to the "Franklin."

T H E

Journal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.
PUBLISHED WEEKLY.

Vol. XIII.

CHICAGO, NOVEMBER 2. 1889.

No. 18.

ADDRESSES.

THE ADDRESS DELIVERED BEFORE

THE AMERICAN PUBLIC HEALTH

ASSOCIATION,

Ai Brooklyn, N. }'., Od. 22, i88g.

BY H. K. JOHNSON, M.D.,

PRESIDENT.

[Abstracted for The Journal. J

Gentkinen of the Association, Ladies and Gen-
tlemen: Article second of the Constitution of
the American Public Health Association declares
that the object of this Association shall be the
advancement of sanitary science and the pro-
motion of organizations, and measures for the
practical application of public hygiene.

In the furtherance of this object it has seemed
wise that there should be at its annual meetings
not only papers upon purel}^ scientific subjects,
but that also, in the form of essays or public
addresses, an effort should be made to secure the
interest and cooperation of those of our citizens
who have no official or professional relations to
the objects of the organization. In other words,
to invite the stipport of all classes of society in
the advancement of public health.

To do this we must demonstrate the truth of
the maxim of one of our greatest philosophers
that " Public Health is Public Wealth." I shall
not, therefore, address myself so much to the
scientist, the official and professional sanitarian,
as to the people, who, bj- their presence here to-
night, give evidence of sympathj* and interest in
our work — or rather their work — and to whom,
after all, we must look for means to carry out
such measures as science shall demonstrate to be
for our race most beneficent. Through the ages
but little has been done to prolong life and
mitigate distress. We know now that much can
be done, much that is not done, for the ac-
complishment of these results. The world has,
however, in action, never utilized its fullest ca-
pacity for work ; in achievement it has never
reached its power to do. This is true along all
the lines of social and public activity. It is no
more true in preventive medicine than in other
departments of public endeavor. The great

! difficulty in the way of successful sanitation has
! been, and still is a want of adequate knowledge
I as to the causes of our suffering, and the agencies
j of our destruction, and a want of confidence in
the measures proposed for relief.

Of the beginnings of this desirable kind of
knowledge we know but little, but in old records
we find some faint suggestions. We know that
along the eastern border of the old ^Egean sea,
and skirting the coast of Asia Minor are numer-
ous islands Avhose names are embalmed in song
or story of ancient Greece. On a high promon-
torj' of one of these, in the dim twilight of
antiquity, a temple had been erected to .Escu-
lapius. A few miles back, at the base of a line
of low hills, there gushed from the rock a stream
of warm, life-giving water. Its properties were
such as to invigorate and strengthen the wearied
■ and exhausted, and to especially restore to the
blood the qualities in which it is usually deficient
in malarious countries. In a word, they were
chalybeate. Rich in iron, they met most fully
the needs of the dwellers along the shores of the
islands and the continent, and the crowded cities
of Greece. To this temple and fountain the
sick from manj^ lands had come, and there had
been abundant opportunity to test the healing
qualities of the waters. Those who had received
benefit had hung upon the walls, or inscribed on
tablets which were placed around the temple,
brief histories of their diseases and the results of
their offerings to God and Goddess. Here, in
the fifth centurj- before our era, a young student
from a neighboring city, descendant of a long
line of priest phj'sicians, established his home.
He was a lover of nature, and we ma)' presume
that he had been attracted in part b}^ the beauty
\ of the island, with its ridges of low mountains,
or rather hills, which skirted the southern border,
and which gave birth to cool streams of delicious
water destined to give fertility to the northern
slopes, the land of the grape, the home of the
most generous of wines. The scholar had
lingered, not so much for the beauty of the land-
scape, however, or for the delicacy of the fruits,
as for the interest which he felt in the curative
properties of the fountain itself. While he be-
; lieved in the Gods, he was, nevertheless, a close
observer of nature. Here in the temple had

6i6

AMERICAN PUBLIC HEAI^TH ASSOCIATION.

[November 2,

already been established a school of medicine.
The facts were the inscriptions just alluded to,
placed upon the walls, left b}' those who had
been cured by their visit to the temple and the
grove, and in answer to their prayer to the
deities of health and medicine. The young
truth-seeker approached reverently the altar, but
looked at the phenomena occurring under these
influences as, nevertheless, the product of some-
thing in the world of matter. Time passed
swiftly and happily in the pursuit of a more
reasonable understanding of disease and its
cause, and a more accurate knowledge of the in-
strumentalities by which it is modified.

His fame began to spread through the island
and to the shores of Asia and Europe. Numbers
came to consult him. His advice was sought in
times of pestilence, and he had come to be re-
garded as one of the wise men of his age.
Whether myth or history we know not certainly,
but the story is that while he was patiently pur-
suing his studies and questioning nature, a mes-
senger from the chief city of Greece landed upon
the island. The angry gods, so the stranger
said, had stricken in their wrath, the whole pop-
ulation. The peasant and the prince fell alike
beneath the arrows of the destroyer. The chief
ruler in his great distress had sent for the master.
His favorite son had alread)^ fallen, and he him-
self had been accused b}- the people as the author
of the scourge. He therefore prayed the learned
man to visit the suffering city and advise what
should be done to save, if possible, the remnant
of the plague-stricken inhabitants.

In answer to the summons, the physician im-
mediately prepared to leave his pupils, for he had
already many such, and enter, as many of his
followers have since done, the field of death. He
gave a few simple instructions to those best fitted
to carrj' on his work, and at once embarked. On
reaching his destination, he found the citj- in a
condition which the graphic pen of her chief
historian has made to us so fearfully realistic.
His first act was to note carefully the soil and
drainage of the parts most severely afllcted.
He also investigated the water sources. He
studied the climatic conditions, and especially
did he carefully note the occupations and habits
of the inhabitants. He observed that filth every-
where abounded. While there was great mag-
nificence in the architecture, and the palaces of
the rich were in the most wonderful condition of
adonnnent, there was Iteneath all this opulence of
display a reeking hot-bed of foul matter giving
off the most disagreeable and offensive odors.
Under his advice there was an effort made to
I)urify, as far as po.ssible, the atmosphere. The
city was besieged by an enemy, and the thickly
crowded metropolis did not present a promising
field for sanitary work. In the meantime, the
great ruler, broken with his many cares and ill-

requited labors, was himself prostrated. The
end was soon reached, and the greatest of the
Athenians, Pericles, was among the immortals.
Hippocrates returned to Cos, there to ponder
upon the lesson which had been opened before
him in the plague of Athens, and to write his
book on "Airs, Waters and Places," the oldest
treatise of which we have any knowledge on
h}'giene or public health. We find stated in it
with almost the definiteness of modern sanitary
science, the great importance of pure water, as
well as some of the diseases which are likely to
result from the presence of filth. From the time
of the father of medicine to the revival of learn-
in the fifteenth century, we have but verj- little
progress in the -work of saving life. The older
doctrines as to the cause of disease, whether
among pagan or Christian people, were not en-
couraging to efforts in this direction. It has,
therefore, come to pass that measures looking to
the prevention of disease by the use of scientific
methods, are modern.

BUT LITTLE DONE DOWN TO RECENT TIMES.

The maxims of Hippocrates, the ceremonial of
the Hebrew law as to bathing, and the establish-
ment of quarantines, are almost the only excep-
tions. For the most part suffering has been re-
garded as an infliction of the gods, or, among
Hebrews and Christians, as a dispensation of
Divine Providence. . . .

So long as life and its disorders were made to
depend upon the unknowable, but little en-
couragement could be found, in fact for an effort
to prolong the one, or to prevent the other.
Even the materialists were content with phe-
nomena, and wearily warred with existing con-
ditions. Slowly with the revolving centuries
better notions of the conditions of life have been
reached. A better understanding and observa-
tion of sanitar}- laws has been brought about.
Gradual chahges in the modes of living and
larger means of comfort on the part of the people
have been accomplished. With all these im-
provements something has been done towards in-
creasing the length of life. We have, as a race,
made some progress, and by surviving we have
demonstrated our fitness to survive. We do not
know accurately the death-rate in the earlier
centuries, but we do know that famine and pesti-
lence carried away its hecatombs. As we come
to more recent times we reach some approxima-
tion, at least to accuracy. In the seventeenth
century, and for some hundreds of years before,
the population of England and northwestern
Europe had remained, if not stationary, with
onlj' a very slow growth. The cities, it is true,
increased in population, hut this increase could
only be appreciated by comparing periods sep-
arated by many years. The agricultural districts
very slowly became occupied. Life was short

1889.]

AMERICAN PUBUC HEALTH ASSOCIATION.

617

and its product small. After the revival of learn-
ing, that great awakening of the sixteenth cen-
tury, however, life became more valuable, and it
was worth while to make a greater effort to save
it. In the diaries of individuals and in the
writings of medical men, we find some informa-
tion, meager it is true, but some statements as to
the life movements of the dead old centuries.

A few facts in the sanitary, or rather unsani-
tar3% history of London during the seventeenth
centur}', are suggestive of what was frequently
taking place over all the then civilized world.
These facts also give us a satisfactor>' explana-
tion for the slow growth of the population of
that century as compared with the nineteenth.

In 1625, a writer says : "The plague caused
the death of 5,000 a week during a part of the
summer." In 1665, July 16, he writes : "There
died of the plague in London this week 1,100."
In the week following, 2,000. August 8, he
writes in his diar>', " Died this week in London,
4,000." August 15, the same summer, "There
perished this week, 4,000." He seems to have
left the city for awhile, for on September 7, he
says, ' ' Came home. There perishing nearlj'
10,000 poor creatures weekly."

S5-denham, a very reliable medical authority,
says of the same summer ; ' ' There died in one
week 8,000, while two-thirds of the population
v.ere out of the citj'. ' ' The population is not
certainly known, but probably at the time referred
to was not more than half a million, as it was
onh^ something over 800,000 at the beginning of
the present century.

Small-pox also ravaged the cities of Europe in
winter, while plague decimated them in summer.
In 1695, a reliable writer (Pepys) says, casually,
in the discussion of other subjects ; "The deaths
were from small-pox increased to 500 more this
week than last." What should we think in
Brooklyn to-day with 500 deaths more this week
than last from small-pox, with the probabilities
that last week the number had reached into the
thousands ? But for vaccination, such might be
our experience. The same writer comments
upon the fearful spectacle in the streets of
London. "Almost everyone," he says, "who
has survived this .scourge, was scarred and pitted
by the pestilence and presented the most ghastly
appearance." There was no effort to escape it
except by flight to the countrj'. It was believed
that the epidemic constitution of the air, another
unknown and mysterious quantity, made the
plague a necessity once, at least, in thirtj' or fortj^
years. Small-pox was always present and
caused the death of one-sixth of the population
of all the larger cities. The death-rate was
greater than the birth-rate, and the population of
London and other cities was maintained by a
constant influx from the provincial districts.
During all this time, the means of communica-

tion were few and a prion', we should not expect
contagious diseases to spread with anj^thing like
the degree of rapiditj^ made possible in this age
of railroads and steamships.

ADVANCES IN THE LATER YEARS.

How much the death-rate has been reduced in
England in the last two hundred years, we do
not certainh^ know, but there is reason to believe
that in London it has diminished from forty or
more in the 1,000, at the beginning of the pres-
ent century, to about one-half that number. The
plague is a grim spectre of the dead past. Small-
pox is a Samson shorn. The increase in popula-
tion has been correspondingly rapid. I think we
may safely infer that the diminution in the death-
rate and the increase in the population through-
out Great Britain has borne some proportion, at
least, to what has been accomplished in the
metropolis. This increase of population has
taken place notwithstanding the fact that during
the last half century, millions have come from
the British Isles to our own shores, while yet
other millions have found other homes, and yet
the work-shops of Britain are beehives, and the
hill-sides of merry old England teem with in-
dustrious workers. A great change has been
wrought in this last three-quarters of a century.
We know much more accurately how long people
live, from what causes they die, and at what ages
they die. We begin to see more clearly how the
death-rate can be still more reduced. If we
follow the course of a given number of individu-
als from birth to death, as we can well do by the
aid of statistical tables, we shall find that in
England and Wales out of one million persons
born, more than one-fourth die in the first five
years. If we divide the country into healthy
and unhealthy districts, grouping together the
different cities and counties according to the
death-rate, we find that in the healthy districts
only about one-sixth of the million die within
this first period of five years, while in the un-
healthy districts, of which Manchester may be
taken as a type, nearly one-half of the million
born, die within the first five years. In other
words, of a million of children born in the un-
healthy districts, more than 280,000 die within
the first five years for the want of proper sanitarj^
care; 280,000 would have lived beyond this five
j-ears if they had been born in the healthy
districts.

The same startling contrast between the worse
and the better districts, will meet us if we studj'
the later life history of this 1,000,000 of human
beings.

By cooperation on the part of the people the
unhealthy districts might be made as healthy as
London, and as the other provincial towns and
shires in which the death-rate is so low. In
fact, Liverpool has within the last twentj^-five

6i8

AMERICAN PUBIvIC HEAI^TH ASSOCIATION.

[November 2,

years been transformed. It was one of the most ! those who claim too much, who speak as having
unhealthy, it is now one of the most healthy of 1 authority, but have not the wisdom to see the
English cities. The application of money by ' limitations and difficulties in the way of practical
scientific methods might change all this, and pre- , results.

vent this fearful slaughter of the innocents. ... 1 While, therefore, we should by all possible

■means strive to instruct and interest the great
LEGISLATION BASED UPON KNOWLEDGE. [ p^^^jj^ -^ ^he work of preventive medicine, the

The other field, and the one to which I more | task of devising the means and methods must re-
particularl}^ desire to call attention, embraces the , main in the hands of those who have special
problems of public health. Society has always ! knowledge of these matters. These specialists
recognized certain evils growing out of aggrega- should not be taken wholly from the profession
tion, and has sought to control these evils. By of medicine. As an illustration of what a lay-
legislative enactment and the establishment of' man may do, I have only to mention the name of
police regulations, an effort has been made to se- 1 England's greatest sanitarian, Mr. Edwin Chad-
cure the greatest good to the greatest number, wick. Through a long life he has devoted him-
Persons and property have been protected, crime , self to the work of improving the condition of
has been punished ; and mainly with the motive ; London and other English districts, and it is safe
to prevent crime. In these later years the obli- to say that during the last fift}' years his services
gation of the public to protect, not only the ! have in value not been excelled by those of an\'

' Englishman in even the highest position of
official or social life. What we want is on this

j side of the ocean such men as Mr. Chadwick.

j If we are to reach that measure of success which
we believe to be possible, the world must not be
mined. The registration of births, deaths and left entirely to the medical profession or to health
marriages, the causes of death, the collection of I officers.

information as to prevailing diseases, the coUec- i The egoism that leads manufacturers and
tion and preservation of meteorological statistics, 1 others engaged in the various industrial occupa-
the collection and tabulation of statistics of the \ tions to ignore, in their eager pursuit of wealth,

worldly goods of the citizen, but also his health,
begins to be realized. An intelligent foundation
has been laid for sanitary reforms. These con-
sist first, in the collection of statistics by which
the value of certain procedures may be deter-

movements of the people, emigration, the growth ^
of cities and States — all these accumulations:
serve as material out of which may be developed
more accurate knowledge and better methods.
Governments begin to recognize a responsibility
in these matters. But for the most part, legisla-
tion is still crude, and the administration of sani-
tary laws full of blunders. In this respect the
history of sanitarj' enactments and their execu-
tion does not materially differ from that of other
social and political reforms. It is the want of ac-
curate knowledge that leads to our mistakes of
legislation ; the want of practical acquaintance
with the methods of administration that leads to
the blunders to which we have referred.

As our oldest literature on sanitation was born
of the pestilence, so our legislation has been
stimulated by epidemics and has for the most
part been provisional. Wise legislation must be
based upon knowledge, knowledge on the part
not only of professional sanitarians, but knowl-
edge on the part of the public. It cannot be ex-
pected that this general or public knowledge will
be technical ; it must be general and related to
the results that can be reached by scientific means
and methods. A knowledge that begets faith in
the agencies of protection and that secures effici-
ent cooperation, and not, as has been too often
the case, obstruction in the execution of sanitary
laws. There are dangers, however, in this field
of work, as in most others, that grow out of a
smattering of knowledge. There will always be

the public welfare, will always be an obstacle to
the enactment and execution of health laws, but
this general enlightment on the part of the pub-
lic which we so confidently^ look for, will compel
obedience to these as well as to other forms of
police regulation.

WHAT HAS BEEN DONE IN THE WAV OF
LEGISLATION ?

It is only within the last few years that sani-
tary organizations have come to be recognized as
a necessarj^ part of the machiner\' of State,
Within the memory of many here present, there
was not an efficient board of health in any city or
State of this country, or in fact of the world.
Police regulations establishing quarantine, it is
true, existed, but these quarantines instead of be-
ing beneficient in their character, were often use-
less, and in many instances they became mon-
.strous crimes again.st humanity. All this is
being changed. Society recognizes its obligations
in two directions : First, to remove from its
midst or destroy every possible source of disea.se,
and to so control the cau.'ies that cannot be re-
moved or destroyed as to diminish to a minimum
their deleterious influences upon public health.
Secondly, the obligation to prev^ent the introduc-
tion of disea.ses from without, by such measures
as shall be found the most efficient for the ac-
complishment of this end, and at the same time
work the least amount of inconvenience to the
social and commercial interests of the communitv.

1889.]

AMERICAN PUBLIC HEALTH ASSOCIATION.

619

For the accomplishment of the first purpose
we have already done something, but there re-
mains much more to be done. There should be
in every town or city or district a health author-
ity. Under the direction of this authority there
should be a survey first made with a view to de-
termine the presence or absence of the physical
conditions that unfavorablj- aifect health. This
study should include not only the natural condi-
tions, such as the climate, soil, exposure to sun
and air, neighborhood, including water, wood
and elevation, etc., as suggested by Hippocrates
many centuries ago, but it should also embrace
the condition of the population, their nationalitj',
occupations, dwellings, density and food. It
should also show the methods of removal of ac-
cumulations and, in the more populous districts,
the disposal of .sewage, the condition of streets
and alleys, and the character of drinking water.
There should also be noted any special industries
b)' which air or water may be contaminated.
The bearing of most of these different industries
upon public health is now well known. In addi-
tion to these studies of the surroundings and the
activities of the population, there should be a
careful collection and preservation of the statistics
of births, deaths, marriages, the prevailing dis-
eases, the causes of death, and the increase or de-
crease, if such be the case, of population. This
is onl}' a suggestion of a few things that should
be done, and these should be done in the smaller
towns and villages, as well as in the larger
cities

WH-\T REM.ilNS TO BE DONE.

It appears that the death-rate of twenty- six of
the principal cities of America, with a population
of 9,873,448. is 20 per 1,000, I think it morally
certain that this rate could be reduced, bj- means '
and methods now knoicn to sanitary^ science, to
16 per 1,000, and probably still less than that.
The death-rate for London for the year 1 888 was
18.5 per 1,000. This can be still further reduced.
That of New York and Brooklyn for the same
year, taken together, was 25.5 per 1,000 — New
York 25.9, Brooklj-n 23.7. The death-rate of
these two cities, if reduced to that of London,
would secure a saving of 7 per 1,000, or, annual-
ly, 15,986 lives. These lives are public wealth.

But this is not all. For one death annually
two persons are sick during the entire year ; or,
in other words, there are two years of disabling
sickness to one death — 31, 972 years, in New York
and Brooklyn, of sickness, preventable sickness,
annualh-. The value of these years of sickness
cannot be reached with accuracy, but the wages
lost on account of sickness, the cost of care and
maintenance during sickness and convalescence,
and the money value of the lives destroyed, con-
sidering them onh- as machines, will in New York
and Brooklyn reach annually into the millions.

I venture to suggest to the business men of these
cities that this loss is enough everj- year to buy
a great railroad, or to build and subsidize a fleet
of ocean-going steel steamships.

The sorrow of i6,ooo homes, the years of grief,,
and the 32,000 years annually of anxious watch-
ing and waiting over the sick-beds of those who
finally recover, are not taken into this estimate.
Such considerations do not, except spasmodically,
move legislatures or executives. It is onh- as
these touch property, only as epidemics interrupt
commerce, that we are able to secure eflBcient
legislation. I firmly believe that the death-rate
of nearly all our large cities may be reduced 3 to
4 per 1,000 from the present rate. I am fully-
satisfied that this might be accomplished in our
chief cities, and that sickness might be dimin-
ished in a corresponding degree.

This lengthening of years, this relief of dis-
tress, this saving of public wealth, is worth work-
ing for. What is true of the cities is, to a great
extent, true of the rural districts. All over our
broad land are farm-houses and small villages
which become every year the seat of diseases that
grow out of filth. Foul drains, foul water, badly
constructed and ill-ventilated dwellings and
school- houses are the cause of thousands of deaths
every year — deaths that might be prevented by
the application of acquired knowledge upon this
subject. Sir James Paget, before the London
Health Exhibition, discusses the problem of na-
tional health, and very conclusively shows that
among the wage- earners of England and Wales
probably one- fourth of the sickness is preventable.
Of the 20,000,000 ofweeks lost by about 15,000,-
000 of the population, 5,000,000 weeks, or more
than 95,000 years of work might be saved. This
estimate is based upon the population between
15 and 65 years of age. The extension of this
computation of sickness to all ages in Great Brit-
ain and Ireland would present us with a most
startling array of figures

Up to the present time these problems of public
health have received but little attention at the
hands of statesmen; but it is no longer a question
of possibilities, it is certain that this great saving
of the best kind of public wealth is within our
reach. It may not be accomplished by methods
hitherto used, but the result is possible by methods
that are known and which we know how to adopt.
What we want is a recognition of the evil, and a
disposition to invest at least a very small percent-
age of the loss in money value of life and work —
wasted life and work — for the purpo.se of prevent-
ing this waste — hardly more than \>t)uld be paid
for the insurance upon our public buildings, or
upon our dwellings in proportion to the value of
the buildings themselves

We do not know with certainty how long life
may be prolonged, but we are morally certain
that it may be extended much beyond its present

620

THE CURE OF HERNIA.

[November 2,

limits, and with a fair degree of usefulness. It
is believed that its normal limit is about 100
j-ears. Instead of about 40 }■ ears under the most
favorable conditions, as at present, it is quite
probable that 60 or more j'ears should be attained
bj- the best use of the means now known; that is,
the average should be 60 or more years. With a
better understanding and more faithful obser^^-
ance of health laws 40 additional years should be
reached. This obedience to law, this adjustment
of our surroundings and regulation of our whole
being, mind and bodj-, in accord with the condi-
tions of physical health, will prove to be the

onl}' true elixir of life

The future is full of hope. Everywhere science
"vvith the microscope and the crucible is following
the germs of disease and the agencies of death.
Politicians even are beginning to think it is worth
while to preserve the lives of their constituents,
The great public is beginning to believe that
something more potent than fasting and sackcloth
can be devised for their protection from pestilence
and the grave. Let us all work together and we
can do much even now, and in doing what we
know how to do we shall find out other ways to
do still greater things. So shall we lengthen the
cords and strengthen the stakes of the great tent
of life, under which the cry of distress and wail
of bereavement shall ijecome ever less and less ;
while in swelling chorus shall be heard, through
the ages, the laughing of children, the sweet
voices of j'oung men and maidens, and the strong
words of old men and matrons.
4 Sixteenth street, Chicago.

ORIGINAL ARTICLES.

THE CURE OF HERNIA BY THE USE OF
THE BURIED ANIMAL SUTURE.

Read in the Sec/ion of Surgery and Anatomy at the Fortieth Annual

Meeting of the American Medical Association held at

Nezvport, R. /..fune 2S, 1SS9.

BY HENRY O. MARCY, A.M., M.D., LIv.D.,

OF BOSTON.

This paper is offered as a clinical study of
operative measures for the cure of hernia. The
cases reported represent all the usual varieties
and were operated on during the eight months
ending with April, 1889.

Case I. — J. R., aged 45, an invalid for years
from a large scrotal tumor. I had twice aspirated a
few ounces of bloody fluid. There was also dis-
ease of the t|sticle. From the external ring there
was a firm mass the size of the fist, continuous
with the scrotal tumor. He had consulted sev-
eral physicians, including members of the surgical
staff of the Massachusetts General Hospital.
Diagnosis luicertain, perhaps a malignant tumor;
operative measures unadvisable. I operated

August 29, 1888, assisted by Dr. S. N. Nelson,
of Boston. Removed the diseased testis ; opened
the hernial sac, which was found to contain onlj-
compressed omentum. Its folds were adherent,
but were separated into the specimen here shown,
which measures 6x8 inches. It was sutured
across at its base, freed from adhesions to the
internal ring, and divided. The stump was
returned within the abdominal cavity. The large
peritoneal sac was everj-where closely blended
with the external tissues and was dissected with
difficulty. It was freed to within the internal
ring, well drawn down, and sewed e\-enl3- across
at its base with five or six continuous sutures.
This was excised and the closed peritoneum
replaced within the ring. The internal ring was
closed with a deep layer of double continuous
tendinous sutures. A second laj-er of sutures
was continued in the same manner, approximating
the structures external to the pillars of the ring.
The scrotal tissues were also closed by laj-ers of
buried continuous animal sutures. The skin was
approximated subcutaneously by a blind stitch and
the wound sealed with iodoform collodion. The
operation, as were all of the entire series, was
performed under strict antiseptic precautions,
including continuous irrigation with a yh-'ttu sub-
limate solution. The wound healed without
suppuration or even in au}- degree scrotal oedema.
The patient was free from pain almost from the
first.

At the discussion upon the subject of the cure of
hernia in the Surgical Section of the Suffolk District
Medical Society, January, 1889, Mr. R. kindly
consented to be present and let the result be seen.
The wound remains firm to date, the patient has
resumed his ordinar}- occupation, suffers no in-
convenience, and has not worn a truss. The sac
in the specimen presented is stuffed with cotton
and exhibits the peritoneal surface, in order to
show the extraordinarj- changes that occurred in
the development of its fibres.

Case 2. — M. H., aged 30, patient of Dr. C. \V.
Stevens, of Charlestown; is of exceptional phj^sical
development, fond of athletics. A large scrotal
hernia of the right side, which for a considerable
period has been irreducible and painful ; incapaci-
tated him at times for any labor. Had previously
worn a variety of strong trusses with inability of
retention. I operated September 29, 1888; opened
sac, which contained an easily reducible loop of
intestine and a large mass of compressed adherent
omentum. The ring admitted two fingers. The
operation was conducted as in case i , except that,
in the closure of the ring, the cord was gently
lifted to one side and the internal ring closed
from below upward, closelj- upon the cord at its
entrance within the abdominal cavitj". This was
done in order to restore the obliquity of the
canal. The cord was then replaced, and with the
same suture the pillars of the ring were closed

1889.]

THE CURE OF HERNIA.

621

down externally upon the cord, quite to the level
of the external ring of the opposite side. The
patient made a rapid recover}-, the tissues uniting
by first intention without oedema and almost
without pain. Recent examination showed a
slight bulging of the right inguinal region, but
without opening of the canal. On account of a
feeling of weakness and to prevent further yield-
ing of the parts, he has been fitted by Dr. Cod-
man with a light truss, which he wears with
comfort.

Case J. — J. M., age 55, coachman. He had
been troubled with a right inguinal hernia for a
long time, complicated with hydrocele, for the
relief of which he has been frequently tapped ;
fluid withdrawn at the Massachusetts General
Hospital a few days previous to operation, Octo-
ber 4, 1888. He was unable to reduce the hernia,
and after two days of severe vomiting, the latter
part of which was stercoraceous, he sought sur-
gical aid. Taxis under ether proved unavailing.
Assisted by Dr. H. D. Didama, of Syracuse, N.
Y., I divided the constricting ring, restored the
hernial contents and completed the operation for
radical cure. After rallying from the ether the
patient was taken in a carriage to his home,
where he remained in bed two weeks, almost
without attendance, but he made a rapid and
painless recovery. He was also exhibited at the
meeting of the Suffolk District Society above
referred to. Although the hj-drocele has twice
refilled to inconvenient size, he remains entirely
without discomfort from the hernia, has not worn
a truss, and is actively at work.

Case 4. — S. N., physician, age 31, upon whom
I operated for the cure of an inguinal hernia of
the left side in the autumn of 1886, which has
remained firm up to the present time. During
the summer of 1 888 he first uoticed a slight bulg-
ing of the right side, for the support of which he
applied a light truss. Notwithstanding, the her-
nia rapidly became scrotal and irreducible. I
operated October 12, 1888, assisted by Dr. H. D.
Didama. The sac was thickened, everywhere
adherent, and dissected with difficulty. The
loop of the intestine was easih^ reduced, but a
considerable amount of omentum was adherent,
and so changed that it was removed. The speci-
men here presented is interesting because of its
rapidity of formation. The patient suffered ex-
tremely from pain in the back on account of con-
finement to the bed. For this reason he was
allowed to sit in a reclining chair each day after
the first, and in two weeks from the operation
walked a quarter of a mile without inconvenience.
The side feels perfectly firm at date. He has not
worn a truss.

Case 5. — Mrs. J., age 40, entered private hos-
pital on account of ruptured cervix and perineum.
She had suffered also for years from a femoral
hernia of the right side, easily reducible, but

which was imperfectly retained with a truss. In
addition to the operations for repair of cer\'ix and
the perineum, I removed the hernial sac Decem-
ber 3, 1888, which is here exhibited. The recov-
ery was rapid without any unfavorable symptoms
and the patient remains cured at date.

Case 6. — G. S., age 40. The general health of
the patient excellent, but for years he has been
incapacitated for active labor because of a large
left inguinal hernia, complicated with a varicocele.
The scrotal tumor is so large as to extend at
times quite one-third to the knee. The hernial
tumor is imperfectly retained by a truss, the
pressure of which causes pain by impeding the
venous outflow. Assisted by Dr. H. D. Didama,
of Syracuse, N. Y., I operated December 4, 1888.
In addition to the operation for the radical cure
of the hernia I dissected and tied the veins of the
scrotum in three different places, some of which
were varicosed to the size of the little finger.
The wounds healed without oedema or suppura-
tion, but the scrotum remained somewhat tender
to pressure, and the patient still wears a suspen-
sory bandage. The patient remained in the hos-
pital three weeks and was discharged cured. No
return of or inconvenience from the hernia, and
no truss has been worn. Is actively at work.

Case 7. — Mrs. J. S., age 43. For many years
has suffered from a right femoral hernia, for
which she had worn a truss. For the last year
she had noticed a tumor in the groin, something
larger than a hen's egg. At times it is painful
and always a source of discomfort, is slightlj^
tender to the touch, and does not diminish under
pressure. Femoral canal admits the tip of the
little finger. Operation performed January 2,
1889. Sac contained clear serum and was con-
tinuous above through the femoral canal with
the peritoneum, but its cavity had been obliter-
ated under the pressure of the truss, thus reducing
it to the characteristics of a simple cyst. This I
removed and closed the ring. Rapid primary
union followed, and the cure remains complete
without support. Specimen exhibited shows the
intimate adhesion of the sac to the surrounding
tissues.

Case S. — Mrs. B., age 34. Has for a long time
been a semi-invalid from a right femoral hernia,
for which she has worn a truss. In preparation
for moving she lifted more than usual, causing
the descent of the hernial tumor, which immedi-
ately produced great suffering, with faintness and
vomiting. The phj^sician summoned to her relief
attempted the reduction of the tumor by taxis,
which he continued more than an hour. His
j efforts proved unavailing and he left the patient
with directions to use opiates and hot fomentations.
1 1 was summoned twenty-four hours later, Januarj'
31, 1889. At once I removed her to hospital,
etherized and operated. The ring was divided
with difficulty and several inches of congested

622

THE CURE OF HERNIA.

[November 2,

intestine liberated and returned. The patient
made an excellent recoverj-, although between
three and four months pregnant at the time of op-
eration. She remains cured at date, although
Hearing her deliverj'. She has not worn a truss.
The sac here exhibited shows the constriction of
the neck, through which a piece of rubber tubing
has been passed.

Case g. — Strangulated umbilical hernia, five
daj's' duration; patient of Dr. J. H. Parks, of
East Boston. Case came under his observation
only a few hours prior to his sending for me in
consultation. Stout Irish woman, aged about 50.
For some years had suffered from an umbilical
hernia, double fist's size, a portion of which for a
considerable period had been irreducible. Stereo -
raceous vomiting had continued for two days.
Operation considered permissible, although the
result would be doubtful. The thin-walled in-
teguments covering the tumor were sphacelated.
The hernial contents were found to consist of a
large mass of adherent omentum, within which a
considerable loop of small intestine was incarcer-
ated. The constriction was easilj- divided, but
the intestine was gangrenous and tore asunder
under gentle traction. The ends were brought
out from the wound, resected, and coaptation
affected by means of a double row of continuous
Lembert sutures. These were easily and rapidly
applied and the divided mesenterj- united in
continuous suture. The parts were well washed
with hot sublimate and returned within the ab-
domen. The hernial sac was resected and the
abdominal wall closed in layers by continuous
tendon suturing, as after an ordinary laparotomy.
When partially recovered from ether regurgitating
vomiting occurred, several pints of dirty fluid,
W'hich was so continuous as to impede respiration
and, despite all efforts, proved the cau.se of death.
In order to anticipate such a possible accident it
had been the intention to wash out the stomach
prior to etherization, but in the hasty preparation
the stomach tube had been unfortunately for-
gotten.

Case 10. — I. J,, aged 75. Strangulated left
inguinal hernia. Retired sea captain ; general
health good. Has for years suffered with double
inguinal hernia, imperfectly retained by a tmss.
About four weeks prior to operation the left
hernia became strangulated and, under ether, was
reduced with difficulty. I was .summoned shortly
after the strangulation occurred. Failing in
taxis I operated at once, March 7, 1889, assisted
by Drs. Nelson and Cook. The tumor was
double fi.st size and reduction was effected only
after a wide division upward of the constricting
ring. The sac contained about fifteen inches of
small intestine, closely adherent by lymph ex-
udation, probably dating from the strangulation
of four weeks previous. Adhesions broken down
prior to the return of the intestine into the ab-

domen. Vomiting ensued soon after the close of
the operation, and insufflation of a portion of the
liquid contents into the bronchi well nigh caused
death. Acute pneumonia supervened, which
caused the greatest anxietj- for the two subse-
quent weeks. Although the strain from cough-
ing was severe, the sutures did not yield, and yet,
ten days after the operation, a considerable por-
tion of devitalized, broken-down tissue was ex-
foliated. Repair went on satisfactorily by granu-
lation, although the recoverj' was necessarih'
protracted. A considerable depression marks the
site of the wound, but the abdominal wall is firm
and unyielding. The patient is actively about,
wearing a truss to support the opposite side. The
accompanying specimen shows the everted sac
stuffed with cotton and nearly fills a quart jar.
The peritoneum affords an interesting studj-.

Case II. — Mrs. P. Right femoral hernia. I
operated upon the lacerated cervix and restored
the perineum at the same sitting, April 17, 1889.
Recover}- rapidh' followed, the patient apparently
suffering little or nothing more from multiplicity
of operations. Union in each priman,\ Speci-
men exhibits an interesting condition of the
changed peritoneum. The patient returned home,
several hundred miles distant, at the expiration
of three weeks, and reports condition satisfactorj-.

Case 12. — Right scrotal hernia. Patient aged
about 60, inmate of the Soldiers' Home at Chel-
sea because of this disability. Operated upon
by Dr. Nelson and myself April 10, 1889. Sac
everywhere adherent. Dissected with difficulty.
Obliquity of canal restored. Recovery slow, but
result reported as satisfactorj-. The a/:company-
ing specimen exhibits the peritoneal sac most
remarkablj' reenforced b}- interlacing bands of
hj'pertrophied connective tissue.

Case ij. — Right femoral hernia. Female aged
27; seamstress. Hernia retained imperfectly by a
truss. Disability and suffering ver\- pronounced.
Operation April 27, 18S9. Recoverj- rapid; dis-
charged from the hospital at the close of the sec-
ond week, and she has resumed her ordinary oc-
cupation.

Case i^. — Miss N. C, aged 28. Large ventral
hernia. In August, 1S86, I removed a multiple
ovarian cystoma weighing about 30 pounds. In-
cision was 3 inches in length. Wound closed by
interrupted sutures taken through the entire
thickness of the abdominal wall. Following the
recovery the patient rapidly gained 40 pounds in
weight. Ventral tumor at time of operation.
May 10, 1889, nearly the size of an adult head.
Resected the sac and closed the abdominal wall
by continuous tendon sutures in four layers, the
skin with blind .stitch. Sealed the wound with
iodoform collodion, as in all the previous cases.
Patient made rapid recovery and was discharged
from the hospital in two weeks, wearing an ab-
dominal support. The specimen of the cyst

1 889- J

THE CURE OF HERNIA.

623

shown, exhibits remarkable diverticuli. The | the suture thus applied to hernia, is naturall}' of
lower portion of the sac was filled with a mass of ! ver>' great value for the approximation and reten-
adherent omentum. | tion of all wounded surfaces. In aseptic wounds

The series of cases reported above, operaced '• it now promises to do awaj- entirely with drain-

upon within eight months, include all the usual
varieties of hernia. They complete a list of
operations, now numbering nearly 100, which I
have performed during the last eighteen years.
The method followed, from the first, has been sub-
ject substantially to the same factorage, although
varying somewhat in detail.

Since I have recently given to the profession
my views upon the conditions, symptoms and
treatment of hernia at length,' I shall limit my-
self in this paper to a brief discussion of what I
deem to be the essentials of the operation for the
cure of hernia. I do this with the greater inter-
est and pleasure since the cure of hernia is con-
fessedly an opprobium of surgery, and it is not
until a ver}- recent date that surgeons in either
Europe or America have been willing to discuss
seriously the advantages to be derived from
operation.

In 1878 I first reported to this Association my

age and the multiplicitj- of antiseptic surgical
dressings.

Under the new regime of surgerj-, in competent
hands, the claim for operative measures for the
cure of hernia maj' be strongly made :

jFirsi. — It is eminently a safe operation. In my
own experience, extending through all these
years, in all cases operated upon where the integ-
rity of the intestine was not involved, I have not
had a fatal case, or one where it appeared that
even the danger line was in any wa}^ approached.
In my recent work upon hernia above referred to
I have collated, as far as possible, all the reported
cases of operation under aseptic precautions.
From the reports of recent operators I find 779
cases of hernia which have been operated on for
a variety of causes, with only five deaths, and
these are explained as having resulted from con-
ditions not referable to the operation. This con-
trasts so extraordinarily with the earlier experi-

method, illustrated by a series of cases with ' ence of the profe.ssion, when, usually, all hernial
specimens, which have been supplemented, from ! operations were septic and peritoneal infection
time to time, by further contributions until \ the rule, often followed with fatal issue, that the
the present. The basic and fundamental factor { modern operation for hernia may be claimed as
consists in closing the divided and weakened one of the greatest triumphs of aseptic surgery-,
structures by strong sewing with a carefully pre- Secoiid/y. — The results of the attempt at radical
pared animal suture after the removal of the sac. cure are almost equally surprising. I have found

This is aseptically applied and approximates the
refreshened tissues by layers of buried suturing,
so as to avoid the necessity of drainage, and thus
allows of the complete closure of the wound, her-
meticall}- sealed with iodoform collodion, a ver)'

it quite impossible to trace the subsequent history
of everj- patient, but recent investigation shows
that of those of whose histories I have a knowl-
edge fully 90 per cent, are permanently cured,
and in no instance do I advise the subsequent

simple, but germ-proof dressing. I first published j wearing of a truss. The essentials of my opera-

it in the Boston Med. and Surg. Jour, in 1871. My
first case thus operated upon was in 1870. In this I
case the use of the buried suture was accidental
and applied to serve a temporarj- purpose, but a
permanent cure resulted. After mature delibera-
tion I judged it sound surgical practice thus to
attempt the cure of hernia, and other equally suc-
cessful cases thus treated soon followed, the first
fruits of my personal instruction received from
Prof. Lister in Edinburgh, in 1869. He had
limited his studies at that time to the results of
the ligation of arteries by catgut left buried in
the wound. I extended the u,se of the catgut
ligature to the approximation of tissues, and
made a series of experimental studies in animals
upon the changes in the tissues which ensued. I

tion are briefly as follows :

The hernial sac is opened, its contents restored
to the abdomen, or removed, and it is freely dis-
sected to its very base within the ring. The sac
is then drawn down, sewed across with an even
continuous double suture, resected and removed.
The peritoneum is then carried quite within the
ring. (Fig. i. ) In large direct inguinal hernia
it is important to restore the obliquity of the canal,
nature's wise provision for maintaining the closure
of the canal by intra-abdominal pres-sure in health.

This is effected by commencing at the lower
and inner border of the ring, the cord having
been gently laid to one side, and closing \>y
double suturing quite to the inner opening of the
ring upon the cord, which is now replaced, and

determined that, when properly prepared, if asep- the external pillars of the ring are closed by sim

ticaily applied, they were slowly replaced by
bands of living connective tissue, and thus ser\'ed
an important purpose in the reenforcement and
strengthening of the parts involved. The use of

> "A Treatise on Hernia. The Radical Cure by the Use of the
Buried .\utiseptic Animal Suture.'* i8Sq. G. S. Davis, Detroit.
Mich.

ilar suture downward and inward to the pubic
tubercle. The inguinal rings are thus reformed and
the canal is restored to its normal oblique posi-
tion. ( Fig. 2. ) If the tissues are sufficientlj- thick
to warrant it, a further layer of animal suturing
completes the closure, and the skin is neatly and
accurately approximated by a blind running

624

THE CURE OF HERNIA.

[November 2,

Figure I. — Represents the introduction of the first stitch, taken to close the ring from below upwards
in order to restore the obliquity of the canal.

stitch, perhaps best applied with a fine Hager-
dorn needle, taken through from side to side,
including only the deeper layer of the skin. This
completes the closure of the wound, each step of
which is done under irrigation with a weak sub-
limate solution, and without the vestige of a
stitch in sight. The incision is now dried, dusted
with iodoform and covered with iodoform collo-
dion, into which a few fibres of cotton are incor-
porated. No further dressing is necessary.

Femoral hernia is treated essentially in the
same manner. Here it is necessary, after the
removal of the sac, to close the ring. Protect
the femoral vessels in their sheath by pressing
them gently outwards, and introduce the needle,
as directed in inguinal hernia, from below, through
the falciform process, the fascia lata, avoiding the
internal saphenous vein, upwards through Pou-
part's ligament, withdrawing the opposite end of
the suture with the needle. (Fig. 3.) A second
stitch is taken through the same tis.sue, parallel to
the first, about one-fourth of an inch nearer the
median line. The third .stitch is introduced
through the pubic portion of the fascia lata, paral-

lel to the saphenous vein, and is carried upwards
to include Gimbernat's ligament, or its divided
fibres if cut in strangulation. (Fig. 4.) A fourth,
and as many more stitches as may be required
to close the saphenous opening, is carried below
and parallel to Poupart's ligament, through the
pubic fascia and falciform fascia. In this way
the peritoneal pouch is obliterated and the neck
of the sac firmly closed.

The folding over of the fascia carries the saph-
enous opening quite a little to the inner side of
its former site, while the femoral vessels are un-
disturbed in their sheath. (Fig. 5.) The super-
ficial tissue and skin are closely held in conjunc-
tion by buried continuous animal sutures and the
wound dressed with iodoform collodion, as advised
in inguinal hernia.

If the cure of hernia is to be attempted under
modern surgical methods, most surgeons will
readily admit that it should be by a free dissec-
tion, or the open wound method, under rigid
antiseptic precautions. Modern operators are
divided in opinion as to the treatment of the sac.
All are determined that it must in some way be

1889.]

THE CURE OF HERNIA.

625

Figure II. — The internal ring closed. The completion of the last deep stitch of the double continuous suture.

disposed of. Most advise ligation at its base and
removal. Mr. Ball, of Liverpool, and his follow-
ers, twist it firmly upon itself, in order to render
tense the peritoneum of the abdominal wall before
ligation. Mr. MacEwen, on the contrar)-, whose
brilliant results challenge admiration, advises the
careful dissection of the sac, folding it back upon
itself by a running catgut suture and then, with
a needle with eye near the point carried through
the peritoneum above the internal ring, the whole
sac, puckered into folds, is drawn within to ser\-e,
as he thinks, as a buttress for the further protec-
tion of the internal ring. The advantages of this
method are probably theoretic rather than real.
The use of the sac as a plug to close the ring,
there sutured and retained, has verj' generally
been abandoned as unsatisfactory. Utilized as
proposed by Mr. MacEwen, if it forms a buttress,
as supposed, to receive the intestinal impulse,
may it not be equally inferred that it would be
likely to act as a wedge to press unevenly against
the newly formed tissues of the restored canal,
and thereby cause harm rather than ser\'e as a
deflector of pressure ? Although the peritone-
um forms a pouch or pocket surrounding the
hernial contents, nature did not intend it to

serve as a part of the supporting abdominal
wall, but by an even elastic, smooth surface
lining the firm muscular and tendinous struc-
tures to allow the abdominal contents to glide
easily and evenly in every direction. As will
be seen by the specimens exhibited, in a very
considerable number of cases of old hernia, the
disposition of the sac, as advised by Mr. Mac-
ewen, would be quite impossible. In illustration
in Case 10, where the sac is nearly the size of a
child's head at birth. Again, also, the sac is so
intimately blended with the surrounding tissues
that, with all due care in dissection, it is so devi-
talized and injured that, even if aseptically re-
stored within the internal ring, its presence could
furnish only a doubtful factor toward the subse-
quent repair of the parts. On the other hand,
not seldom, especially in children, the sac is so
thin and unimportant that it may often be com-
paratively immaterial in what way it is treated.
Normally the internal ring is ovate, and in clos-
ing the sac at its mouth it is doubtless better to
do this in the direction of its longer diameter,
which gives as the resultant a smooth rather than
a puckered peritoneum, in the largest degree vital-
ized and resilient, freely movable upon its exteri-

626

THE CURE OF HERNIA.

[November 2,

Figure III. — Femoral hernia. The first stitch taken parallel to the vein for closing the crural ring.

orl}' loosely attached fascia. In the attempt at
this normal restoration no method, theoretical
at least, is equal to that of closing the mouth
of the sac in continuous seam. Good results,
however, follow all the various ways for the
obliteration of the mouth of the sac at the in-
ternal ring. The method of sewing may be in
considerable variet3^ The simple over and over
stitch will give good results. I cannot doubt,
however, that the closure of the canal and ab-
dominal wall by my method of suturing with
double stitch has certain marked advantages. It
is equally simple in application and carries a
double thread, like the shoemaker's stitch, from
opposite directions, through the same opening.
The approximation of the tissues therebj' is even
and uniform, and necessarilj^ nothing can escape
its grasp. The continuity of stitch renders equa-
ble pressure, an important gain over the inter-
rupted suture, while a single knot only is required.
It is necessary to use a needle with the eye near
the point, which must also be in considerable
curve. To avoid unnece.ssary multiplicity' of in-
struments, I have had the larger size of Hagedorn
needle drilled with eye near the point, which
serves a very good purpose. It is, however, more
convenient to have the needle set in a firm handle
as here exhibited, and I have found a certain ad-

vantage in continuing each end of the ej'e in a
narrow slot in order to catch and hold the thread
from slipping. (Fig. 6.) Well prepared catgut
may be safely used in this operation, however, I
cannot doubt that the tendon suture, especiallj'
that prepared from the tail of the kangaroo, is in
ever>' way greatly' superior.

When to operate is a subject of the greatest
interest, but the limit of this paper must necessa-
rily debar its discussion. Judged from mj- own
experience, the operation is permissible in the
very large proportion of all the sufferers from
hernia. There is much to be .said in favor of
operation upon children. Certainly in adults all
hernia imperfectly controlled by a truss should be
carefully considered from the view of the advisa-
bility of operation. In the old large hernia, irre-
ducible in great measure, rendering the sufferer
incapacitated for all active pursuits, the operation
should be advised.

Adherent omentum is likely to be .so much,
changed as to render its return to the abdom-
inal cavity ill-advised, but the removal of it ap-
pears to add little to the danger of the operation.
Age per se should not debar operation. I have
myself operated upon one child of 16 months
who, after recovery from ether, gave little evi-
dence of any discomfort. Several of my patients.

1889.]

THE CURE OF HERNIA.

627

f0"

KiGl'RE v.— Shows the internal ring closed bv the double-
continuous tendon suture. Stitches loose to show method
of suturing.

Figure IV. — Femoral hernia, showing a third stitch taken for closing
of the canal by the use of the doi;ble continuous tendon suture. The
stitches are represented as loosely draw-n in order to show the method of
suturing. The needle is passed' through the firm pubic fascia and the
outer border of the saphenous opening, and when drawn closely will fold
the latter inwards.

have been past 70. Mj- frieud Dr. L. S. Pilcher,
of Brooklyn, has twice operated, followed with
complete cure, upon patients, each over 80 years
of age. Dr. John H. Mackie, of New Bedford,
writes me: "I operated on a man aged 83, right
inguinal hernia, strangulated ; recovery perfect,
but one year later I operated on the same man
for left strangulated hernia and he made a good
recovery, living several years,"

The advisabilitj- of operation in any given pa-
tient is always to be seriously considered as an
independent problem, the factorage of which must
consist of man}' individual details. There is lit-
tle question that the large percentage of sufferers
from hernia will profit from the surgerj' of the near

future whom the conser\-ative surgieou' of to-dajr
conscientiously relegates to the truss bearing army
of invalids.

Dr. T. H. Manlev, of New York Cit>': With
reference to Dr. Marcy's paper there are a few
points on which I wish to make a few comments.
They are briefly, first, that the method described
and practiced by him is no open method at all,,
and has no claim to any such designation. The
next is, that though Dr. Marcy has fair results,
there has been no mention of the operation of Dr^
Chas. McBurney, of New York, which is the on/]\
/rfl-Zopen method applied in the operations of her-
nia. By this method McBurney has now operated

628

THE CURE OF HERNIA.

[November 2,

more than forty times, with only one death —
which had no connection in anj' waj- with the
operative procedures — and with only one return
of hernia. McBurney, instead of endeavoring to
secure immediate union, purposely prevents it,
and always aims at healing the furrow from the
bottom, by keeping the wound margins separated
till the granulation and cicatrization of tissue has
progressed towards the periphery" of the wound.

With reference to suture material, while I find
catgut useful when primary union is sought for,
where there is an)' tension put on the suture or
where there are large blood-vessels to close, it
should not be used, owing to its tendency to
either disintegrate, or strip away.

The ideal, the simplest and, every zcay consid-
ered the safest method, I think, yet known for
operating in cases of strangulated hernia, is Mc-
JBurnej-'s. Here, every time, we can promise /><';■-
i>ia7ient cxxre., if the patient survive operation. But
he must be operated on early. General practi-
tioners, when they encounter hernia resisting
taxis, and threatening to become constricted,
should advise hiiDiediale operation provided the
patient's general health is good. He can effect a
radical and speedy cure here, which in itself en-
tails no danger to life. I have applied the Mc-
Burney method in strangulated cases. I have
•operated during the past spring three times for
strangulated hernia by the open method ; two re-
covering and one dying,, who was practicallj'
moribund when he went under ether.

Both surviving, with their hernias permanentlj'
•closed, and being confined to bed only twenty-
eight days in each instance.

Dr. J. O. Whitney, of Pawtucket, R. I., said
there is no such thing as congenital hernia. It is
•due to straining from crying, or at urination with
adherent prepuce. If the prepuce be split up no
trusses are necessar>'.

Dr. H. D. Didama, of Syracuse, N. Y., had
been present at several of Dr. Marcy's operations.
The performance was as described by him. The
stitching was so complete that a return of the
hernia was impossible luiless the tendon should
be absorbed too soon and give way. But his ex-
perience has proved to him and should satisfy us
that this tendon never gi\'es way, and that we
need not lie awake fearing any bad result from
this source. He uses no drainage whatever and
never needs any. He never removes a suture be-
cause none ever appears on the surface of the
skin. There are never any stitch abscesses which
are so common in laparotomies performed by sew-
ing through the entire thickness of the abdominal
walls.

Dr. Marcj''s operation does not confine the pa-
•tient to the bed for a long time, sometimes not
more than two or three days, and there is no pain
in any considerable luimber of cases, and not even
•nconvenience. His operation seems simplicity

simplified and a temptation to any one who has a
hernia, even if it gives him no trouble.

Dr. Joseph H. Warrex, of Boston, Mass.,
said : While I endorse in general the operation of
suturing advocated by Dr. Marcy, I have certain
points of technique in my own method essentialh-
differing from his method which I will mention.

I am aware of the claims advanced for animal
sutures, but I have always feared their advan-
tages might be too great and the absorption
claimed for them might be premature. I have
used those furnished by Dr. Marc}- himself first
in a case of ovariotomj', and I passed sleepless
and anxious days and nights in consequence.
The constant dread of the melting awaj' of the
ligatures, although perhaps not probable, was
sufficiently possible to give me no rest until the
patient was beyond doubt cured. The case was
especiall}- dangerous, as acute mania set in and
the patient persisted in tossing and kicking about,
to the total destruction of a mechanical bed which
I used for such cases and with imminent danger
of destroying herself Still, the ligature held, and
I presume this would be construed as a success
by one in favor of animal ligatures. Still the
uncertainty remains.

Another objection to the animal ligature is the
large size compared to silk of the same strength,
and the consequent large needle necessary for its
use. In my own operations I use braided silk,
and feel secure when the parts are approximated
they will staj- so until united.

The essential difference in my method is the
stj'le of lacing. The sac and omentum are in-
cluded in a gathered suture, the silk being run in
from both sides like the puckering string of a bag.
Redundant tissue is cut off" with scissors just below
the stitch. The mass is then returned, the two
ends of the suture being left outside and the mass
drawn down by them to the internal surface of
the ring. A series of stitches is taken in the
edges of the ring, each suture being interrupted,
all passing each other at the centre, forming a
multiple cross or star-shaped plan. This is the
first stage. After this I insert a series of stitches
superimposed upon the first, each stitch being
taken some distance back from the edge of the
ring, the stitch not passing entirely through the
muscular walls but entering the surface, passing
backward and coming out beyond the point of
entrance about '4 inch. These stitches are tied
sufficiently tight to pucker the tissues and infold
the muscular tissue at the site of the ring. This
results in a raised cicatrix, the elevation pointing
toward the abdominal cavity and rendering a re-
currence of the hernia at that spot less likelj',
whereas in the plain lacing of the tissue a de-
pressed scar results which offers a constant point
d'appiii for the intestines to work against, and
sooner or later may allow the entrance of the
wedge and consequently rupture.

1889.]

THE CURE OF HERNIA.

629

This reduplication of tissue also gives a larger
uniting surface, the edges and contiguous surfaces
being freshened that adhesion maj' more readilj-
take place. This freshening is most completely
done with scissors or scraping rather than with a
sharp scalpel, it being m\- experience in special
and general surger\- that torn or roughlj- dressed
tissues heal more readilj^ than those cut with
sharp, keen scalpels. M}- preference for the fin-
gers or tearing instruments in place of sharp in-
struments is founded on good results obtained by
this method, and this is especially the case in the
cutting of arteries and veins. When put on the
stretch and thus severed the vessel is closed so
effectually that in my own practice I have never
had a case of secondary' haemorrhage, and the
primary loss of blood is very slight.

At one time I advocated the use of the galvano-
cautery in securing a consolidation of the hernial
rings. Several cases were successfully treated by
this method, and should a very large hernia with
weak walls present itself I think I should still
prefer this method. The adhesive and contractile
power of a burn is well known, and it is as pow-
erful in the hernial rings as elsewhere.

In ordinary cases the freshening and lacing is
sufficient. In the majority of cases I still adhere
to the subcutaneous injection, and in selected
cases, those of good physique and where the her-
nia is small and of recent occurrence, I still have
good results, a ratio of 96 per cent. Its failure in
the hands of some operators is not due to the op-
eration. It is due to the selection of cases in the
first place that ought never to have been attempt-
ed ; and secondly it is due to non-observance of
minor matters of technique. While I have given
its description in the plainest manner possible, I
am convinced that there are elements of technique
which can be caught only by intuition or careful
clinical instruction. The fact that it is practiced
by advertising specialists with advantage to the
patient and pecuniarily to themselves, and that
they claim to have license from me (a claim not
founded on fact), proves that there is some good
in it.

My name has unfortunately become so firmly
united with the operation by injection that many
think I advocate no other method and practice no
other part of the profession. This is untrue in
both cases. My motto is to choose the best for
the case in hand, and I would not for a moment
be prejudiced in favor of any pet method to the
prejudice of the case. The case in all its details
determines my method of procedure.

Dr. H. J. Herrick, of Cleveland, O., said: I
have taken much interest in the papers presented
looking to the relief of this distressing and fre-
quent danger to which so many are subject. Most
of the cases reported are of those which have
come under the care of the surgeon when the
emergency was upon them. In this connection I

desire to call attention to that large class of cases
in which the hernial tumor is so large and the
opening so patent that strangulation is not and is
not liable to be present, but, on account of the
size and inconvenience as well as danger of in-
flammation, life becomes intolerable except as it
may be devoted to nursing this as yet almost
hopeless infirmity.

Have we not a duty towards this class of suf^
ferers ? In illustration of the points indicated I
will mention the following cases : A young man
28 years of age came to me from a neighboring
city with a double scrotal hernia each side of
which was the size of the two fists, the openings
so great that the gut could not be retained with
any appliance. Patient was anxious for matri-
mony- and the business of life, yet with the exist-
ing deformity could not. I advised an operation
for the radical cure. Not being satisfied with any
of the concealed, obscure and empirical means
that had been devised, I proposed an open radical
operation, which I made upon both sides at the
same operation. With antiseptic precautions I
made an incision along the neck of the sac 3
inches in length, dissected my way to the sac,
emptied it of its contents, at the same time draw-
ing it out. Holding the empty pouch I applied
a temporized clamp made by the handle of a
dressing forceps closely to the neck, then ampu-
tated the sac near the clamp, leaving space for
the closing of the neck with a continuous suture,,
with care to bring the edges of the amputated sac
in apposition. The ligature u.sed was the iron
dyed silk. Thus the peritoneal cavit3' was kept
closed from the entrance of air, fluid or any sep-
tic material. The edges of the ring were made
bare and brought together with an interrupted
suture of the same material. In the same way I
brought together the divided parts of the deep
fascia, also superficial fascia and connective tissue
and finally the integument, taking special care to
leave no contused or lacerated fibres, remove all
clots and bring together gently in apposition all
the divided parts. No drainage tube was used.
Antiseptic dressing was made. The case pro-
ceeded to recoveiy^ with no unfavorable symptoms,
temperature having reached only 100°. In two
weeks' time the wounds were entirely healed,
with no suppuration. After three weeks, patient
returned to his home, since which time he has
pursued his former plans of matrimony and busi-
ness with no return of the hernia. About two
months ago a woman with an inguinal hernia of
the left side came to me. The tumor was the
size of the two fists and involved the left labia,
which was ver>' greatly distended and tumefied.
It could not be retained by truss, and being re-
quired to gain her living by work she expressed
the feeling that she would rather die than endure
the suffering and care neces-sary. I advised the
open operation for radical cure, to which she con-

630

EARLY LAPAROTOMY.

[November 2,

sented. The operation was performed two months
later in substantial!}' the same manner as in the
previous case. The large pouch of the labia was
treated antiseptically with a bichloride solution,
with the expectation that no suppuration would
occur. Owing to its size, tumefaction and ine-
lastic structure suppuration followed and came
near destroying the hopes in the case. The in-
flammation did not extend to the line of deep
incision, but was limited to the pouch of the labia,
which being opened freely, cleansed and washed
with sol. carbolic acid, inflammation subsided and
all dangerous symptoms subsided, so that patient
before I left home was up, parts perfectly healed,
and discharged from the hospital apparently well.
It is too early at present to speak assuredly of the
absolute success of the operation, though all ap-
pearances at present justify the fullest hopes.

I used in this last operation the clamp used for
the treatment of haemorrhoids and found it a most
appropriate instrument. By reason of the handle
it enabled the assistant to hold the part in the
most convenient wa}' for suturing, and the thumb
screw enables the surgeon to regulate the pressure
to be applied so cautiously as not to endanger the
integrity of the parts.

Feeling that the profession has a new duty to
perform to this class of unfortunates, these cases
in this connection may not be amiss.

Dr. Marcy, in closing the discussion, said
that the large number present at this late hour
(nearly midnight) shows the interest which
American surgeons have in the subject under de-
Ijate. He would detain the members but a few
moments, although many points of both interest
and profit had been alluded to only briefly. He
would ask a critical examination of the specimens
of the peritoneal sac which he had been to the
trouble of bringing, since they showed important
pathological changes which appeared recently to
have been, in a large measure, overlooked. They
are of the first importance to understand if we
are to utilize the sac by any method of surgical
procedure. Cloquet, in his masterly work, em-
phasized the great changes which the sac in old
Jierniae usually presented. Dr. Manley evidently
entirely misunderstood the use Dr. Marcy made
of the words open wound. This was in contra-
distinction to subcutaneous methods of treatment,
as by the yet too generally accepted plan of Dr.
Wood of .subcutaneous closure by the wire suture,
or the methods of cure by injection. He was
quite familiar with Dr. McBurney's operation,
and had only recently carefully reviewed his
method, showing what he thought were primal
faults. Elsewhere, in all parts of the body, th«
aim of modern surgeons was to secure primary
union, and it would indeed be strange if a hernial
wound should prove an exception. Why not
adopt this plan in the closure of all laparotomies,
if so greatly to be preferred. Dr. McBurney's

method has found advocates chiefly because the
hernial wounds, as ordinarily dressed, are ver>'
liable to become infected. Dr. Warren has re-
ferred to the large size of the animal suture, as
compared with silk, which is necessary to be
used. This, in a measure, is true if catgut is
used, but does not appl}' to tendon. On the con-
trary, the tendon suture, the size of silk, is verj'
much stronger, as may be tested by the samples
here shown. Dr. Pancoast has just made an elo-
quent plea for the use of his iron- dyed silk.
However he, with most others, admits that it
generally must be removed. At the best, silk is
encapsuled, while the aseptic animal suture is
replaced by bonds of living connective tissue
cells. Upon this fact, long since demonstrated,
is based, in a large measure, the method here
advocated, and it is not too much to believe that
the profession will earlj' accept the great gain re-
sulting from the use of the aseptic animal suture
in the coaptation of all aseptic operative wounds.
Blind surgery is bad surgery. As advocated,
each step of the operation is directed by seeing
the exact condition of the parts. The reformed
peritoneum is carried within the firm tissues of
the abdominal wall. The inguinal canal is re-
formed. The refreshed pillars of the ring are
: closed in even continuous suture. The coaptated
skin is covered by a layer of germ-proof iodoform
collodion. The wound, if aseptic, remains so,
and Dr. Warren may rest undisturbed by dreams
I or visions of discontent, while the patient in se-
curity goes on to rapid convalescence.

A PLEA IN FA\-OR OF EARLY LAPA-
ROTOMY FOR CATARRHAL AND UL-
CERATIVE APPENDICITIS, WITH
THE REPORT OF TWO
CASES.
BY N. SENN, M.D., Ph.D.,

OP MILWAVKEE, WIS. PROFESSOR PRINCIPLES OF SURGERY AND
SURGICAL PATHOLOGY IN THE RUSH MEDIC.\L COLLEGE.
1 CHIC.\GO. ILL.

The literature of the surgical treatment of
affections in the ileo-caecal region has been in-
' creasing very rapidh- during the last few j'ears.
A great deal has been said and written concerning
the propriety' of surgical interference in cases of per-
1 forative appendicitis, typhlitis, paratyphlitis and
[ perityphlitis. Post-mortem examination and clin-
ical experience have demonstrated that with few
exceptions localized and diffuse peritonitis as well
as .suppurative inflammation of the connective tis-
sue originating in the ileocajcal region, are
caused by an antecedent aftection of the appendix
vermiformis, which has resulted in perforation or
gangrene of that structure. While it cannot be
.said that unanimity of opinion exists among
surgeons in reference to the exact indications for

1889.]

EARLY LAPAROTOMY.

631

operative treatment in cases of appendicitis and
suppurative perityphlitis, it is safe to assert that
the majority of them would not hesitate to resort
to the knife in everj' instance where it would be
possible to ascertain bej-ond a doubt that per-
foration had taken place. Numerous cases have
been reported during the last three j-ears where
prompt action on part of the surgeon has been
the means of saving life in cases of phlegmonous
inflammation and circumscribed peritonitis caused
by perforation of the appendix vermiformis ; but,
on the other hand, man}- laparotomies for diffuse
peritonitis due to the same cause proved power-
less as a life-saving measure, because the direct
invasion of the peritoneal cavity had given rise
to a diffuse septic peritonitis alike beyond the
reach of medicinal and surgical measures. The
principal object in writing this paper is to call
the attention of the profession to the necessity of
treating the primary disease of the appendix by
radical measures before the advent of incurable
complications, that is, before disease due to per-
foration has occurred. I believe that in many
cases the development of perityphlitis is preceded
by a well-marked complexus of symptoms point-
ing directly to the existence of appendicitis.
Many patients suffer from well-defined symptoms
indicative of the presence of an inflammatory
lesion of the appendix for months and years be-
fore it gives rise to a perityphlitis or perforative
peritonitis. It is of the greatest practical mo-
ment to recognize the exact condition in time,
and to anticipate the dangerous and only too
often absolutely fatal complications by removing
permanently the source of danger which can be
done at this time with comparative ease and
almost perfect safetj' by the extirpation of the ap-
pendix.

The following cases will serve to illustrate the
correctness of these a.ssertions :

Case I. — ^J. S., 22 years of age, clerk by occu-
pation, came under my obser^-ation during the
last week in April, 1889. He consulted me at
my office, and informed me that during the last
fifteen months he had suffered from five attacks
of what his physician called perityphlitis. Each
attack was attended by excruciating pain in the
ileo-caecal region, vomiting and constipation, and
usually lasted from one week to twelve daj-s.
During the intervals he was able to follow his
occupation, but never quite regained his former
health. The treatment consisted of rest in bed
and opiates. Between the attacks the bowels
moved regularly, and the patient was free from
pain. At the first examination I found the
temperature 99.2° F., pulse 80, tongue heavily
coated. Patient somewhat emaciated and pale.
Pain was referred to the ileo caecal region, and
directly over the location of the appendix vermi-
formis a circum.scribed area of tenderness could
be mapped out. Palpation and percussion failed

to show any appreciable swelling, but on deep
pressure while the patient's chest was elevated
and thighs flexed, a firm cord-like body could be
felt behind the caecum over a point corresponding
to the location of the appendix vermiformis.
No tj'mpanites or am- other symptoms of peri-
tonitis were present. I was satisfied of the ex-
istence of appendicitis from the history of the
case and the symptoms and signs presented, and
feared that during this or subsequent attacks
perforation with all its uncertain consequences
might take place. In view of the probability of
such an occurrence, I advised a radical operation
as the only means calculated to afford permanent
relief The patient had suffered so severely
during the five preceding attacks that he readily
consented to the proposed operation. During
this attack he was confined to bed only at times,
and took opiates as required for the pain. As
the symptoms did not subside he was admitted
into the Milwaukee Hospital April 30, for the
purpose of having the appendix removed. A
saline cathartic was administered the day before
operation, and the following morning the colon
was evacuated by a copious enema. The evening
before operation the abdomen was shaved and
thoroughly cleansed with warm water and potash
soap, after which a compress wrung out of a
sublimate solution 1:2000 was applied.

Operation Maj- i : Chloroform anaesthesia.
After removal of the compress the surface was
washed with undiluted alcohol. An incision
about four inches in length was made directly
over the center of the caecum and parallel to the
ascending colon, the lower angle of which
reached to within an inch of Poupart's ligament.
All haemorrhage was carefulh- arrested before the
abdominal cavity was opened. The peritoneum
was divided between two anatomical forceps, when
two fingers of the left hand were introduced and
between them the opening was enlarged.
Through this incision the caecum came directl}-
in view and presented a normal appearance both
as to size and structure. No evidences of peri-
tonitis or perityphlitis. On making pressure
over the lower portion of the caecum an elongated
body about the thickness of an ordinary lead
pencil could be distinctly felt rolling under the
tip of the finger. The lower margin of the
caecum was grasped with the fingers, elevated,
and brought into the wound. This manipulation
brought into view the appendix which was
directed upwards and inwards from its point of
attachment, along the posterior wall of the
caecum. No adhesions between the appendix
and the caecum, but the mesentery of the ap-
pendix appeared to be shortened and exceedinglj-
vascular. The peritoneal covering of the ap-
pendix appeared healthy, having retained its
normal smoothness and lustre. The appendix
was uniformly enlarged from its junction with

632

EARLY LAPAROTOMY.

[November 2,

the caecum to its distal extremity, and imparted
a sensation of unusual hardness when grasped
between the thumb and index finger. The mes-
enterj- of the appendix was ligated in several
sections with fine silk and cut close to the ap-
pendix. The appendix was ligated near the
caecum with a silk ligature and amputated about
a quarter of an inch below the point of ligation.
The lumen of the appendix at the point of section
was quite small, but as it was more than probable
that it communicated with the caecum, I deemed
it necessarj' to prevent the possibilit}- of a subse-
quent perforation from cutting through of the
ligature by covering the stump with peritoneum.
The stump was disinfected, dusted with iodo-
form, and buried by stitching the peritoneum
from each side over it bj- a number of stitches of
the continued suture. The caecum was now re-
turned and , the wound closed by suturing the
peritoneum with catgut, while the external
sutures of silk were passed down to, but not
through, the peritoneum. A compress of iodo-
form gauze and a thick layer of salicylated cot-
ton retained by a number of strips of adhesive
plaster encircling two-thirds of the bodj' consti-
tuted the dressing. The subsequent history- of
the case was one of uninterrupted recovery. The
pain disappeared as if bj- magic. The patient
took no opiates after the operation. Tempera-
ture never above normal. On the third day the
bowels were moved by a saline cathartic after
which no further medication was necessarj'. At
the end of a week the dressing was removed
when the wound was found united throughout
and the sutures were removed. At the end of
the second week the patient left the hospital, and
in the course of another week resumed his occu-
pation. He is now in perfect health, has gained
in flesh, and has been perfectl}- free from pain.
The amputated appendix proved to be a ver}- in-
teresting pathological specimen. The part re-
moved measured two inches in length, and in
thickness corresponded in size to the last joint of
the little finger. The lumen was uniform in
size throughout and was large enough to admit
a small-sized lead pencil. The appendix was
slit open its whole length at a point opposite to
the mesenteric attachment. On inspection of the
mucous membrane lining it an oblong ulcer was
discovered near the middle and opposite the
mesenteric attachment. The ulcer measured
about half an inch in length, and a quarter of an
inch in width, its greater diameter corresponding
to the long axis of the appendix. The margins
of the ulcer were regular in outline and not
undennined. It presented no evidences of repair.
Its greatest depth corresponded to its centre. The
whole mucous membrane was exceedingly va.scu-
lar and much thickened, the .submucous infiltration
being uniform over its entire area. A transverse
section of the appendix through the centre of the

ulcer, examined under the microscope, showed
that the entire thickness of the mucous mem-
brane and part of the muscular coat were de-
stroyed by the ulcerative process, and that the
remaining thickness of the wall as far as the peri-
toneum was infiltrated with embrj-onal cells and
leucocytes which were closely grouped together
in the connective tissue reticulum. The submuc-
ous tissue and part of the muscular coat were
similarly infiltrated throughout. No faecal mat-
ter and no foreign body could be found in the
lumen of the appendix, the whole contents con-
sisted of a few drops of a highly viscid odorless
secretion. The absence of any macroscopical
cause of the inflammation, the condition of the
mucous membrane, and the appearance of the
ulcer substantiate the diagnosis of catarrhal ap-
pendicitis, which in this case had resulted in the
formation of a catarrhal ulcer of considerable
size and depth. There can be but little doubt
that repeated acute exacerbations of the chronic
inflammation would have finalh- resulted in per-
foration, and as the ulcer was located on the free
side of the appendix there would have been great
danger in such an event of invasion of the peri-
toneal cavit}-, and death from difi"use septic peri-
tonitis. The second case came under the obser-
vation of Dr. Knut Hoegh, of Minneapolis,
Minn., and through his courtesy I am permitted
to incorporate it in this paper. It furnishes an
illustration of another form of appendicitis
(suppurative) amenable to earlj' successful surgi
cal treatment.

Case 2. — H. M., 37 years of age, merchant by
occupation. For the last six or seven j-ears he
has suffered at inter\-als from attacks of pain in J
the abdomen. At first these attacks were not \
very severe, and of short duration, the general
health remaining unimpaired. Questioned as to
the condition of the bowels the patient stated
that the attacks were usually attended bj- diar-
rhcea. The onset of pain was always sudden
and apparently' without any appreciable cause, as
they often occurred , during the night after the
patient had retired the evening before in perfect
health. In the beginning the attacks occurred
about every six months, but later they came on
more frequently, more severe, and of longer
duration, and at the same time the general health
became impaired. The later attacks he describes
as commencing with a severe pain in the ileo-
caecal region which at times became excruciating,
accompanied by sensations of chilliness. No
vomiting, but more or less retching ; bowels con-
stipated ; abdomen often distended and always
tender on pressure over a limited space, at a
point from which the pain al\va\'s seemed to
start.

Patient is not aware that he ever passed blood,
mucus or pus with the stools. During the last
fifteen months he has passed through five attacks.

1889.]

EARLY LAPAROTOMY.

633

the last one two months before the operation was
performed. Since the last attack he has been un-
able to resume his business as he has suffered
constantly from pain and tenderness in the ileo-
caecal region, loss of appetite, and an increasing
debility. The patient looks prematurely old,
showing evidences of senile marasmus seldom
found in persons of his age. He is of medium
height, somewhat emaciated, having lost twenty-
five pounds of his customarj' weight. Examina- j
tiou of the abdomen revealed no tympanites and
no swelling, but midway between umbilicus and
the right anterior superior spine of the ilium a
space about two inches square was found tender
on pressure. Rectal exploration yielded a nega-
tive result. The usual internal treatment in such
cases consisting of the administration of bella-
donna, nux vomica, and alkaline cathartics was
not followed by any material improvement, so
that the patient readily consented to an operation
which had for its object the removal of the ap-
pendix vermiformis which it was believed was in
a condition of catarrhal inflammation. The ab-
sence of swelling and fever seemed to render it
improbable that the symptoms were due to cir-
cumscribed peritonitis, or inflammation in the
caecal me.senterj- or para-csecal connective tissue.
The repeated attacks of pain, the localized
tenderness, and the digestive disturbances pointed
to a localized inflammation depending upon
some chronic pathological change within or near
the appendix vermiformis. Dr. Foster, of Min-
neapolis, saw the case in consultation with Dr.
Hoegh, and concurred in the opinion that an op-
eration should be performed. The writer was j
consulted by letter, and strongly urged the pro-
priety of a speedy resort to surgical treatment.
The operation was performed by Dr. Hoegh in
the St. Barnabas Hospital, August 19, 1889, as-
sisted by Drs. Foster and Wood. Chloroform
was used as an ansesthetic. Operation performed
under strict antiseptic precautions. Incision
through right linea semilunaris. On opening
the peritoneal cavity the appendix came at once
in sight lying free in the peritoneal cavity, point-
ing towards the pelvis. It was about two inches
in length, remarkably firm to the touch, and its
.serous surface quite vascular. At some points it
had formed adhesions with the surrounding
structures. The adhesions were separated and a
ligature applied near its junction with the caecum.
The stump was buried in the same manner as in
case I. The caecum showed nothing abnormal.
It was noticed that the point of communication
between the appendix and caecum was very nar-
row, the lumen not exceeding the size of a knit-
ting needle. The abdominal incision was closed
in the usual manner. Soon after the operation
the patient suffered considerabl}' from nau.sea
and retching which gav^e rise to considerable pain
in the wound. A slight elevation in the tem- 1

perature a few days after the operation announced
a slight suppuration in the superficial portion of
the wound, which, however, soon subsided, and
the healing by granulation proceeded in a satis-
factor}' manner. Aside from this disturbance the
patient went on to an uninterrupted and perma-
nent recovery. Examination of the appendix
after its removal showed that it was somewhat
distended in its central part b^' a few drops of a
thick, very offensive, purulent fluid of the consis-
tency of cream, of a brownish color ; the odor was
not feculent, but rather foetid. No concretion or
foreign body was found. The mucous lining of
the appendix showed two distinct but not very
deep ulcers, both involved the entire thickness of
the mucous membrane. The ulcer nearest the
caecum was the largest occupying the whole cir-
cumference of the lumen about one-quarter of an
inch wide. The second ulcer nearer the apex
was not larger in circumference than the size of
a split pea. The serous coat near the junction of
the caecum was considerably thickened. Micro-
scopical examination of the fluid showed broken
down tissue, pus corpuscles, and pigment
granules.

GENERAL REMARKS ON EARLY R.AUICAL OPER-
ATION FOR APPENDICITIS.

Excision of the appendix in cases as reported
above must be considered in the light of a cura-
tive and prophylactic operation. It is curative,
as by it the cause of the disease with the dis-
eased tissues is completely removed, and it is
prophylactic, as b}' it the disastrous consequences
of a probable later perforation are positively pre-
vented. Extirpation of the appendix at a time
before the inflammatory process has reached the
serous coat is one of the easiest and safest of all
intra-abdominal operations. The operation is
performed in a healthy aseptic peritoneal cavity,
and if the customary antiseptic precautions are
carried out healing of the visceral and abdominal
wounds by primary intention maj' be confidently
expected. The operation eliminates a structure
which if not entirely useless has at most only an
unimportant physiological importance.

INDICATIONS FOR OPERATION.

It may be stated as a general rule, to which
there can be but few exceptions, that the ap-
pendix should be extirpated in all cases where
from the symptoms and history of the case the
existence of a localized destructive inflammatorj-
process can be surmised. From a diagnostic and
practical standpoint all cases of appendicitis can
be divided into two classes : i. Acute. 2.
Chronic. There can be but little doubt that
most, if not all, acute cases are preceded by a
chronic lesion. The history of many cases, and
the pathological conditions of numerous speci-
mens corroborate this statement. A foreign
body, for instance, may be present for a long

634

EARLY LAPAROTOMY.

[November 2,

time without giving rise to serious symptoms,
but it cannot remain for any length of time with-
out causing a catarrhal inflammation and super-
ficial ulceration. An ulcerative catarrhal inflam-
mation may exist for a long time before it gives
rise to acute symptoms, and when the acute at-
tack makes its appearance the inflammation has
reached the peritoneal surface and the connective
tissue underlying the appendix and caecum ; it is
then no longer an uncomplicated case of ap-
pendicitis as the primary inflammation has ex-
tended beyond the structures of the appendix,
and has given rise to perityphlitis, with or without
perforation. Chronic appendicitis is character-
ized by acute exacerbations of short duration,
the attacks of greater or less severity occurring
at intervals of a few months or weeks. Between
the attacks the patient may be in perfect health,
unless the attacks recur with great frequency,
when impairment of the digestive functions pro-
duces general ill health. The most important
symptoms which point to the existence of chronic
appendicitis are localized pain and a circumscribed
area of tenderness at a place corresponding to the
location of the appendix. Simple appendicitis
does not give rise to any appreciable swelling as
long as the lumen of the appendix remains in
communication with the caecum, as the resist-
ance of the indurated walls is suflBcient to force
the contents of the appendix into the caecum.
In persons with thin abdominal walls it is possi-
ble to feel the hardened and thickened appendix
b}^ making deep pressure while the patient is
placed in a position that favors relaxation of the
abdominal muscles. Tympanites is usually ab-
sent unless the appendicitis is complicated by
circumscribed peritonitis. Rigidity of the ab-
dominal muscles is absent as long as the inflam-
mation is limited to the deeper structures of the
appendix. During the acute exacerbations of the
chronic form of the disease aside of the pain the
general symptoms are not severe. The tempera-
ture is either normal or there is only a slight rise
seldom above 100° F. The pulse is only slightly
increased in frequency, and shows none of the
characteristic features which it presents in peri-
tonitis.

Vomiting is occasionally present, but is not a
constant nor even a frequent symptom. Consti-
pation which is usually present is probably more
the result of a change in diet, rest, and the medi-
cines taken for the relief of pain than the dis-
ease. The frequency of catarrhal and ulcerative
inflammation in the interior of the appendix as
compared with the remaining portion of the in-
testinal tract is probably owing to the anatomical
location of this structure. The lumen of the
appendix constitutes a cul-de-sac which is in
communication with the intestinal canal, but
which is virtually excluded from the ftecal circu-
lation, hence it .sers'es an admirable purpose as a

reservoir for the collection, localization and re-
tention of pathogenic microbes. That the ana-
tomical location of the appendix acts as a predis-
posing cause in the etiology of localized forms of
infection is evident from the course of the disease.
The inflammatory process remains limited and
does not extend by continuity to the caecum, the
extension of the disease being only in a peri-
pheral direction from the mucous membrane to
the deeper structures. In conclusion it may be
said that recurring attacks of pain in the region
of the appendix with a circumscribed area of
tenderness over the same point are presumptive
evidences of the existence of appendicitis, and if
the other symptoms and signs point in the same
direction treatment by abdominal section is in-
dicated.

TECHNIQUE OF OPERATION.

As an operation for simple appendicitis always
presupposes an aseptic condition of the peritoneal
cavity, it is of the utmost importance to secure
by thorough antiseptic precautions an aseptic
condition of everything that has to be brought in
contact with the wound. The field of operation
should be disinfected b}' shaving and thorough
washing with warm water and potash soap, after
which a moist compress saturated either with a
1-2000 solution of sublimate or a 2)^ per cent,
solution of carbolic acid is applied and allowed
to remain from the time the disinfection is made
the evening before the operation until the patient
is ready for the operation the next day. Im-
mediately before the incision is made, I am in the
habit of washing the surface once more with one
of the disinfectant solutions, and lastly with ab-
solute alcohol. The instruments should be
sterilized by boiling for ten or fifteen minutes
immediately before the operation. The operator
and assistants should disinfect their hands by
washing thoroughly with warm water and potash
soap, and subsequently a i-iooo solution of sub-
limate. If everything has been rendered thor-
oughly aseptic, that is to be brought in contact
with the wound, no antiseptic solutions will be
necessarj' during the operation, unless perhaps
for the disinfection of the stump after amputa-
tion of the appendix. Sterilized water is used
for the sponges.

Incision. — The incision that renders the caecum
and appendix most accessible to inspection, ex-
amination and operative manipulation is one
made parallel to the long axis of the ascending
colon and caecum. It should be about four
inches in length and directlj' over the centre of
the caecum, and extend to within an inch of
Poupart's ligament. With a sharp scalpel the
skin, fa.scia and successive mu.scular layers are
rapidly divided without the use of any director
until the peritoneum is reached. At this stage a
pause is made in the operation in order to arrest

1889.]

EARLY LAPAROTOMY.

635

hfemorrhage by applying haemostatic forceps to
every bleeding point, the forceps remain until the
surgeon is ready to close the wound, when it will
generally be found that ligatures are superfluous,
as the compression and crushing of the tissues
caused by the forceps have been sufficient to ar-
rest the bleeding. By following this plan un-
necessary ligation of small vessels is avoided.
The peritoneum is picked up by two catch-
toothed forceps, and between them the abdominal
cavity is opened, and the incision subsequently
■enlarged to the desired extent between the index
and middle finger of the left hand. As soon as
the peritoneal cavity is opened the further steps
of the operation will be greatly facilitated by
packing around the csecum a small compress of:
aseptic gauze wrung out of sterilized water for I
the purpose of preventing prolapse of the small 1
intestines. If the appendix is below the caecum !
it will come into sight at once, when it can be
examined and directly dealt with. If, as is more
frequently the case, it is behind and towards the
inner side of the caecum its size and direction can
be readily ascertained by palpation through the
caecum, but to make it accessible to direct exam-
ination and operative treatment it is necessary to
raise the lower margin of the caecum.

Excision of the Appendix. — If the serous coat
lias not been implicated by the inflammation the
only attachment to be separated is the mesentery
of the appendix. This is always present, but
varies greatlj- in length and width. If it is at-
tached to the whole length of the appendix it
should be ligated in several sections with fine
silk ligatures as far as the caecum. If inflamma-
tory adhesions are present they are separated,
and all bleeding points carefully tied. When
the appendix has been thus completely isolated
a ligature of fine silk is tied around its base close
to the CEecum, and about a quarter of an inch be-
low it the section is made with scissors.

Treaimcnt of Stump. — As the interior of the
appendix under such circumstances necessarily
must always contain pathogenic microorganisms
it is necessarj- to disinfect the cut surface of the
stump thoroughly. This can be done with one
of the disinfectant solutions, after which the
stump should be dusted with iodoform. After
amputating the appendix it has been heretofore
customars' to drop the stump without making
any provision against the possibility of perfora-
tion, subsequently taking place at the point of
ligation. This I consider a great mistake. The
ligature approximates a diseased mucous mem-
brane, and if after the operation the entire stump
is not speedily surrounded by a wall of imper-
meable granulation tissue which is later trans-
formed into a connective tissue capsule, there is
great danger that perforation will take place after
cutting through of the ligature, thus exposing
the patient to the same danger he was in before

the operation. To obviate the possibility of such
an occurrence the stump, after thorough disin-
fection and iodoformization should be covered
with peritoneum by stitching the serous surfaces
of the ccecum from both sides over it bj' a num-
ber of Lembert sutures. The serous surfaces
will become agglutinated in a few hours, and in
a few days the adhesions will have become suffici-
ently firm to protect the surrounding tissues and
the peritoneal cavity against extravasation should
leakage take place at the point of ligation. By
resorting to this precaution we protect the pa-
tient against all possibility of the occurrence of
perforative peritonitis subsequently, as the per-
foration, should it occur, of necessity would take
place into the caecum.

Closure of Abdominal Incision. — More care is
required in closing an incision made through the
several muscular layers of the abdominal wall than
by going through the median line, as the ordinar}-
way of closing a median incision would be very
likely to be followed by a ventral hernia. The
peritoneum must be sutured separately with fine
catgut or silk sutures, while the remaining
sutures are passed down to, but not through, the
peritoneum. No provision for drainage is neces-
sary in these cases.

Dressing of Wound. — After dusting the wound
with iodoform a narrow .strip of protective silk is
applied over it, when it is covered with a com-
press of iodoform gauze and a larger compress of
salicylated cotton which are retained with a few
broad strips of rubber adhesive plaster encircling
two-thirds of the body. After this the whole
abdomen is enveloped with a thick layer of com-
mon cotton over which a well-fitting binder is
snugly pinned ; this not only gives additional
support to the wound, but furnishes likewise an
agreeable and efficient support to the abdominal
wall.

After Treatment. — As it is advisable to move
the bowels the da^^ before the operation by a
saline cathartic, and to empty the colon by enema
the following morning, the bowels should not be
disturbed again for several days after the operation.
This can be accomplished by administering sev-
eral ten-drop doses of deodorized tincture of
opium, and placing the patient on absolute diet
for at least two or three days. On the third day
a saline cathartic is administered, and, if neces-
sarj', this is followed by an enema. The sutures
are removed at the end of the first week, but the
patient is not allowed to leave the bed for another
week for fear that the adhesions might yield and
a hernia might follow. For several weeks after
this he .should wear some kind of an efficient
abdominal support to guard still longer against
the same accidents.

CONCLUSIONS.

I, All cases of catarrhal and ulcerative ap-

636

MEDICAL PROGRESS.

[November 2,

pendicitis should be treated by laparotomy and
excision of the appendix as soon as the lesion
can be recognized.

2. Excision of the appendix in cases of simple
uncomplicated appendicitis is one of the easiest
and safest of all intra-abdominal operations.

3. Excision of the appendix in cases of ap-
pendicitis before perforation has occurred is both
a curative and proph}'lactic measure.

4. The most constant and reliable symptom in-
dicating the existence of appendicitis are recur-
ring pains and circumscribed tenderness in the
region of the appendix.

5. All operations on the appendix should be
done through a straight incision parallel to and
directly over the caecum.

6. The stump after excision of the appendix
should be carefully disinfected, iodoformized, and
covered with peritoneum by suturing the serous
surface of the ctecum on each side over it with a
number of Lembert stitches.

7. The abdominal incision should be closed by
two rows of sutures, the first embracing the peri-
toneum, and the second the remaining structures
of the margins of the wound.

8. Drainage in such cases is unnecessary and
should be dispensed with.

MEDICAL PROGRESS.

Hydatid Cyst of the Liver. Rupture-
Recovery. — Dr. H. C. Markham, of Indepen-
dence, Iowa i^North American Praditioner, Octo-
ber, 1889) reports a case of this description. The
cyst was first discovered three years ago. Under
rest and alterative treatment amelioration of the
symptoms apparently took place. In December
last the patient's condition became much worse.
The tumor, which appeared at the inferior border
of the lower ribs, anteriorly, was now tense and
as large as a pint bowl. A diagnosis of hydatid
cyst was ventured at this time. A specimen of
the cystic contents was obtained with a hypo-
dermic needle, a subsequent examination of which
confirmed the diagnosis. Upon the withdrawal of
the needle the patient experienced excruciating
pain and gave signs of collapse; the tumor mean-
while had disappeared, having evidently ruptured.
The cyst refilled and soon reached the size of a
foetal head at term. It was aspirated and 3 pints
of turbid serum removed, after which a strong so-
lution of iodine was injected and allowed to re-
main for some time. An apparent cure was thus
effected. At present deep palpation detects the
hardened residue of the sac.

Galactocete Testis. — A case is reported from
the clinic of Dr. A. B. Miles, New Orleans,

which, for want of a better term, is indicated by
this title. The testicle had been swelling for
three months at the time of the examination.
With the hypodermic needle a small quantity of
a milky-looking fluid was drawn ofi". Examined
in the pathological department of the Charity
Hospital it was found to contain numerous fine
granules in a state of active movement. No bac-
teria were present. Five hours later the testicle
was found to be greatly diminished in size and
within twenty-four hours the patient was dis-
charged apparently cured. Five days later there
was no evidence of a return of rhe former symp-
toms.— N. O. Med. and Surg, fount., Sept., 1889.

The Relations of Growth of the Body to
ITS Organs. — From an analysis of a large num-
ber of observations made in the Pathological In-
stitute of Munich, K. Oppenheimer makes the
following deductions :

1. The bodily weight reaches its highest rela-
tive standing earlier in females than in males.
The weight of the adult man is about twenty
times as great as at birth; that of the adult woman
eighteen times as great. The length of the body
reaches its highest relative point in man at the
age of 15 years, when it amounts to 158 cm.; in
woman the highest relative point is reached at
the same age and amounts to 153.6 cm.

2. The growth of the lungs surpasses that of
the body as a whole at nearlj' all periods, and es-
pecially at the middle period of growth.

3. The heart increases approximately in propor-
tion to the entire body.

4. The spleen and kidneys increase proportion-
ately with the heart.

5. The liver and notably the brain do not de-
velop proportionately with the body.

6. The relative lack of development in the
liver and brain is compensated by the rapid rela-
tive increase of fat and muscle, particularly the
latter.

Incomplete Abortions. — Dr. A. B. Carpen-
ter, of Cleveland {Cleveland Med. Gaz.), is
strongly opposed to the expectant treatment of
these cases, as he finds in it v^xy grave sources of
danger to the patient. Such cases require, on
the contrary, prompt and radical treatment,
whereby the retained products of conception are
removed manually or otherwise. He finds the
manual, method unsatisfactor}^ and is disposed to
adopt the method of Martin, of Berlin, who ances-
thetizes his patients and curettes and douches
the uterus with antiseptic precautions, complet-
ing the operation by applying tincture of iodine
to the endometrium by means of the uterine
syringe. In the after-treatment Dr. Carpenter
avoids the use of opiates, but employs antipyrin
with advantage.

1889.]

EDITORIAL.

637

Journal of the American Medical Association

PUBLISHED WEEKLY.

Subscription Price, Including Postage.

Per Annum, in Advance $5.00

Single Copies 10 cents.

Subscription may begin at any time. The safest mode of remit-
■tance is by bank check or postal money order, drawn to the order
'Of The Journal. When neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
letters.

Address

Journal of the American Medical Association,

No. 68 Wabash Ave.,

Chicago, Illinois.
All members of the Association should send their Annual Dues
to the Treasurer, Richard J. Dunglison, M.D., Lock Box 1274, Phila
delphia. Pa.

London Office, 57 and 59 Ludgate Hill.
SATURDAY, NOVEMBER 2, 1889.

CRIME AND INSANITY.

The universal testimony of all who have paid
attention to the subject, is that insanitj' is in-
comparably more frequent among the inmates of
prisons than in the general population. While
one insane person to three hundred would be con-
sidered a large proportion of insane in a commun-
ity, careful observers have found from 3 to 5 per
cent, of prisoners to be either insane or imbecile.
Such a state of affairs can onh' be accounted for
on the supposition that verj' many convicts are
either insane or strongly predisposed to insanity
at the time of their conviction, or that there
is something in the influence of prision life speci-
ally favorable to the development of mental de-
rangement. Doubtless all of these elements con-
tribute to the result. Frequently as the plea of
insanity has been abused to defeat the ends of
justice, there can, unfortunately, be no doubt
that it is far from being a rare occurrence for
persons to be sentenced as criminals who were,
at the time of the commission of the unlawful
act, influenced by insane delusions, actuated by
morbid impulses, or incapable, by reason of
mental enfeeblement of appreciating the true
nature and results of their actions. The mistakes
of juries in this respect are numerous, and the in-
terpretation of the law, in this country and Great
Britain, has been such that many persons whose
mental unsoundness was recognized and ad-
mitted, have still been held legally responsible
for the results of their disease. In a still larger
proportion of cases, probablj', although no dis-

tinctlj' morbid sj-mptoms had been noticed before
the commission of crime, there was such a pre-
disposition to mental disease as rendered its de-
velopment certain under favoring conditions. It
is well known that habitual criminals are, as a
class, not only uneducated, but of a low order of
intellect, and incapable of any high degree of
mental development. Defects of physical de-
velopment, such as are frequent among the in-
sane and idiotic, are so common in criminals that
lyOMBROSO and his followers maintain that habit-
ual criminality is a disease, capable of physical
diagnosis, and equivalent to moral insanity. We
do not believe that this view is correct, as it
certainly is not indorsed b}' most of those who
have made a stud}- of the subject, but although
we believe it a mistake to elevate criminalitj- to
the rank of a distinct disease, there can be no
reasonable doubt that it is often the result of an
abnormal organization.

Making all reasonable allowance for these fac-
tors, it must, we fear be admitted that the influ-
ences of prison life are, in many cases, calculated
to develop tendencies to mental disease which
might, under more favorable circumstances, lie
dormant. This is, probablj', to a certain extent,
unavoidable. The sense of disgrace, the loss of
liberty, the injury as regards prospects for the
future, are depressing influences which might be
sufiicient, of themselves, to unbalance a brain
already predisposed to disease. In many ca.ses,
however, even in what are considered well-
managed prisons, there are influences at work, in
the monotony of the life and the lack of healthy
occupations for the mind, to say nothing of the
frequently unwholesome conditions as regards
light, ventilation and food, which are needlesslj'
unfavorable to the preservation of mental sound-
ness. To discuss the general subject of prison
administration would not be in place here, but it
need hardlj' be said that in so far as a system, or
lack of system, favors the development of in-
sanitj', it is neither humane, just, nor economical.
Judging from the experience of the past, it is
scarcely to be expected that any efforts for a more
scientific and humane interpretation of the law in
reference to the in.sane accused of crime will meet
with immediate success. The prospect in regard
to prison reform is perhaps more encouraging.
The law passed at the last session of the New
York legislature, providing for an extension to

638

CRIME AND INSANITY.

[November 2,.

all the prisons of the State of the system of grad-
ing convicts according to their conduct, furnish-
ing regular instruction and allowing suitable
cases liberty on parole, which has worked so sat-
isfactorily at the Elmira Reformator3^ must be
considered a long step in advance, and can hardly
fail to find imitators elsewhere. By rendering
the conditions of prison life more health)', and
less hopeless, it is reasonable to expect that it will
materiallj' reduce the number of those becoming
insane during their confinement. The proportion
of insane among convicts will, however, doubt-
less continue to be large, and the question of
their treatment is one in which our profession
should feel an interest and might reasonabl}' hope
to exert an influence.

In most of the States of this countr>% so far as
we are aware, insane convicts receive very little
treatment appropriate to their condition. If it is
impracticable or unsafe to work them with other
prisoners, thej' are generally confined in solitary
cells, and no systematic attempt is made to divert
their minds from their morbid ideas by recreation
or employment. The natural result is that cases
which might recover under suitable management
drift on into hopeless dementia. At the expira-
tion of their term of imprisonment the)' are sent
to swell the multitude of hopeless chronic cases
which crowd the wards of public asylums.
Their presence there is objectionable in manj'
ways. Although manj' of them are as inoffensive
as most of those with whom they are brought in
contact, there is alwaj's a considerable proportion
in whom moral degradation is more conspicuous
than intellectual impairment, and who, by their
violence, insubordination, and continual attempts
to escape, exercise a constant disturbing influence.
Even when not personally objectionable, their
presence is often felt as a degradation bj^ such of
their fellow-patients as are capable of being in-
fluenced by such feelings.

In addition to discharged convicts, nearlj' all
State asylums contain more or less patients who
have escaped trial or conviction for crime on the
ground of insanity, to whom the same objections
apply. In some such cases insanity has been
feigned in order to escape the just penalty of
wrong-doing, and it is frequently the case that it
is not so well marked as to satisfy the public
sentiment as to the innocence of the accused.
Escapes under such circumstances are particu-

larly unfortunate, and we have reason to think
they are not very infrequent. The organization
and discipline required by this class are diSerent

I from those best adapted to the treatment of the
great bulk of the insane, and to the attempt to
treat both classes together is not calculated to
promote the best interests of either.

The .solution of the difficulty lies, unquestion-
ablj', in the provision of separate institutions for
the treatment of this class. Of these there are
already two in this countn.-, in New York and
Michigan, and the Legislature of Yermont, at its
last session, provided, in the act establishing a
State asylum, that detached wards should be
built for the accommodation of the criminal in-
sane. The experience of the institutions already
in operation has shown the advantages of this
plan both to the insane convicts and the popula-
tion of the other asylums. Such institutions
should be constructed and administered with
prime regard to security, which need not be in-
consistent with a verj' considerable degree of lib-
ert)^ and comfort to a large proportion of the in-
mates. They should receive all insane convicts
as soon as their malady becomes evident, that
they may have the benefit of early treatment.
In case of recovery, they should be returned tc^
prison to serve out the unexpired portions of their
sentences. Persons accused of felony and found
to be insane should also be committed to these

1 institutions ; and it might be well to provide, as
has been done in Michigan, for the removal to
them, from the other asj'lums, of those patients

I who, b}- persistent homicidal propensities, are a
constant menace to the safetv of their fellows.
Each of our more populous States has enough

I insane of these classes to justify the erection of a
separate in.stitution for their care, and there are
few in which the existing asylums are not already

I so crowded as to make additional accommodation
necessary.

j In Arkansas additional room is needed for the

j insane, and the superintendents of the asylums
and the State Board of Charities unite in recom-
mending the erection of a separate institution for
this class. It is to be hoped, in the interest of
all concerned, that the Legislature will take
prompt action on this subject at its next session.

1889.]

RADICAL TREATMENT OF SPINA BIFIDA.

639

THE RADICAL TREATMENT OF SPINA BIFIDA.

Considerable attention is being directed, of late,
to the treatment of spina bifida {id est, hydrorrha-
chis) by means of excision of the sac of the
tumor. This is distinctly a reversion to first
principles, inasmuch as the operation is by no
means a new one, and has for many years past been
discountenanced by the authorities as unproduc-
tive of the best results. But, like raanj' another
surgical procedure that has long since been laid
away on the shelf, it bids fair to be freed from its
venerable dust and appear again with new lustre.
There are times, no doubt, when we all wish we
were surgeons to take our part in the mighty in-
novations of modern surgery which are so rapidly
removing the opprobria of our art ; but whether
we are surgeons or not, we take a just pride in
the promotion of medical science, and hail with
pleasure every advancement made in the direction
of saving life and promoting human welfare.

Many years ago the surgeons felt obliged to
abandon the radical operation for the relief of
hydrorrhachis as altogether too dangerous and too
barren of good results ; indeed, most of our au-
thoritative writers on surgery and obstetrics are
still outspoken in their condemnation of such an
operation, and as late as 1885 a committee ap-
pointed b}' the Clinical Society 0/ London reported
unfavorabljr upon the radical operation and ap-
proved of the treatment by iodine injections as
the one most nearly imitating the process of nat-
ural cure and, therefore, most widely applicable.
Nevertheless a sufficiently large number of suc-
cesses obtained by the radical method have been
recorded to raise a reasonable hope that a very
decided improvement may be obtained by return-
ing to the older plan of treatment. The treat-
ment by iodine injections, which was popularized
by the results secured in the hands of Brainard,
Velpeau, Morton, Watt, Eate, Ewart and others,
is, at best, unproductive of verj' satisfactory results.
Thus, Brainard obtained a permanent cure in
three cases out of seven, and Velpeau in five out
of ten. On the other hand, Robson, of l,eeds,
reports successful results in three of four cases
operated upon by excision, while other and simi-
lar results are reported by Wilson, Atkinson,
Howson and Barton, of England, and by Hayes
and Hurd, of our own countrj'. The latter, Dr.
H. P. Hurd {Ther. Gaz., Oct. 15, 1889), in de-
scribing his own case, has also reviewed the lit-

erature of the subject. As Dr. Kurd's citations,
of cases are mostly from English sources, it is
with pleasure that we direct attention to four
other cases which have recently been given pub-
licity in Chicago, Dr. A. E. Hoadley having
reported a successful case to the Chicago Medical
Society (Oct. 7, 1889), and Dr. Chas. T. Parkes
having reported to the Chicago Gynecological
Society (Oct. 18, 1889) three cases operated on,
with two successful results. Although such cases
as these are not yet sufiiciently numerous to enable
one to predicate definite conclusions, they have
at least subserved excellent purposes in proving
that the radical method, in proper hands, is capa-
ble of yielding satisfaction. Furthermore, the
testimony of these operators seems to indicate
three pretty clearly defined facts :

1 . That the escape of a considerable quantity
of fluid from the sac is not necessarily attended
by dangerous sequelae.

2. That there is less danger from injur}' to the
nerve structures than has been believed, and

3. That many of the unfavorable results of for-
mer operations were, doubtless, due to lack of
proper precautions relative to the prevention of
sepsis.

EDITORIAL NOTES.
HOME.
The first medical degree ever given to an Am-
erican woman was given forty years ago. To-day
there are 2,500 women in this country having di-
plomas from either American or foreign schools.

Yellow Fever in Florida. — Surgeon-Gen-
eral Hamilton, of the Marine-Hospital Service,
has received a telegram from Dr. Porter, at Key
West, reporting another case of yellow fever at
that place, and that quarantine restrictions have
been resumed. The patient in this case is E. El-
linger, who left Havana September 21, bound for
New York.

The Southern Surgical and Gynecologi-
cal Association will hold its annual session at
Nashville, Tenn., November 12, 13 and 14, 1889.
The following are the papers to be read : The
President's Annual Address, Dr. Hunter Mc-
Guire, Richmond, Va. ; "Report of Gynecologi-
cal Work, with Especial Reference to Methods,"
Dr. R, B. Maury, Memphis, Tenn.; " Direct Her-
niotomy, with Cases," Dr. W. O. Roberts, Louis-

640

EDITORIAL NOTES.

[NoVEWtBER 2,

ville, Ky.; " Open Abdominal Treatment" Dr. B.
E. Hadra, Galveston, Tex.; "The Abortive Treat-
ment of Acute Pelvic Inflammation," Dr. Virgil
O. Harden, Atlanta, Ga.; "The Importance of
Earh- Treatment of Inflammatory Affections of
the Uterus," Dr. Wm. C. Dabney, University of
Virginia ; ' ' The Relation of the Nerve System to
Reparative Surgery," Dr. Thos. O. Summers,
Jacksonville, Fla.; "Concerning the Causes of
Frequent Failure of Relief of Reflex Symptoms
after Trachelorrhaphy," Dr. W. F. Hyer, Merid-
ian, Miss.; "Cranial Surgery," Dr. DeSaussure
Ford, Augusta, Ga.; " The Treatment of Ectopic
Pregnancy," Dr. W. H. Wathen, Louisville, Ky. ;
"Laparotomy in Extra-Uterine Pregnancy," Dr.
Waldo Briggs, St. Louis, Mo.; "Epithelioma of the
Penis," with the Report of a Case," Dr. D. W. Yan-
dell, Louisville, Ky.; "Laparotomy in Intestinal
Obstruction," Dr. C. KoUock, Cheraw, S.C. ; " An
Experimental Study of Intestinal Anastomosis,"
Dr. Jno. D. S. Davis, Birmingham, Ala.; " Opera-
tive Interference in Ascites, ' ' Dr. Hugh M. Taylor,
Richmond, Va. ; ' ' Observations Pertaining to Preg-
nancy and Parturition," Dr. W. Duncan, Savan-
nah, Ga.; "Puerperal Convulsions," Dr. Jno. Her-
bert Claiborne, Petersburg, Va. ; "Some Remarks
Upon Aneurisms, Relating More Especially to
their Surgical Treatment," Dr. F. T. Meriwether,
Asheville, N. C; " Coccygodynia and Its Treat-
ment," Dr. Hunter P. Cooper, Atlanta, Ga. ; "The
Improved Caesarean Section vs. Craniotomy," Dr.
W. D. Haggard, Nashville, Tenn.; "Conservative
Surgery in Injuries of the Foot," Dr.J.T. Wilson,
Sherman, Texas; " Gun-Shot Fractures of the
Femur," Dr. Jno. Brownrigg, Columbus, Miss.;
" Tropho -Neurosis as a Factor in the Phenomena
of Syphilis," Dr. G. Frank Lydston, Chicago,
111.; "Trophic Changes Following Nerve Injury
in Fractures, with report of two cases," Dr.Wm.
Perrin Nicolson, Atlanta, Ga.; "Treatment of
Malignant Diseases of the Rectum," Dr. W. T.
Briggs, Nashville, Tenn.; "Gynecology in its
Relations to Obstetrics," Dr. W. L. Robinson,
Danville, Va.; " Ob.servations Ba.sed Upon an
Experience of Seventy-five Abdominal Opera-
tions," Dr. Jos. Taber Johnson, Washington, D.
C. ; "Twenty Consecutive Cases of Abdominal
Section," Dr, L. S. McMurtr>', Danville, Ky.;
"Triple Amputations," Dr. J. B. Luckie, Bir-
mingham, Ala.; "The Treatment of Contracted
Bladder by Hot Water Dilatation," Dr. I. S.

Stone, Lincoln, Va.; "Complications Occurring
in the Clinical History of Ovarian Tumors," Dr.
Richard Douglas, Nashville, Tenn.; "What Kind
of Instruments Does Modern Antiseptic Surgerj'
Demand?" Dr. J. W. Long, Randleman, N. C;
" Inte.stinal Anastomotic Operations with Seg-
mented Rubber Rings, with Some Practical Sug-
gestions as to Their Use in Other Surgical Pro-
cedures," Dr. A. V. L. Brokaw, St. Louis, Mo.;
" Leucocythaemic Tumors as a Neoplastic Expo-
nent of Rheumatism and Their Similarity to Ma-
lignancy— with a Case," Dr. W. Locke Chew,
Birmingham, Ala.; "What Civilization is Doing
for the Human Female," Dr. A. Lapthorn Smith,
Montreal, Canada; "The Achievements of Modern
Surgery," Dr. J. EwingMears, Philadelphia, Pa.;
"The Treatment of the Pedicle in Suprapubic
Hysterectomy," Dr. Wm. M. Polk, New York;
" Pus in the Pelvis and How to Deal with it,"
Dr. Joseph Price, Philadelphia, Pa.

Members of the profession are invited to attend.

Extent of the Opium Traffic. —The Mas-
sachusetts Board of Health has been making a
series of investigations for the purpose of learning
the extent of the opium traffic in that State. The
result shows that while the use of the drug is not
rapidly increasing it yet has a strong hold among
all classes. Circulars were sent to the druggists
and older physicians. Among the inquiries and
replies are these :

1. From your own observation is the use of opium and
its preparations increasing in the community in which
you live? Two hundred and twenty-five answers received;
66 per cent, replied no, 28 per cent yes, 6 per cent, do not
know.

2. If such be the case, what is the probable cause of
such increase? Twenty per cent, give the use of opium
by physicians as the sole cause, 1 1 per cent, give this as
the cause in part. Ease of obtaining opium from drug-
gists, excessive brain work, desire for stimulation, fast
living, comprise most of the remaining answers.

3. Are diseases calling for the use of opium increasing?
Two hundred and nine answers; 84 per cent, no, 16 per
cent. )'es.

4. In what form or manner is it employed? One hun-
dred and sixty answers; 30 per cent, all forms, 22 per
cent, morphia, 13 per cent, morphine and laudanum, 12
per cent, morphia by the month and hypodermically, lo
per cent, morphia hypodermically.

5. Does the prohibition of alcohol increase its (opium)
use? Two hundred and two answers; 67 per cent, no, 10
per cent, yes, 3 per cent, possibly, 20 per cent, do not
know.

6. What classes of people mostly use it? One hundred

1889.]

EDITORIAL NOTES.

641

and sixty-six answers; 30 per cent, all classes, 22 per
cent, higher, S per cent, middle, 6 per cent, lower, 12 per
cent, middle and higher, 14 per cent, nervous women, S
per cent, do not know.

The Philadelphia Polyclinic and College
FOR Graduates in Medicine. — The Board of
Trustees, in recognition of distinguished services
rendered the institution, as former Professors,
have elected Richard Levis, M.D., Emeritus Pro-
fessor of Surgerj' ; J. Solis-Cohen, M.D., Emeritus
Professor of Laryngology ; Charles H. Burnett ,
M.D., Emeritus Professor of Otology ; and Charles
B. Nancrede, M.D., who was recently called to
the Chair of Surgery in the University of Michi-
gan, Emeritus Professor of General Orthopaedic
Surgery.

An additional Chair of Orthopaedic Surgery
was created and Thomas G. Morton was elected
Professor. Professor Morton will utilize the vast
clinics of the Orthopaedic Hospital and Infirmary
for nervous diseases. Professor S. Weir Mitchell
having for some time past used the Nervous De-
partment.

A new Department of Dentistry was created
and the Faculty was authorized to place a compe-
tent teacher in charge until the next meeting of
the Trustees.

A new Department of Experimental Therapeu-
tics and Physiology was created, and Thomas J.
Mays, M.D., was elected Professor.

The Chair of Clinical Surgery was filled by the
election of Thomas S. K. Morton, M.D., Professor.

C. L. Bower, M.D., was elected Adjunct Profes-
.sor of Clinical and Operative Surgery, and J. Ab-
bott Cantrell, M.D., Adjunct Professor of Diseases
of the Skin.

The Chair of Pathology was left vacant until
the next meeting.

The report of the Building Committee was read,
in which it was stated that contracts had been
signed for preliminary work to the amount of
$23,150. About $30,000 will be required to finish
the building, and it was decided to push the build-
ing to completion as fast as the donations for the
purpose could be obtained. The overcrowded
condition of the present building makes it neces-
sary to u.se every exertion to move into the new
building in the early spring, even though it be
unfinished.

Rembrandt's "Lesson in Anatomy." — Rem-

brandt's celebrated picture entitled " A Lesson in
Anatomy," a full size copy of which hangs at
present in the hall of the College of Physicians
of Philadelphia, has, we understand, been pur-
chased by Mr. Ellesworth, for the Institute of
Art, of Chicago. It formerly belonged to the
Princess de Sagan, and until recently has been in
an art gallery in the Hague.

The Red Cross at Johnstown. — Miss Clara
Barton has communicated to one of the Johns-
town newspapers the decision of the Red Cross
Association to bring to an end the relief campaign
in the Conemaugh valley. The present organi-
zation will be disbanded to give place to a lesser
relief administration, under local control, which
will receive from Miss Barton all supplies that
remain undispensed when she departs. This has
been the most exacting campaign through which
the American Red Cross Society has been called
to pass ; the records .show that over 30,000 re-
liefs, medical and other, have been granted dur-
ing the past four months.

foreign.

Dr. Philippe Ricord, the celebrated French
surgeon, is dead. He was born in Baltimore,
Md., December 10, 1800.

German Students' Duels. — The British Med-
ical Journal says that two students, one belonging
to the medical and the other to the legal faculty
of the University of Halle, have recently been
condemned to three months' imprisonment in a
fortress for fighting a duel with pistols, although
neither of them was hurt. It appears from this-
that a paternal Government will only allow belli-
cose Biirschen to avenge their honor by slashing
each other's faces.

Dr. p. Meniere has resigned the management
of the Gazette de Gymrologie, published in Paris,
France, on account of ill-health. Dr. Phillippeau
is his successor.

British Medical Assoclation. — It is proba-
ble that the 1891 meeting of the Association will
be held in the ancient city of Bristol, the metrop-
olis of the West of England, a city noted for its
historic buildings and romantic surroundings.

President de Winton, of the geographical
section of the British Association, states that
American climate has improved the physique of
the Anglo-Saxon race.

I

642

TOPICS OF THE WEEK.

[November 2,

TOPICS OF THE WEEK.

THE ACIDS OF THE STOMACH.

There is no doubt that the chief acid found in the
stomach during natural digestion is free hydrochloric
acid. This has been abundantly proved by Bidder and
Schmidt, and numerous observers succeeding them. The
methods used are, however, too long and too compli-
cated to employ in clinical work. The physician wishes
to know what, in a particular case of disease, are the
chemical changes going on in the stomach : whether, for
example, hydrochloric acid is present as well as pepsin
and organic acids. Now, in the examination of the con-
tents of a diseased stomach three forms of acid may be
present — hydrochloric acid, a mineral acid ; organic
acids, such as lactic acid, butyric, etc. ; and thirdU', acid
phosphates. It is chiefly of importance to determine the
presence of .hj'drochloric acid and of organic acids.
Many methods have been proposed for doing this ; they
consist mainly in testing the effect of the stomach con-
tents on various colored solutions. Thus a solution of
methyl-violet is decolorized by hydrochloric acid, so that
if this reaction is obtained the free acid is present in the
liquid tested. Lactic acid turns the violet a dirt}- yellow.
Troparolin also is turned deep reddish-brown b}- free
hydrochloric acid. Unfortunately these tests, simple as
they appear, are not accurate, since the reactions are in-
terfered with by the presence of peptones and of some
neutral salts, and, as these are usualh' present in the
stomach contents, no reliable results can be obtained by
tising methyl-violet and tropKolin. They have been
superseded bj' congo-red, which is turned blue by free

salt is present. ' If, moreover, organic acids be present,
they must be first removed by shaking with ether before
the chalk is added. It does not seem that Leo's method
is one that can be applied at the bedside, because the de-
tection of free hydrochloric acid is chiefly requisite in
those cases in which organic acids are also present, as in
cases of dilated stomach. At present, indeed, a ready
method, suitable in clinical practice for the detection of
free h}-drochloric acid in organic liquids is a desideratum.
— British Medical Journal.

PROFESSOR CHARCOT.

It would seem almost superfluous to say anything of
Dr. Charcot, as he is already so well known in the pro-
fession. He is certainly one of the most remarkable
medical characters of the day, and even phjsically his
person and features bear a peculiar stamp. He is a man
of ordinary stature, 55 years of age, and stoops a little.
His face is pale and clean-shaven, resembling very much
that of the first Napoleon, and giving the impression of
a thoughtful mind. After having for a long time devoted
himself to the study of pure pathological anatomj-. he
gave himself up to the clinical study of nerv'ous affec-
tions, a scientific territory till then almost unexplored.
He here displayed rare qualities of observation, an ex-
emplary patience, a mar\'elous prudence, and the most
perfect method. He has won the intellectual esteem of
his bitterest opponents, a world-wide reputation, and the
assurance of having attached his name to a work which
will remaiu imperishable. Prof. Charcot's clinic at the
Salpetriere is well known, and constitutes the greatest
scientific centre in France for the study of the pathology,
diagnosis and treatment of nervous diseases. It is at-

hydrochloric acid, and by a solution of vanillin and , tended by physicians and students from all parts of the
phloroghicin in alcohol, which is turned a deep red by world, where they find a vast amount of clinical material

the same acid. These simple clinical tests are, however,
rendered useless by the fact that they are interfered with
by the presence of peptone, ammonium salts, chlorides,
and phosphates.

In the present state of our knowledge, therefore, there
is no reliable indicator for the presence of free hydro-
chloric acid in the stomach contents. Other methods
which may be used are too complicated for clinical use.
Thus ether has the property of dissolving organic acids
from a liquid, leaving the mineral acids in solution. It
may thus be used for separating the lactic, butyric, and
other acids from the hydrochloric acid ; and if in a liquid
obtained from the stomach it is found that ether removes
the whole of the acids present, it may be concluded that
no free hj^drochloric acid is present. In many cases this
conclusion would be an important one as a clear indica-
tion for a line of treatment. Dr. Leo has lately' pub-
lished a new method for the indication of free hydro-
chloric acid which may prove useful. Leo considers the
case where it is only a question of the presence of free
hydric chloride, and of an acid phosphate. To a few
drops of the stomach contents a pinch of carbonate of
calcium is added ; if the acidity, as tested bj' litmus
paper, disappears, only a free acid is present, but if the

and the complete methods of study organized and devel-
oped by the eminent professor, aided by a body of dis-
tinguished pupils and assistants who surround him in
his dailj' visits. For many years Prof. Charcot has taken
a foremost place among the leaders of medical science ;
his clinique, his laboratories, his works and his pupils
constitute one of the chief glories of the faculties of Paris.
His lectures are most impressive; he is sober in manner,
clear in diction, picturesque in illustration, original in
conception, indefatigable in research, and spares neither
time, labor nor wealth in using all the methods of clin-
ical illustration at his disposal. It would be fastidious
and useless to anal}'ze here all his discoveries ; I would
simply refer to some which leave the narrow limits of
medicine and touch somewhat on philosophy. In the
chaos of the notions acquired on cerebral function it can
not be denied that it was Charcot who was the first to
throw light on the subject, in finding, as if by a stroke
of genius, the method which permitted him to fix the
cerebral motor localizations. He, at the same time with
Kussmaul, taught men the mechanism of their memory
and of their language. And who does not remember the
debates on the questions of magnetism and of hysteria
that have so recently taken place among the lay and

liquid is still acid after the addition of the chalk, an acid i medical public? It was Dr. Charcot who, armed with

I his scientific sangfroid and method, reduced to definite

' Centralblatt fiir die medictnishen Wissenschafteii, No. 26.

1889.]

TOPICS OF THE WEEK.

643

laws facts which, in appearance, were the most incoher-
ent. I may here observe that to the Hospice of the
Salpetriere, which was originall}' intended onlj' for the
aged and insane of the female sex, there being 3,145 of
the former and 720 of the latter, there have been added
forty-two beds for male patients and a certain number of
female patients suffering from nervous diseases, which
additions were made for the most special study of dis-
eases of the nervous system. It may be said that Dr.
Charcot began his professional career at that asylum.
He was interne in it in 1852, and became physician in
1862. He was appointed professor of diseases of the
uervoTis system in i88i, a chair which was created for
him. Since 1S62 he has not ceased to give his memora-
■ble series of lectures and clinical conferences, which are
held every Tuesday morning at the Salpetriere, and on
Friday morning he holds consultations, both of which
are alwaj-s well attended. In addition to the above there
are thirty beds for children afflicted with ner\ous dis-
eases, and 200 beds for epileptics. Besides these he has
the control of a series of infirmary wards, into which are
brought all the patients whom he desires to select from
among the infirm women who are the permanent inmates
of the other parts of the Salpetriere. Altogether he has
at his disposal for clinical study and under direct treat-
ment more than 2,000 patients. No wonder, then, that
with this vast experience Prof. Charcot should be re-
garded as the highest authority on ners-ous affections.
He is also a member of the Academy of Medicine. — Paris
Correspondence, Boston Med. and Surg. Journal.

WHAT RE.\I, V.MAE HAVE THE NATURAL MINERAL

WATERS IN THE TREATMENT OF DISEASES

OF THE SKIN?

-•Vt the recent meeting of the American Dermatological
Association Dr. L. D. Bulkley, of New York, presented
a paper in which he discussed the subject of natural min-
eral waters iu the treatment of disease, and from which
we make the following extract:

It is the popular impression that natural mineral waters
help certain skin diseases; that some are to be applied on
the outside, and some are to be taken internally for the
purpose of washing out the noxious agent. No doubt
many cases are benefited, but an}- one who has seen
many cases of the effects of natural mineral waters must
be many times disappointed. The water is but one ele-
ment in the case; hope and faith may pla)- an important
part. Then there is the change of scene, rest from ordi-
nary occupation, and, perhaps, the enforcement of regu-
lar hours.

In Europe, most of the springs have resident medical
advisers, but, unfortunately, there are few of them in
this country. It should be remembered that in certain
instances other appropriate remedies are being taken at
the same time; witness the treatment of syphilis at the
hot springs of Arkansas. But in any case it is the water,
pure and simple, which contributes most to the cure.
Most of the waters have little effect upon the skin, but
reach especially the kidneys, liver, bowels, etc. We can-
not always predict the effect of the water from its chem-
ical analysis. Certain mineral waters are taken hot at

the springs, but cold, or even in ice, when at a distance.
In the case of iron, arsenic and bromine springs, the re-
sults are rather indefinite. Sometimes cutaneous dis-
eases depending on debility will be improved. We have
all seen cases of eczema which have been treated at the
sulphur springs in vain. Where there is a rheumatic
element back of the cutaneous lesion, no doubt some
good can be received; but in those cases it is the alkaline
water, and not the sulphur, which is of benefit.

Like all other remedies, the use of springs must be
carefully prescribed iu order to be of the greatest use.
Probably more benefit is derived in eczema than in other
diseases, and even then it should be toward the close of
the case. First, should be used the alkaline and moder-
ately purgative waters, and then a tonic course. Carls-
bad is advisable where there is a large abdominal pleth-
ora. In acute cases the hot springs should be used. Care
must be taken lest acute eczema be excited by the springs,
for some very severe cases have been lighted up in this
manner. In psoriasis, sometimes sea-bathing is of far
more benefit than the mineral springs. In syphilis, lit-
tle benefit follows unless other treatment is kept up.
Acne will sometimes be benefited somewhat, and the
iron springs are better than the sulphur. The chief diffi-
culty in the use of this treatment is the fact that these
patients are not under supervision, and are apt to follow
their own faucv or the guidance of the attendants at the
baths.

INJURIES BY RAILROAD.

Railroad business and travel is a topic that is absorbing
increased attention every year, and new guards against
danger are being constantly applied. A monster peti-
tion, containing nearly 10,000, names of brakemen, has
lately been sent to the Interstate Commerce Commission,
asking them to urge upon Congress the necessity for
legislation requiring the use of automatic brakes and
couplers on freight cars ; and when it is remembered
that something like 450 men are killed, and 4,000 injured
every year iu operating freight cars, the subject assumes
great importance. An article in Scribner's Magazine for
September gives the following facts on the general topic
of safety in railroad travel :

When one reflects upon the destructive energy which
is contained in a swiftly moving train, and sees its effects
in a wreck ; when he understands how many minute
mechanical details, and how many minds and hands
must work together in harmony to insure its safe arrival
at its destination, he must marvel at the safet}- of railroad
travel. In the year 1887, the passengers killed iu train
accidents in the United States were 207 ; those injured
were 916. The employes killed were 406, and injured
890. These were in train accidents only, it must be re-
membered, and do not include persons killed at crossings,
or while trespassing on the track, or employi^s killed and
injured making up trains. As will be seen later, the
casualties in these two classes are much greater than
those from train accidents. The total passenger move-
ment in 1887 was equal to one passenger traveling
10,570,306,710 miles. That is to say, a passenger might
have traveled 51,000,000 miles before being killed, or
12,000,000 miles before being injured. Or he might
travel day and night steadily at the rate of 30 miles an
hour for 194 years before being killed. Mark Twain
would doubtless conclude from this that traveling b}-
rail is much the safest profession that a man could adopt.
It is unquestionably true that it is safer than traveling bj-
coach or on horseback, and probably it is safer than any
other method of getting over the earth's surface that
man has jet contrived, unless it may be by ocean steamer.
If one wants anything safer, he must walk.

644

PRACTICAL NOTES.

[November 2,

PRACTICAL NOTES.

EXALGINE IN NEURALGIA.

Attracted by the report of Dujardin-Beaumetz
and Bardet on the properties of this agent, Dr.
Frederick Peterson, of New York, has em-
phasized it in a number of neuralgic cases with
satisfactor}' results. He administered it both in
the form of pills containing 2 grains each, and a
cordial with 2^i' grains to the tablespoonful. He
finds it a valuable analgesic, and has succeeded in
curing with it a number of cases of cephalalgia,
facial neuralgia, brachial neuritis, etc. In some
cases of failure he believes that his doses were
too small and that one should, in most cases, be-
gin with doses of from 4 to 6 grains, repeated
every two to four hours. Exalgine is verj- solu-
ble in wate'r containing a little alcohol, but only
slightly soluble in cold water. It acts very ener-
getically upon the cerebro-spinal a.^is in animals,
giving rise to phenomena of impulsion, tremor
and paralysis of the respiratory muscles. In non-
toxic doses sensibility to pain disappears, but
that of touch persists ; it produces also a gradual
but notable fall of temperature. Its effects are
somewhat similar to those of antipyrin, but its
effect upon sensibility is more marked and upon
the thermogenic centres less. In therapeutical
use exalgine produces no rash cyanosis or gastro-
intestinal irritation. It is eliminated by the urine
modifying its secretion, and in diabetic polyuria
it diminishes the daily amount of urine and the
quantity of sugar. — New York Medical Record.

incompatibility of antipyrin with other

DRUGS.

M. Charles has called attention to the pre-
cipitate which is formed by mixing solutions of
antipyrin and cinchona, and M. Ferand has made
later some experiments which warrant him in
saying that in mixtures containing antipyrin and
cinchona all the active principles of the potion
are precipitated and leave in the filtered liquid
scarcely a perceptible trace of antipyrin and the
alkaloids. He notices, as did M. Charles, that
the precipitate is readily soluble in weak acids,
from which he concludes that the potion does not
become inert, as the precipitate should dissolve
in the gastric juice.

M. Blainville, pharmacist, records a new in-
compatible with antipyrin ; having had occasion
to mix 4 grams of antipyrin and 5 grams of hy-
drate of chloral and 15 grams of water, he found
the mixture became milky, then clearing, depos-
ited an oleaginous liqtiid. Decanted, this liquid
possessed neither the ta.ste of antipyrin nor of
chloral, but resembled coriander .seeds.

Upon the subject of incompatibles, which are
discovered each day by pharmacists, M. Ferand

remarks that they should avoid mixing substan-
ces as complex as antipyrin with chemicals capa-
ble of modifying its composition and, consequent-
ly, its physiological action.

Formulas the most simple, said he, such as
distilled water sweetened, should be the rule
when prescribing a new body used in therapeu-
tics before all its chemical characteristics are
thoroughly studied. — La France Medicalc— Times
and Register.

PICROTOXIN .\S AN ANTIDOTE TO MORPHINE.

From experimental investigations A. B6k.\i
{Cent, fi'ir Klin. Med., No. 33, 1889) is convinced
that picrotoxin is the most rational antidote to
morphine. Picrotoxin and morphine produce
antagonistic effects upon the respiratory centre,
the latter paralyzing its action, while small doses
of picrotoxin increase it and inhibit the paralyz-
ing influence of morphine. Further, picrotoxin
irritates the vaso-constricting center of the me-
dulla and is, therefore, capable of hindering the
rapid fall of blood pressure in morphine poison-
ing. The two agents likewise have opposing
effects upon the hemispheres. Picrotoxin also
deserves attention from the fact that it may be
given in the place of the nux vomica preparations
and may perhaps be found a good prophylactic
for chloroform a.sphyxia.

CHLOROFORM .\DMINISTR.\TION.

The administration of chloroform in preference
to ether is much more common in Europe than
in this countr>-. Several deaths having recently
occurred in the Paris hospitals from the use of
chloroform, the surgeons are beginning to seek a
safer anaesthetic, and it is now proposed to sub-
stitute the chloride of methylene, or, more prop-
erly, methylic chloroform. Prof. Regnauld has
called the attention of the Academic de Medecine
to this agent, which was formerly regarded with
favor bj- Sir Spencer Wells and Richardson.
Regnauld finds that in reality the so-called chlor-
ide of methj'lene is nothing but a mixture of four
parts of chloroform and one part of methylic alco-
hol. Its action is very much slower than that of
chloroform, but it is hoped that it will prove pro-
portionatelj- safer. — N. Y. Medical Journal.

DEATH from SULPHONAL.

Dk. R. R. Petitt reports a case of death from
the administration of sulphonal. The patient, a
woman 28 years old, was suffering from melan-
cholia. She took 15 grains of sulphonal, and
about an hour later the dose was repeated. Soon
after she went to sleep and could not be aroused
for twenty-four hours. Death occurred from fail-
ure of respiration forty hours after the dose was
taken. — Medical News.

1889.

SOCIETY PROCEEDINGS.

645

SOCIETY PROCEEDINGS.

Obstetrical Society of Plilladelplila.

Stated Meeting, September 5, i88p.
Dr. John C. Da Costa in the Chair.

Dr. John Da Costa :
an easy method of repairing the perineum.

There is probably not any operation in gj-ne-
colog3' which gives a woman so much relief as
the proper restoration of a torn perineum.

In describing this operation I shall not say a
word in regard to the anatomy of the perineum,
which is the same as it was a hundred years ago.
The same muscles are torn now as were torn
then. This subject of tear of the perineum may
seem to be a very simple matter ; but when we
consider that 20 per cent, of women have their
perinea torn in first labors, and 4 per cent, in
subsequent labors, it ceases to be a little matter,
and becomes one of importance.

I do not claim anything new. The operation
is the result of a combination of old ideas. It is
an easy and simple method of repairing the peri-
neum, and answers equally well whether the
tear is long or short. I thought I had something
new in the use of these rubber bars, when I got
it up eight years ago, but afterwards found that
one of my ideas had been anticipated twenty
}-ears before.

Mr. Lane, of London, in i860, used ivory bars
with small perforations, and reports thirty con-
secutive cases without a failure. Dr. Thompson,
of Washington, used flat rubber bars with small
holes in them, and reports fifty-three consecutive
cases, all cured. Dr. Thomas, after speaking of
the quill suture, leads us to infer that he used
perforated bars, and states that he does not recall
a failure in the operation.

I do not know how many present are believers
in the idea advanced four or five years ago, at
the meeting of the American Gynaecological So-
ciety in this city, "that there is no such thing
as a perineum ;" but there certainlj' is a triangu-
lar body between the vagina on one side and the
rectum on the other, and this triangular body is
often torn through during labor, and becomes
what I call a ruptured perineum. There are
many waj's of repairing it. Some
are very simple, some are verj'
striking but verj' useless ; what I
strive to do is to restore the peri-
neum verj- much as nature made C
it. The operation is easy and the
armamentarium is simple. We re-
quire a pair of scissors (I use " ■
pair of blunt-pointed scissors), a - ^«

perineal needle, a little silver wire Bar, jj size.
and shot, a shot compressor, and two bars shaped
like the cut.

The operation is begun at the bottom of the
tear in the vagina. With one or two fingers in the
rectum, I make a little slit at the lowest point and
denude subcutaneously all the tissue that has
been torn. I do not know how far up I go — it
may be 2 inches, or even nearly the length of the
finger. This depends altogether upon the extent
of the tear. The important thing is to get rid of
all the scar tissue. Unless this is done, good
union will not be secured. After denuding up
the proper distance the scissors are turned to the
right and to the left, and each side denuded.
Then, with four cuts of the scissors, the loosened
cicatricial tissue is removed. A denudation of
this kind freshens the torn perineum as I think
no other method does. The first stitch near the
bottom of raw surface is passed three-fourths of
an inch from the edge of the cut portion, buried
in the tissue the whole distance, and comes out
at the same distance on the other side. The
needle is then threaded with silver wire and with-
drawn. The second stitch is put in the same
way. The third stitch is started in the skin like
the others, and three-fourths of an inch from the
edge of the cut, carried along just under the edge
of the denudation the whole way around. This
is the most important stitch of all. It was the
idea of the late Albert H. Smith, when one of the
physicians-in-chief at the Nurses' Home some
j'ears ago. The stitches are buried throughout,
and only three are used in the operation. All
that is necessary is to bring them out in nearly a
straight line.

Surface denuded, and stitches in place.

The wires are then slipped through slotted rub-
ber bars, on each side, and shot-clamped on them.
After the shot are clamped the ends of the wires
are twisted over the median line and the ends
passed through a piece of catheter. In twenty-

646

SOCIETY PROCEEDlNGa.

[November 2,

four hours there is swelling and a certain amount
of inflammation. I then cut the wires off close
above the shot, and this at once relieves the ten-
sion and the pain. Any desired dressing may
then be applied, if it is thought advisable to use
any dressing.

Operation finished, and bars in place.

What are the advantages of this operation ? In
the first place you have but three stitches. I
think that probably everj' gentleman has seen
perinea operated on where there has been deep
quilting, and ha\-e seen the tissue slough but be-
cause the circulation has been so interfered with
that nutrition could not be maintained. These
three sutures interfere very little with the circu-
lation and they hold together the deep parts of
the wound, which is very important. When in-
flammation takes place you cut the wires over
the shot, the bars spread and relieve the tension,
and prevent any tendency to sloughing, while
still supporting the parts.

After the wound is closed, you may take a
piece of catgut and whip up the edges in the
vagina, and along the line of the raphe. This is
not necessarj' unless we want to make a very
perfect job. The operation is easily and quickly
performed. I have never timed myself and
have never tried to do the operation in a hurry,
but I accidentally found out how long it takes.

On one occasion, in thirty minutes from the
time that I began, I had operated on two cases,
and this included the time necessary to put one
patient under ether from perfect consciousness to
unconsciousness. The denudation is accomplished
in four or five minutes.

This is a different operation from that in which
the denudation is made in curved lines, and
where another operation is required for any ex-

isting rectocle. The operation described above
will include also a rectocele. It is better than
another popular operation, which does not restore
the triangle which nature made, but makes a
beautiful skin-flap, which looks well from the
outside, but affords no support.

I do not claim anything novel. It is simply a
combination of ideas that I have picked up from,
time to time. In regard to the results of the op-
eration, it is a rare occurrence to have a failure.

Dr. J. Price : There are a few points about
which I should like to speak in connection with
this procedure and like procedures. As Dr. Da
Costa has said, this is an old operation, and is.
illustrated in all the books. It is the old opera-
tion upon the posterior wall, and has the merit
he referred to, of in manj' cases, making a super-
ficial or skin perinseum. The principle of sutur-
ing described is one not adopted in any other
branch of surger)', and Dr. Da Costa would him-
self not apply this principle in any other portion
of the body. He says that sometimes he denudes
a distance of three inches. In no other part
would he approximate such a surface with three
sutures, and three sutures will not close it.

A word in regard to the denudation. He
speaks of four clips of the scissors — the button-
hole, the central, and the two lateral. In manj-
cases it is impossible to make such a denudation.
You will button-hole the flap many times. That
was the trouble vs'ith the Smith and Jenks opera-
tion. It is difficult to make a clean denudation-
in the midst of scar tissue by such a method.

One of these illustrations shows what takes-
place in many perineal tears. The skin-perineum
side is not harmed ; but if you place 3'our finger
in the sulcus on one side, you will find a sense of
resistance which is absent on the other side.
The sulcus is a deep one, and is a lateral tear.
As has been remarked by Dr. Deaver, "It is for
all the world like the lateral cut for stone." In
such a case the procedure is almost a unilateral
one to bring up the pelvic floor. It is just such
a state of affairs that Emmet had in view in his
classical operation for the restoration of the pelvic
floor or diaphragm, and he has most beautifully
succeeded.

In regard to the use of this needle. Dr. Da
Costa has referred to the fifty-three cases re-
ported by Dr. Thompson of the Columbia Hos-
pital ; but he lost one or two from tetanus, and
this bayonet was at the bottom of the tetanus.
I look upon this needle as wholly unjustifiable in
any surgery. No man has a right to have such
a thing among his instruments. I am surprised
that more do not die from such a stab, including,
as it does, incongruous masses of tissue, .skin,
fat, muscles, vessels, and nerves. I remember,
while a student, of seeing a death from such a
stab. I use the smallest sewing needle possible.

These procedures are verj- old, and are illu.s-

1889.]

DOMESTIC CORRESPONDENCE.

647

trated in all the old works. I consider all two-
or-three-stitch methods of closing the perineum
as emphatically imperfect procedures.

Dr. John C. Da Costa : What Dr. Price has
said in regard to one of these illustrations has
nothing to do with the subject under discussion.
He refers to a tear of the vagina, which has
nothing to do with a tear of the perineum. If
there is a line of cicatricial tissue on one side,
we do not need to denude both sides to repair the
condition. It is a simple matter to remove the
scar tissue and sew it up, as in any other surgical
operation.

I am sorry^ to hear this tirade against this
needle. Some very able men use this needle,
and they get verj' good results. Albert H. Smith,
who did a good deal of gynaecological work,
used a needle much like this. One of the most
successful abdominal surgeons in Philadelphia
uses a needle much like this. Surgeons in all
branches of surgery use needles ven,' like this —
either a little more or a little less curved. One
who came from Europe a jear ago showed me a
long, curved needle which he brought with him
and said was Tait's needle. It was preciselj'
similar to one which I have had in m}- box for
some years for use in complete laceration of the
perineum. This is only the Baker-Brown needle
modified.

I do not know that Dr. Price has said anything
against this operation. He has talked a good
deal about the needle and about a tear that does
not apply at all. I can only say, that, despite
his fears, the operations are almost uniformly
successful. Any one who can do the ordinary
quill operation can do this. After analyzing the
various operations eight years ago, I found that
the best results were obtained by the old-fashioned
operation. The quill operation, however, made
a V-shaped sinus to the bottom of the wound,
and sometimes caused a great deal of trouble ;
and it was to overcome this objection that I sub-
stituted the hard rubber bars with the wires run-
ning through.

{To be continued.')

DOMESTIC CORRESPONDENCE.

LETTER FROM XEW YORK.

(from our own correspondent.^

Meeting of the Section on Practice, jVew York
Academy of Medicine — Dr. A. facobi 071 Chronic
Peritonitis — Discussioti by Drs. Francis Delajield,
VVm. H. Thomson and L. Weber.

At the October meeting of the Section on Prac-
tice of the Academy of Medicine Dr. A. Jacobi
read a paper on " Chronic Peritonitis, with Spe-
cial Reference to the Differential Diagnosis of Some

of its Varieties. ' ' Most of the cases, he said, were
of a secondary' nature, with a great variety of
causes. Having mentioned a considerable num-
ber of these, he referred to the case of a youno-
woman whom he saw dying of acute peritonitis,
who had been affected with purpura for some
weeks. At the autopsy the peritonitis was found
to have resulted from the rupture of some of the-
vessels of the diaphragm. He considered the
most frequent cau.se of peritonitis a precedino-
peritonitis, and stated that in most cases exam-
ined after death the positive proofs of one or more
attacks previous to the fatal one were found. He
did not remember ever having seen a case of peri--
typhlitis which did not exhibit the adhesions, dis--
colorations and contractions due to former perito-
nitis, and he thought it probable that there were
but few, if any, cases of foreign bodies entering
the vermiform process unless the latter had previ-
ously lost its elasticity and contractility by an in-
flammatory change.

Alterations of the mucous membrane of the
intestine, he went on to say, constituted the ini-
tial stages of local peritonitis in many instances,
and of general peritonitis in some. It was not
I only the intima and the submucous tissue which
suffered, but the muscular layer was also impli-
cated in the morbid process. No morbid process
could remain isolated in a locality supplied with
an active blood and lymph circulation, and hence
a simple intestinal catarrh might grow to be an
enteritis, the enteritis a peritonitis. This condi-
tion of things was still more frequently observed
in cases of intestinal ulceration, both acute and
chronic. Even without perforation, an ulceration
would lead to peritonitis which was mosth- local,
but liable to change into an acute attack under
favorable circumstances. Where there was an
open ulcer, or even one that had cicatrized months
or years before, in the stomach or in the intestines
(no matter what its nature might be), we fre-
quently found opposite it a local peritonitis. In
the peritoneal covering there was a thickening,
circumscribed and distinct, which in recent cases
was rather soft and accompanied by much vascu-
lar injection. In old cases the original cell prolif-
eration had undergone organization and harden-
ing, and the thickened spot was gray, or whitish
and hard. It had lost its elasticity, and was ver\'
apt to burst under a moderate amount of pressure;
thus leading to perforation. In the midst of ap-
parent health intestinal perforation would often
set in, and death ensue within a day ; and at the
autopsy the physician would learn that the patient
was the victim of the perforation of the cicatrix
of a typhoid ulceration perhaps contracted a dozen
years before.

The diagnosis of chronic peritonitis, he said,
was frequently missed. Unsuspected adhesions
often existed around tumors, movable kidneys
became fixed, intestines glued together, all with^

648

DOMESTIC CORRESPONDENCE.

[November 2,

out recognizable symptoms. In chronic perito-
nitis respiration was not necessarily accelerated ;
and especially was this symptom lacking in pelvic
peritonitis, perimetritis and pericj-stitis. There
might be occasional vomiting, particularly when
there happened to be an intercurrent acute catarrh;
but there were other conditions, as, for instance,
renal and biliary colic, which were more likely to
exhibit this sj^mptom, and to an excessive degree.
It was often entirely absent, and even in manj'
acute cases of peritonitis this was the case. Con-
stipation was frequent, but diarrhoea, on the other
hand, was not unusual. The horizontal position
was often uncomfortable, but a common colic, de-
pending on gas not absorbed or expelled, also
caused drawing up of the knees. When the hor-
izontal posture was shunned in chronic peritoni-
tis, however, the patient was more apt to remain
quiet with i;aised knees than one who was suffer-
ing from flatulency; in which condition the limbs
were generallj- tossed about continually'.

While the abdomen was apt to be tumid, it was
to be remembered that general adiposity is most
fully developed in this region, that women who
have borne children are apt to have a large and
prominent abdomen, that the abdomen of a healthy
infant is so large as to measure one-third of its
length, that a simple hysterical dilatation and in-
flation may simulate the tumefaction resulting
from peritonitis, and that there may occur a local
dilatation of the intestine from habitual constipa-
tion only. Moreover, in hj^steria there was some-
times met with an oedematous swelling of both
hypogastric regions ; which would still more seri-
oush' complicate the diagnosis. The surface of
the abdomen exhibited networks of dilated veins
more frequentlj- in peritonitis than in any other
condition except certain hepatic diseases. Inspec-
tion might also reveal solitary convolutions rising
above the surface, and palpation and percussion
might lead to the discovery of exudations of va-
rious sizes and shapes ; these consisting of either
organized material, thickened omentum, or intes-
tines glued together. Fluctuation would show
the presence of fluid more readily than percu-ssion,
which might fail in this, that there might be ad-
hesions between the parietal peritoneum and in-
testines in the flanks. The gas contained in the
adherent bowel might yield a tympanitic percus-
sion note although the region might be filled with
fluid. A change of position, from one side to
the other, or from the horizontal to the vertical
posture, or vice versa, might contribute to dispel
the doubt.

A chronic peritonitis was sometimes diagnosti-
cated in the following manner : The patient lies
on his back, with the extremities now extended
and now flexed. Pressure is tried ; hard or light,
sudden or gradual, superficial or deep. Accord-
ing to the seat of the pain experienced, inflamma-
tion or adhe.sion is most manifest. When deep

pressure is first made with the palm or finger there
may perhaps be no pain. Relieve the pressure
suddenly, and a local, verv' distinct, and circum-
scribed pain may be felt. Repetition of the ex-
periment will always give the same result ; the
symptom being elicited by the sudden change in
the relative position of the bowels. Not onlj'
pain, but the presence of hard, floating exuda-
tions can be distinguished bj- this and similar
manoeuvres.

Pain of varying degree and persistency, he con-
tinued, was a very frequent symptom in chronic
peritonitis. Its intensity often depended on the
degree of irritation or congestion present, and
acute attacks were frequent where there was a
cause for exacerbations. Extensive peritonitis in
the pelvis might not give rise to pain, except
such as resulted from defecation, sexual inter-
course, or micturition. In some cases the pain of
chronic peritonitis could not be distinguished
from the enteralgia produced b}- other causes,
such as abnormal contents, fermentation, and flat-
ulenc\-. Indeed, the anatomical causes of chronic
peritonitis gave rise to these ver)' conditions ; for
by it the intestinal movements were retarded, and
from it there might result stenosis and adhesions,
interfering with everv* function.

The results of chronic peritonitis were very va-
rious. A simple attack of acute exudation might
shape the future of the patient, and the histories
of previous acute attacks were often not remem-
bered. Experience showed that the most exten-
sive changes might occur without any known his-
tory whatever.

The concluding portion of the paper was de-
voted to an exhaustive consideration of the im-
portant form of chronic peritonitis known as tabes
mesenterica. The different manifestations in dif-
ferent cases of this affection Dr. Jacobi thought
went to prove that there were several distinct va-
rieties of tabes, depending on different causes and
attended with varying anatomical alterations.
Besides the simple secondary hyperplasia of the
I mesenteric glands, resulting in obstruction, and
! the tubercular infiltration terminating in the se-
\ vere disturbance of function, he said there was a
i third condition which led to symptoms constitu-
I ting what is known as tabes mesenterica, viz.:
chronic tubercular peritonitis. The diagnosis of
: tubercular peritonitis was apt to be quite difficult,
and there were many chronic cases which could
not be differentiated from non-infectious peritoni-
! tis and simple inflammatory processes. There
were, however, cases of tumid abdomen with atro-
1 phy, of both an acute and chronic character, in
which the nature of the aff'cction could be made
; out with some degree of certainty. The progno-
' sis of so called tabes mesenterica was always un-
certain except in the very worst ca.ses. It was
absolutely fatal when there was peritoneal and
glandular tuberculosis complicated with or de-

1889.]

MISCELLANY.

649

pending on generalized tuberculosis. In cases
where the diagnosis of a non-infectious hyperpla-
sia of the mesenteric glands could be made out,
it was decidedlj' more favorable. When the di-
agnosis of chronic peritoneal tuberculosis had
been made, the case was less promising ; still the
possibility of recovery, or partial recovery, was
not excluded.

In the discussion on the paper Dr. Francis Del-
afield said that there were few morbid conditions
of greater clinical interest than chronic peritonitis,
as it was constantly coming up for diagnosis, and
as many mistakes regarding it were made as about
any affection with which he was acquainted. He
had been accustomed to look at the disease with
reference to the anatomical conditions present, and
hence divided the cases into three classes : first,
those in which there were simply adhesions of con-
nective tissue ; second, those in which there were
present both adhesions and fluid, either serous or
purulent; and third, those in which there was dif-
fuse thickening with fluid, but without adhesions.

In the first class of cases the condition was
often not recognized until it was revealed by an
autopsy. The symptoms often corresponded very
nearly with those met with in what is known as
" irritable colon," and it was very difficult to dis-
tinguish between the two. In many cases it was
also difficult to distinguish it from tubercular per-
itonitis, when, in addition to connective tissue
adhesions, there was present a large waxy liver.
Still another condition with which it was likely
to be confounded was a dilated pylorus, in which
the stomach felt to the touch almost precisely like
a ma.ss of intestines matted together. Pain in dif-
ferent parts of the abdominal cavity gave the phy-
sician as much trouble in the way of making a
diagnosis, and there was, in fact, very little to
distinguish the pains due to different causes from
each other.

In the second class of cases it was often difficult
to distinguish the condition from tubercular peri-
tonitis, and the diagnosis between it and carcino-
ma was also difficult. Again, we were likely to
be puzzled by the shape which the peritonitis
took. In certain instances fluid was met with in
different parts separated by partitions, and there
were the physical signs of a tumor with fluid.
What seemed like a tumor, however, was simply
the intestines matted together.

In the third cla.ss of cases it was difficult to dis-
tinguish the affection from tuberculous peritonitis,
from multiple cancer, and from cirrhosis of the
liver. Especially was it hard to distinguish it
from the latter when the capsule of the liver was
involved, since we were apt to have the gastric
symptoms and the vomiting of blood which are
so often met with in that affection.

Dr. Wm. H. Thomson called attention to a
feature which appeared to be diagnostic of can-
cerous peritonitis, viz. : a remarkably low per-

centage of urea in the urine (a condition not
found in tuberculous or other forms of peritonitis),
and related two cases in which he had found it
present. He had also found in such cases a diag-
nostic sign which Germain See had called atten-
tion to in cancer of the stomach, viz.: tenderness
and enlargement of the post-clavicular glands.
Again, in cancerous peritonitis there were not the
same fluctuations in temperature that were met
with in the tubercular form. As to tubercular
peritonitis, he had met with one case in a young
man in which there was distinct redness about
the umbilicus, a sign of this affection which
Wilks had pointed out. When ascites was pres-
ent in chronic peritonitis it rendered it very diffi-
cult to distinguish between this condition and
cirrhosis of the liver, and especially where the
history pointed to perihepatitis. The previous
history of the patient, as to habits, etc., however,
would generally throw some light on the question
whether in any given case we had to do with
cirrhosis or not.

Dr. L. Weber said that he had never seen a
case of chronic peritonitis, properly so called,
! which was not infectious in its nature. Such
cases as those described in the early part of the
paper he would look upon as ones in which there
had previously been acute peritonitis, with its ac-
customed results. Of these, adhesions were the
most frequent, and they often had the effect of
impeding the functions. He had no objection to
calling such cases chronic peritonitis, although
personally he did not consider them as true in-
stances of general chronic peritonitis. They sim-
ply exhibited the results of adhesions caused by
the acute disease, and when in such cases a fatal
result occurred the patient really died of acute
peritonitis due to perforation. As to tabes mes-
enterica, he believed that this was always a tu-
berculous affection, and he incidentally remarked
that he had been much impressed by the reports
of the favorable results which had recently been
obtained in this disease by opening the abdomen
and dusting the affected parts with iodoform,

j p. B. P.

MISCELLANY.

Ohio State S.\nit.\rv Association. — We have re-
ceived from Dr. R. Harvey Reed, the energetic Secretary
of this Association, a programme of the seventh annual
meeting, to be held in Dayton, O., on the 21st and 22d
inst. The following papers will be read :

"The Relations of Theologians to Sanitarians," Dr.
D. J. Snyder. Scio; "Sanitation vs. Medication," Dr. S.
P. Bishop, Delta; "Recent Advances in Etiological
Science." Dr. E. R. Eggleston, Mt. Vernon; "Sanitation
in Small Villages," Dr." Austin Hutt, Waverly ; " Bodily
Comfort as a Sanitarv Object," Dr. G. C. Ashniun, Cleve-
land; " Influence of Climate Upon So-called Malarial Fe-
vers," Dr. Wm. Owens, Cincinnati; "The Cadaveric and
Vital Alkaloids," Prof C. C. Howard, Columbus; "Will

650

MISCELLANY.

[November 2, 1889.

General Sanitation Ever Become Popular?" Dr. John
McCurdy, Youngstown; "Address of Welcome," Hon. A.
D. Witt; " Response to the Address of Welcome;" Dr. R.
Har\-ey Reed, Mansfield; Poem, " Bacteria, or the Flies
we Feed on and the Bugs that Kill Us," Dr.W. S. Battles,
Shreve; President's address — i. "The use of Pork; its
relations to Scrofula and Consumption." 2. "Mosaic
prohibition of Pork, as taught by the Scriptures, and
the prejudices of most of the Ancient Nations to its use
as food." 3. " Description of Trichina-Spiralis and their
dangerous effect on the human body," Dr. D, H. Beck-
with, Cleveland; "Food as a Therapeutic Agent," Dr. H.
J. Herrick, Cleveland; "The Best Food for Man," Dr. J.
D. Buck, Cincinnati; "The Relation of Water Supplj- to
Disease," Dr. H.J.Sharp, London; "The Necessity' of
Uniform Rules, Regulations, Reports and Records of
Local Boards of Health." Dr. F. Gunsaullis, Columbus ;
■ The Sanitary Teachings of the Bible," Prof. E. T. Nel-
son, Delaware; "The Hygiene of the Chronic Insane,"
Dr. J. W. Scott, Cleveland; "Garbage and Night Soil
Crematories From a F'inancial and Practical Standpoint,"
Dr. Geo. I. Garrison, Wheeling, W. Va.

Arrangements have been made for reduced railroad
rates on the certificate plan, full particulars of which
may be learned on application to the Secretary' at Mans-
field, Ohio.

LETTERS RECEIVED.

Dr. R. C. Van Wyck, Hopewell Junction, N. Y.; Dr.
D. W. Jones, Portsmouth, N. II.; Gazette de Gyni'cologie,
Paris, France ; Medical and Surgical Sanitarium, Battle
Creek, Mich.; J. H. Chambers & Co., St. Louis, Mo.;
Dr. George S. Sabin, Black River, N. Y.; Dr. J. W.
Nelsou, Winnetka, 111.; Dr. Charles Smart, Washington;
Dr. John O. Robe, Rochester, N. Y.; Dr. Charles C.
Hunt, Dixon, 111.; Health Restorative Co., New York ;
The Maltine Manufacturing Co., New York ; Theodore
Metcalf&Co., Boston; Dr. P. B. Porter, Nev,- York;
George T. Nicholson, Topeka, Kan.; J. H. Bates, New
York ; Dr. A. L. Hummel, Philadelphia ; Dr. Dudley P.
Allen, Cleveland, O.; Geo. P. Rowell & Co., Phila-
delphia ; Dr. F. A. Weir, Jesup, la.; Dr. Wm. G. Gibson,
Saranac Lake, N. Y.; Dr. Thos. S. K. Morton, Phila-
delphia ; Philadelphia Polyclinic ; Dr. I. E. Atkinson,
Baltimore, Md.; Jefferson Medical College, Philadelphia;
Dr. F. B. Hemenway, Kalamazoo, Mich.; Dr. J. R.
Autrey, Columbus, Ark.; Frank Kiernan & Co., New
York ; Gladstone Lamp Co., New York ; Dr. Bransford
Lewis, St. Louis. Mo.; Dr. Leon Leibowitz, Vienna,
Austria; Ward Bros., Jacksonville, 111.; Dr. Henry O.
Marc}', Boston ; Dr. Henry D. Frv, Washington ; Dr. J.
W. Park, Berlin, Germany ; R.' A. Robinson & Co.,
Louisville, Ky.; Longmans, Green & Co., New York;
Dr. F. F. Loury, Chester, Pa.; Lea Bros. & Co., Phila-
delphia ; Publishers Commercial Union, Chicago ;
Provident Chemical Works, St. Louis, Mo.; S. R. Niles,
Boston ; Dr. T. J. Turpin, Tallulah, La.; Dr. C. B.
Powell, Albia, la.; Dr. W. H. De Long, Emporium, Pa.;
Oneita Springs Co., Utica, N. Y.; Dr. J. H. Lyon, Ros;
Ivn, Wash.; Dr. H.J. Smith, Blackshear, Ga.; Dr. Geo.
t. Welsh, Keyport, N. J.; Dr. W. N. Yates, Fayetteville-
Ark.; Reed & Carnrick, New York; Dr. W. F. Grin-
stead, London, Eng.; T. W. Haight, Waukesha, Wis.

Official List of Changes in the Stations and Duties of
Officers Serving in the Medical Department, U. S.
Army, from October ig, i88g, to October 2j, i88g.

So much of par. 2, S. O. 241, October 16, i8<S9, from this
office, as directs Capt. Louis Breclieniin, .\sst. Surgeon,
to report for duty at Ft. Apache, Ariz. Tcr., is revoked.
He will report in person to the counnanding officer, Pre-
sidio of San Francisco, Cal., for dutv at that station.
Par. 7, S. O. 24S, A. G. O., October 24, i.SSg.

Capt. Peter R. Egan, Asst. Surgeon U. S. Army, on being

relieved from duty at Camp Eagle Pass, Texas, will re-
port in person to the commanding officer. Ft. Mcintosh,
Tex., for duty at that station. Par. 7, S. O. 248, A. G.
O., October 24, 1889.

Capt. William J. Wakeman, Asst. Surgeon U. S. A., re-
lieved from duty at Ft. Walla Walla, W. T., and will
report in person to the commanding officer. Ft. Bid-
well, Cal., for duty at that station. Par. 7, S. O. 248, A.
G. 0., October 24. 1889.

Capt. William B. Davis, Asst. Surgeon U. S. A., relieved
from further duty at Ft. Porter, N. Y., and will report
in person, upon expiration of his present sick leave of
absence, to the commanding officer. Ft. Preble. Maine,
for duty. S. O. 248, A. G. O., October 24. 1SS9.

First Lieut. Paul Clendenin, Asst. Surgeon U. S. A., re-
lieved from duty at Ft. Mcintosh, Tex., and will report
in person to the commanding officer, Camp Eagle Pass,
Tex., for dutv at that station. Par. 7. S. O. 248, A. G.
O., October 24, 1889.

Capt. Alonzo R. Chapin, Asst. Surgeon U. S. A. , relieved
from duty at Newport Bks., K5'., and will report in
person to the commanding officer. Ft. Yates, Dak., for
duty at that station. Par. 7, S. O. 24S, A. G. O., Octo-
ber 24, 1S89.

First Lieut. Henry I. Raymond, Asst. Surgeon U. S. A..
upon being relieved from duty at Ft. Bidwell, Cal., will
report in person to the commanding officer, Newport
Bks., Ky., for duty at that station. Par. 7, S. O. 248,
A. G. O., October 24, 1889.

Capt. William C. Shannon, Asst. Surgeon U. S. A., re-
lieved from duty at Ft. Yates, Dak., and will report in
person to the commanding officer. Ft. Apache, Ariz.
Ter., for duty at that station. Par. 7, S. O. 248, A. G.
O., October 24, 1S89.

Asst. Surgeon Marcus E. Taylor, U. S. A., relieved from
dutv at Ft. Stanton, N. M., and ordered to Boise Bks.,
Idaho. Par. 10, S. O. 242, A. G. O., October 17, 1SS9.

Surgeon Joseph R. Gibson, U. S. A., relieved from duty
at Ft. Sheridan, 111., and ordered to Governor's Island,
New York Harbor. Par. 10, S. O. 242, A. G. C, Octo-
ber 17, 1SS9.

Asst. Surgeon Louis. M. Maus, U. S. A., relieved from
dutv at Ft. Porter, N. \'., and ordered to Ft. Stantou,
N. il. Par. 10, S. O. 242, A. G. O., October 17, 1SS9.

Asst. Surgeon Edwin F. Gardner, U. S. A., relieved from
dutv at Ft. Lewis, Col., and ordered to Ft. Porter. N.
Y. 'Par. 10, S. O. 242, A. G. O., October 17, 1889.

Surgeon Clarence Ewen, U. S. A., relieved from duty at
Madison Bks., N. Y., and ordered to Willet's Point, N.
Y. Par. 10, S. O. 242, A. G. O., October 17, 18S9.

Surgeon Alfred C. Girard, U. S. A., relieved from duty at
Boise Bks., Idaho, and ordered to Ft. Niagara, N. Y.
Par. 10, S. O. 242, A. G. O., October 17, 1SS9.

Asst. Surgeon John D. Hall, U. S. A., relieved from duty
at Ft. Niagara, N. Y. , and ordered to Madison Bks.;
N. Y. Par. 10, S. O. 242, A. G. O., October 17, 1S89.

Fir.st Lieut. William P. Kendall, Asst. Surgeon U. S. A.,
leave of absence extended one month. Par. 6, S. O.
244, A. G. O., October 19, 18S9.

Capt. Edgar A. Mearns, Asst. Surgeon U. S. A., granted
leave of absence for two months. Par 5 S. O. 244, A.
G. O., October 19, 1S89.

Official List of Changes of Stations and Duties of Medi-
cal Officers of the U. S. Marine-Hospital Seri'ice,
for the Tico Weeks Ending October ig, iSSg.

Surgeon John Vansant, granted leave of absence for fif-
teen days. October 16, 1889.

Surgeon C. B. Goldsborough, leave of absence extended
thirty days on surgeon's certificate of disability. Oc-
tober 18, iSSq.

Asst. Surgeon T. B. Perry, ordered to temporary duty at
San Francisco, Cal. October 15, 18S9.

Asst. Surgeon G. T. Vaughan, when relieved, to proceed
to Evansvillc, Ind., for temporary dutv. October 9.
1S89.

THE

Journal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.

PUBLISHED WEEKLY.

Vol. XIII.

CHICAGO, NOVEMBER 9> 1889.

No. 19.

ORIGINAL ARTICLES.

THE APPLICATION OF FORCEPS TO |

TRANSVERSE AND OBLIQUE POSI- j

TIONS OF THE HEAD. DESCRIP- j

TION OF A NEW FORCEPS. 1

Head in the Section of Obstetrics and Diseases of Women at the For-
tieth Annual Meeting of the American Medical Association,
June, 1SS9. ■

BY HENRY D. FRY, M.D.,

OF WASHINGTON". D. C.

The obstetric forceps is constantly undergoing ;
modifications of construction, and there is no part ,
of the original instrument that has not been, in
.some manner, altered to suit the ideas of the de-
signer. Blade, shank, lock and handle have been
changed in shape and size. Nevertheless, it may
be said, but two distinct alterations of the original
Chamberleu forceps have been made. They are
the pelvic curve of the blade, and the application
of axis traction.

Varied as are the designs, the method of em-
ploying the forceps is as little fixed as the instru-
ment itself. The application of the blades to the
sides of the pelvis, disregarding entirely the posi- j
tion of the head ; the application of the blades to
the sides of the head whenever practicable : inter-
mittent manual traction ; continuous mechanical
traction; the advisability or non-advisability of
compressing the fcetal head; the utility or inutility
of lever action, express some of the diverse opin-
ions held on the subject. This lack of uniformity
proves the non-existence of a scientific basis.
Labor is absolutely a physical act, accomplished
according to a well defined mechanism, therefore
the laws governing the application of artificial
aid should be precise and absolute. With the
earnest desire that progress may be made in this
direction, I present my communication to the
consideration of the members of the Obstetrical
and Gynaecological Section of the American Med-
ical Association.

The following propositions are advanced, and
suggest for discussion both the methods of em-
ploying the forceps, and the modification of its
construction.

/. The forceps should ahvaj's be applied to the
sides of the child' s head.

2. The obstetrician should not wed any single
for77t or design of instnunent, but he should be
equallv expert icith several, and employ one or an-
other accordi?ig to the ciratmstanccs of the case, al-
ways selectitig that instrume^it which best enables
him to apply the blades to the sides of the head.

First Proposition. The forceps should always be
applied to the sides of the child's head. This is
styled the French method, because it has been so
generall}' advocated bj- the obstetric authors of
France since the time of Baudelocque. Poullet,'
of Lj'ons, in a recent article on this subject states
that the doctrine, French in its conception, has
unfortunately remained exclusively French, in
the sense that it has never been, even partially,
adopted by the obstetricians of other nations. In
spite of the theoretical efforts of the French mas-
ters, the practice has diminished gradually in im-
portance and in frequenc}- of application. In
England, Austria and German}- the forceps are
alwaj's applied symmetrically — one blade to the
right, and the other to the left of the pelvis.
Poullet further states that even in France the cus-
tom is so changed that now the majority of phy-
sicians and many specialists operate in like man-
ner. When the head is at the superior strait, he
says no one counsels the oblique application of
the instrument — an impossibility with the curve
of Levret. Under these circumstances, all agree
that the head must be seized in whatever manner
possible. When, however, it is in the excavation,
the classic French authors at least in theorj- ad-
vise oblique application.

In reply to a letter asking for information as to
the method generally pursued by the Paris ac-
coucheurs. Dr. Paul Bar kindly writes me ; —
' ' When we have to apply the forceps to transverse
positions of the vertex, head in excavation or
above superior strait, we seek, not to grasp the
head from forehead to occiput, but we direct our
efforts to apply one blade anteriorly and the other
.posteriorly."

While it may be that in certain countries the
forceps are usually applied to the sides of the
mother's pelvis, Poullet undoubtedly errs when
he states that the opposite method "has never

been, even partiall}^, adopted by the obstetri-

1 ^

I I " NouveUes Archives d'obst^trique et de Gyndcologie.", Paris,
I 1887, pp. 44-62.

652

THE APPLICATION OF FORCEPS.

[November 9,

cians" of those countries. Smellie, one of the
earliest English workers in this field, paid strict
attention to the situation of the child's ears in
relation to the mother's pelvis, and invariably
sought to appb' the forceps to the sides of the
head. Numerous operators, in England and on
the Continent, follow the same practice.

In order to ascertain the opinion of the profes-
sion in this countrj', circular letters were ad-
dressed to all the teachers of obstetrics, and to
numerous practitioners located in every State of
the Union. Eighty-two replies were received and
the views expressed may be summarized as fol-
lows : Forty-two always apply the blades to the
sides of the head when possible. Thirty-one al-
ways apply the blades to the sides of the moth-
er's pelvis and disregard the position of the head.
Nine recognize no rule and applj- according to
either method.

\^arious exceptions to these methods were pre-
sented.

A number who advocate the first method ap-
plj- the forceps at the sides of the pelvis when the
head is high (transverse or oblique), and after
bringing down the presenting part, remove and
reapply the instrument to the biparietal diameter
of the head. Others, entertaining the same view,
attempt to rectifj- the position of the head, when
transverse, before applying the forceps. This is
done by external manipulation, b\- the hand in
the vagina, alone, or combined with external ma-
nipulation, and with the vectis or forceps.

On the other hand, some of those who follow
the principle to adapt the forceps to the sides of
the pelvis apply them, under some circumstances,
in high situations, to the sides of the head. Sev-
eral obstetricians employ, in these cases, special
forceps with long straight blades.

The advantages of applying the blades to the
sides of the head are well known and generallj-
admitted. Reasons exist, however, to prevent the
universal adoption of the custom. Its strongest
advocates admit it is often impossible to grasp
the head in such manner with the instruments
now in use. The difficulty arises with high sit-
uation of the part when occupying an oblique
position, and with transverse positions whether
at the brim or in the cavity.

On the other hand some, and among the num-
ber many distingui,shed obstetricians, believe it
unnecessary. They claim the application of the
instrument to the sides of the pelvis permits the
head to rotate within the blades and the normal
mechanism of labor is not embarrassed. These
operators, we must bear in mind, exercise intelli-
gent supervision, removing and reapplying the
instrument when necessary and encouraging the
progress of the head according to the natural
laws of labor.

By many practitioners the forceps is used with-
out any attempt being made to ascertain the posi-

tion of the head. It is easy to apply the blades

1 to the sides of the mother's pelvis and the head
can usually be delivered in that manner. No at-

1 tention is paid to the laws governing the passage
of the passenger, and brute force supplies the sci-

! entific employment of artificial aid.

Transverse positions of the head offer special
difficulties in the way of applying the blades to
its sides. The most aimed at is to locate the in-
strument in one or other oblique diameter of the
pelvis, seizing the head with a blade in front of
one ear, and the opposite behind the other ear.
The higher the head is situated the greater the
difficult}', and when engaged at the brim few at-
tempt to pass the blades in an}- manner except to
the sides of the mother's pelvis. Such a grasp,
besides being less secure, exerts injurious com-
pression upon the foetal head. If the forceps be
patterned after the Simpson model forward rota-
tion of the occiput may take place within the
blades, but if the instrument possess greater com-
pressive power, rotation is hindered and the head
is dragged into the pelvis transversely. If, under
the.se circumstances, the forceps be not removed
and rotation effected by nature, or artificially with
the hand, or with the instrument reapplied to the
sides of the head, one of the following results may
be anticipated ;

1 . Continued and forcible extractive eflbrts may
succeed in delivering the head, but it will be born
with its occipito-frontal diameter in the transverse
of the pelvic outlet, causing, as a rule, laceration
of the mother's soft parts, and injurious, if not
fatal, compression of the foetal head.

2. Forcible eff'orts to deliver the head fail, and
it becomes obligatory to attempt to push up the
presenting part, and if the position cannot be rec-
tified, to deliver bj' turning, or,

3. Failing to elevate the head, craniotomy- is
the only alternative.

An important consideration demanding notice,
is the comparative frequency of transverse posi-
tions of the head. Many obstetric writers claim
they are rare ; and some of the gentlemen
who replied to my circular letters expressed this
opinion. My limited experience is opposed to
such a view, but I should hesitate to give voice
to the contrary were my position not fortified by
good authority'. During the past six months I
have had occasion twice to apply the forceps to
the head while transver.se in the excavation.
Lusk' states that when the head is said to occupy
the oblique diameter it is not intended in a math-
ematical sense. It simply implies it is deflected
from the transverse. How easily can one fail to
recognize this deflection ? Let us remember that
the anatomical difference between an oblique and
transverse position is limited to a space upon the
side of the mother's pelvis scarcely more than one

- " Science and .\rt of Midwifery.
Co., iSS^. foot note p. i6ij.

New York: n .^pplcton &

1889.]

THE APPLICATION OF FORCEPS.

653

more frequent than right. Mme. Lachapelle'
claims that transverse positions are more often
met with than R. O. P. Charpentier" writes :
" One of the most frequent calls for interference
is absence of rotation, the head being often trans-
verse, but usually oblique, since these positions,

inch in extent. One who considers the position
rare, is misled by his conviction. Finding the
small fontanelle to the mother's right or left side,
and the sagittal suture passing across the pelvis,
he looks upon it as one of the oblique positions.
A more painstaking examination might reveal to

him the above suture passing directly parallel to ] as we have seen, are the fundamental, the others
the transverse diameter of the pelvis, and the fon- ■ being simply varieties or consequences." Baude-
tanelle situated at its extremity. A digital exam- ; locque, Moreau and Ramsbotham classify these
ination made while the woman occupies the left j positions. Although Playfair' follows the major-
lateral posture contributes to an erroneous conclu- : ity of British obstetric authors, bj- describing only
sion. Advantageous as this obstetric position i the four oblique positions of the head, he says :
may be for other purposes, it does not compare ' Until fairly passed the brim, it more frequently
with the dorsal when our object is to ascertain the : lies in the transverse than has generally been sup-
relative anatomical positions of the presenting | po.sed." PouUet,' in his article referred to, men-
parts of the fcetus and the mother's pelvis. Ab- ! tions the frequent occasions that arise at the
dominal palpation gives little aid in arriving at a Lyons clinique for using forceps in transverse
differential diagnosis between transverse and ob- 1 positions. He recognized the absence of flexion
lique positions of the head. ' in these cases and designed his angular forceps

In cases of pelvic deformity with contraction ; with parallel blades to rectify it. Spiegelberg"
of the conjugate of the brim, it is a well estab- 1 makes no distinction between transverse and ob-
lished rule that the head occupies the transverse lique positions. The first vertex position is de-
position. Doubtless, minor degrees of pelvic con- scribed as follows: "The back of the child
traction, and disproportionately large foetal heads, '■ looks to the mother's left, and the sagittal suture
exist as causal agents of these positions more runs in the transverse or oblique diameter. " His

often than suspected. The opposite conditions,
a roomy pelvis or small head, also tend to pro-
duce, and to maintain in the excavation, trans-
verse positions by failure to secure flexion.

In many unrecognized cases of transverse posi-

second vertex position is the reverse. He further
says : " Occasionally the head passes trans-
versely through the pelvic canal, and the sagittal
suture is at the outlet in the transverse diameter.
"Deep transverse position of the head. The de-

tion, rotation relieves the difficulty and labor ends i layed rotation around the long foetal a.xis is due to
normall}'. In others, nature fails to correct the \ an absence of resistance to the progress of the foe-
position and artificial aid is demanded, conse- 1 tus. If the cause lies in the smallness of the head,
quently the comparative frequency of transverse | or in the width of the whole pelvis being occasion-
to oblique positions is greater in forceps cases ally above the normal, the head may also emerge
than in those which terminate without such a.s- in the same diameter." Again he adds: "Since

the accomplishment of rotation sometimes occupies

sistance. Failure to rotate will delay labor in-
definitely. Binault' extracted with forceps a fce-
tus which was in an advanced state of putrefaction.
The mother had been in labor fourteen da}'S, and
the head of the child occupied the left occipito-
iliac transverse. Four children had previously
been born to her with easy labors, .so that failure
to rotate from a transverse position was the sole
cause of delay in this case.

Charpentier and Cazeau describe these positions
fully, and give explicit directions for the applica-
tion of the forceps. Cazeau,' speaking of the
comparative frequency of different occipital posi-
tions, says that in the results given, " no question
seems to be made of the varieties we have desig-
nated as the transverse ones, and it is highly
probable that they have been approximately
added to one of the four preceding groups, _/<?/•
these positions are not very nnusnal; indeed, I have
often met zoith them myself at the (Unique.''
Transverse positions, he adds, are more common
than R. O. A., and left occipito iliac transverse is

3 " Bun. MM. du Nord," Lille, iS86. 8, vii-ix. 213-220.
*" Theory and Practice of Obstetrics," seventh .\mer. edit. P
Blakiston, Son & Co.

a considerable length of time, the deep transverse
[ position may cause a delay which is not without
danger and may require artificial interference.
Moreover the skull in the deep position is effected
by a marked biparietal obliquity, the anterior pari-
etal bone presents, its eminence appears beneath
the pelvic arch, the great and small fontanelles lie
far back, and are directed straight to the sides."

Without pursuing this line of investigation fur-
ther I hope sufficient authority has been presented
to support the statement advanced, that transverse
positions of the head at the brim and in the ex-
cavation are not infrequent. When they persist,
artificial aid is called for : moreover the applica-
tion of forceps to the biparietal diameter when so
situated is particularly difficult and more often
impossible.

The difi5culty is due to lack of a proper instru-

5 Ibid. Phila., 1SS4. p. 314.
*" Practical Treatise on Obstetrics,'
York. 1882, Vol. iv. p. 91.

7 '• Science and Practice of Midwiferj-,
Lea. Philadelphia, 1S80, p. 262.

8 Ibid.

5 "Text Book of Midwifery." Otto Spiegelberg, London, New
Lyderhara, Society Trans. 1887, Vol. i, p. 210.

Wni. Wood & Co., New
: third .\nier. edit. W. C.

654

THE APPLICATION OF FORCEPS.

[XOVE-MBER o,

ment. Forceps with the usual pelvic cur\'e is
valueless. Only when this instrument is applied
one blade to each side of the mother's pelvis,
and the concave edge directed forwards, is it
placed so that the pelvic curve conforms to the
axis of the pelvic canal. With the forceps in-
serted in such manner, however, it is impossible
to grasp the head in the biparietal diameter when
situated either transversely or obliquely. In pro-
portion as the instrument is turned to one side or
the other for the purpose of grasping the sides of
the head, the pelvic curve of the blades departs
from the line of the pelvic axis and the tip of
the anterior blade is projected backwards. Not
onlv is the pelvic curve of the classic forceps of
no value in these cases, but it complicates its in-
troduction. It becomes necessary at one time to
apply the male blade anteriorly, and at another
the female. ' On this account some obstetricians
employ, for high transverse positions of the head,
long forceps with straight blades.

.\iitero-posterior Forceps.
(Krout view.)

.-Vntcro-posterior I'orceps
(Side view.^

or transversely. The curve adopted is the result
of experimentation upon fresh foetal heads and
articulated female pelves, and corresponds closelj-
to the pelvic curve on the edge of the classic for-
ceps. The instrument is furnished with a com-
pressive screw for use with the axis-traction at-
tachment, which consists of a steel rod having a
handle at one extremity and a hook at the other.
The hook fits closely into the fenestrum on the
anterior blade and cannot injure the soft parts of
the mother. The compressive power of the for-
ceps is about equal to the Hodge, Wallace, and
such instruments that are intended for application
to the sides of the head.

B3' seizing the head in its biparietal diameter
with the long axis of the blades, parallel to the
occipito-mental diameter, we are better able to
control flexion and rotation of the head and to
deliver by imitating the normal movements of
labor. There is also less danger of injuring the
child. Lusk'" states that forceps at the brim is
dangerous to the child, "from the rarity of the
occasions which permit the blades to be applied
to the sides of the head, to which the cephalic
curve is alone adapted." This danger is again
referred to by Lusk when discussing the paper
on " Injur\- of the Foetus During Labor," " read
by Dr. Par\'in before the Philadelphia County
Medical Society. He points out the danger of
destroying the respiratory sense by injur}' to the
medulla when the head is compressed for some
time with the blades applied from occiput to
forehead. At the same meeting Dr. Goodell di-
rected attention to the risk of destroj-ing the
child by pressing the cord between the blade of
the forceps and the occipital bone. This accident
he was sure had occurred at his hands, and he
attributed it, as well as cases of facial paralysis
he had repeatedly- seen, to the blades of the for-
ceps not being applied exactly to the sides of the
head. Dr. Parrish has also reported'^ .several cases
of still birth evidently due to compression of the
cord when coiled around the neck. "Onl}'," he
says, "when the instrument is applied to the
sides of the head, with the long axis of the blades
parallel to the occipito-mental diameter, is the
cord safe. ' '

Objection may be made, on theoretical grounds,
to the application of forceps with antero -posterior
blades to the head when engaged transversely in
the contracted brim, for the reason that the in-
strument encroaches upon the narrow diameter.

To overcome these disadvantages I have de-
.signed a forceps curved on the flat. The intro-
duction is simplified because the same blade is
always the anterior and the opposite the posterior.
The pelvic curve being upon the flat surface, the
head can be .seized in its biparietal diameter,
whether high or low, or whether placed obliquely

'J " Science and .\rt of Midwifery.
18S4 : pp. .mS.

.■Vppleton S: Co.. New York.

New York Medical Journal." Vol. xlvi, Nos. 22 and 23, pp.
606 — 634. In tilis article Pr. Par\*in stated that contused wounds
usually followed difficult delivery with forceps, and resulted if the
blades were applied obliquely or autero-posteriorly to the head.
In reply to my circular letters, one operator stated that he had de-
strovecf the sii;ht of an eye by oblitiue application of the blades to
the Iiead when higfh.

'-■ -'Jotirnal ot the .\tnerican Medical .\ssociation," Vol. xii, Xo.
iS, p. 641.

M " Antero-Poslerior Ct>nipression I-'oiX'eps for .\pp1icfltion at
the Drini of I'lat Pelves " ' British Medical Journal." l"eb. 2. 1SS9.

p. .'2u.

1889.]

THE APPLICATION OF FORCEPS.

655

On the contrary, this is an advantage, as the
abilit}^ to compress the biparietal or bitemporal
diameter of the head more than compensates for
the space occupied by the blades. This view has
happily been confirmed by Dr. Sloan, of Glasgow,
in a recent communication'' to the British Medical
Association. The antero-posterior forceps with
which he experimented is a powerful compressor,
the greatest distance between the blades when
closed being 1I2 inches. The instrument was
designed for application at the brim of flat pelves,
and "is never to be used until craniotomy is the
only resource left." Trials were made with fresh
fcetal heads and dried pelves, and the action of
the forceps compared favorably with that of
Simpson's.

Dr. Sloan had five opportunities to test the in-
strument in cases of obstructed labor, and the re-
sults were as follows :

Cases I and 2 were unsuccessful and had to be
terminated by craniotomy.

Case J. — Flat pelvis. Simpson's forceps failed:
Sloan's antero-posterior forceps applied. Head
brought down in fifteen minutes and delivered
with straight forceps. Child made feeble efforts
to breathe and died.

Cast' 4.. — Flat pelvis, with true conjugate about
3I2 inches ; Simpson's forceps failed; Sloan's ap-
plied and child readily delivered alive.

Case y. — Flat pelvis, true conjugate 2^/4 inches;
child dead. Simpson's forceps failed ; vSloan's
completed labor promptly.

The instrument designed by Dr. Sloan is in-
tended only to compress and bring the head
through the contracted brim. To complete labor
it is necessary' to remove the anterior blade and
apply another instrument, or deliver with the
posterior blade, combined with supra-pubic pres-
sure.

The use of the instrument which I offer is not
restricted to labor in flat pelves, but to all cases
in which, from failure to rotate, the head is sit-
uated transversel)' or obliquely. If necessary, it
can be u.sed to compress as well as to make trac-
tion or rotate, and delivery can be completed
without changing to a different forceps. I have
had but one occasion to test the instrument in
obstructed labor, and it left nothing to be desired.
The woman, a primapara, set. 15 years, had been
in labor thirt\'- three hours when I saw her. The
waters had been evacuated twenty- eight hours,
the OS dilated and retracted, the head was en-
gaged at the pelvic inlet in the transverse diame-
ter, with occiput to right, the promontory of the
sacrum projecting well forwards. The blades
were easily applied to the biparietal diameter
and the head brought down, rotated and deliv- 1
ered. Moulding and elongation of the head had
so diminished the biparietal diameter that very
slight compression brought the handles in con-
tact. The woman recovered and was able to be ;

up on the tenth day." The child, which was at
term and weighed 6'j pounds, was born dead.
The conjugate diameter measured 234 inches.
This case offered a severe test of the value of the
forceps in labor obstructed by diminished con-
jugate, as the deformity was to the limit at which
it is possible to deliver a fully developed child
without mutilation. Turning was out of the
question, Csesarean section not justified, and
craniotomy the only resort, if forceps failed. The
use of the traction rod is designed for application
when the head is high. As soon as the part is
brought through the inlet the rod can be removed
and traction made with the handles. Besides
simplicity, it offers these advantages over other
axis-traction attachments :

Traction made with the rod approximates the
blades and increases the security of the grasp of
the instrument.

The amount of compression exerted is, to some
extent, in proportion to the force required to de-
liver the head.

c d, Axis of inlet ; a b, line of traction, parallel to axis of inlet ;
c f, line of traction with blades inserted at sides of pelvis.

The greatest advantage, however, is that the
direction of traction can be made more completely
in the line of the axis of the brim. With the
Tarnier principle it is absolutely necessary to
apply the blades laterally ; consequently traction
is made from the sides of the pelvis. With the
antero-posterior forceps the line of traction is
downwards and backwards from behind and above
the sj'mphysis.

At the time I designed this forceps I thought
the idea original, but investigation proved it not

656

THE APPLICATION OF FORCEPS.

[November 9,

so. Baumers,'* of Lyons, published in 1849 an
article describing a pair of forceps with antero-
posterior blades constructed on the same princi-
ple. The representations of this forceps depict a
verj' crude instrument having an exaggerated
pelvic cur\'e. No effort seems to have been made
to modify its construction, although Cazean found
it useful in transverse positions of the head. In
such cases, he said,'° he was " convinced that the
biparietal application of the blades, which is im-
possible with the ordinary forceps, is sometimes
easy with that of M, Baumers," and he "thought
it right to recommend their application,"

Antero-posterior Forceps of Baumers (after Charpeiitier).

In conclusion I desire briefly to consider the
second proposition advanced :

The obstetrician s/iould not iced any single form
or design of instrument, but he should be equally
expert with several, and ctnploy one or another,
according to the circumstances of the case, always
selectiyig that instrument 7i'hich best enables him to
apply the blades to the sides of the head.

In direct opposition to this is the statement of
some obstetric writers that one form of instrument
should be made to answer for all cases. For in-
stance Playfair'* says : "It is a decided advantage
for the practitioner to habituate himself to the
use of one instrument, with the application and

u " Gaz. Med. de Paris," 1S49, 3 s. iv, pp. 538 — 558.

Antero-posterior forceps were also clesigiied by Uytterhoven
in 1805. In the discussion of Dr. Sloan's paper Dr. W. I,. Reid. of
Glasgow, exhibited a pair of antero-postenor forceps which he
slated he had used with satisfactory results for seven or eight years.

'5 " System of Midwifery." 3d Am. edit., H. C. Lea, Philadelphia,
liySo, p. 468.

■<• Ibid.

power of which he becomes thoroughly familiar.
It is a mere waste of space and monej- for him to
incumber himself with a number of instruments
of various shapes and sizes, and he may be .sure
that a good pair of long forceps, such as Simp-
son's, will be suitable for every emergency, and
in any position of the head (italics mj' own).
Simpson" and Leishman'' give similar advice.

In order to obtain an expression of opinion on
the subject from the profession in this country',
the following question was embodied in the cir-
cular letter sent out :

"Do you habitually employ one variety or
make of forceps, or do you make use of several
varieties?" The replies were divided in this
manner : Thirtj- employed but one variety of for-
ceps, fifty-three used different varieties, and thirtj-
of the latter recognized the value of axis traction
in high operations, and eleven used the short for-
ceps in low operations.

Of the class that use one instrument for all
cases the Hodge is the favorite ; next in order
come the Simpson and Elliot

Of the fifty-three who use different styles ot
long double curved forceps the Hodge is still the
favorite, the Elliott next, and then the Simpson.

Of the thirty who favor axis traction for high
operations this peculiarity is noted : Only two
use the Hodge for ordinary cases, while the
Simpson and Elliott are verj^ popular.

With the desire to formulate special indications
for the use of different forceps, the question was
asked those who used a variety of stj-les, under
what conditions they employed one or another
instrument. Some were guided by no rule, and
replied: "If one won't answer, try another;"
" use the one that seems to be best suited for the
case;" "often change from one kind to another;"
and one gentleman uses them "just as he picks
them up in his office or residence."

The indications for axis traction and short for-
ceps are fully recognized by those who employ
the classic double curved forceps for ordinary
cases. The selection of the variety of the latter
instrument is guided chiefly^ by its compressive
power. Those who advocate the application of
the blades to the sides of the head select usually
the Hodge, Wallace or Davis. The followers of
the opposite method employ the Simpson or
Elliott. Other indications noted were the use of
Taylor's narrow-bladed forceps in the class of
cases for which it is designed ; straight forceps
for rotation of low posterior positions, and forceps
with long, straight, or nearly straight, blades for
application to the sides of the head when high
and transverse. By one correspondent the short
forceps is employed when the head is at the out-
let, to regulate its movements and save the peri-

■: obstetrical Works, Vol. — . p. 443.
18 " System of Midwifery." 2d Am.
phia, 1875 ; p. 499.

edit. H. C. I,ea. Philadel-

1889.]

OPERATION FOR STONE IN THE BLADDER.

657

Ileum. Two distinguished operators state they
always apply the blades to the biparietal diame-
ter, when possible, and they use the Davis for-
ceps. When, from any cause, the blades cannot
be adjusted to the sides of the head, they are ap-
plied at the sides of the pelvis ; but under these
circumstances both of the gentlemen wisely dis-
card the Davis forceps ; one substitutes the Simp-
son, and the other the Simpson or Tarnier.
There were numerous exceptions to the above
rules ; for instance, one gentleman, emphatic in
his expression of the value of applying the blades
to the sides of the pelvis, uses a strong French
forceps, the tips of which meet, and the greatest
distance between the blades is 2J4 inches.

The comparative compressive power of different
styles of forceps is recognized by a number of
operators, who emploj' one or another under con-
ditions which do or do not require that action.
One correspondent states that in ordinary cases,
as uterine inertia, he uses the Simpson forceps ;
in pelvic or cranial disproportion, when some
compression is necessary, the Elliot ; in greater
narrowing, but above the limit where craniotomy
is to be considered, the Hodge or Wallace.

Another employs the Simpson forceps in first
and second positions of the vertex, the Tarnier
in third and fourth, and the short forceps when
the head is low.

According to the views here expressed, the
only conditions generally recognized for selecting
the different varieties of forceps are :

ist. The high or low situation of the head, and

2d. The compressive power of the instrument.

Accepting the opinion of the majority of replies
to the circular letters regarding the advi.sability
of applj'ing the blades to the sides of the head
when possible, and recognizing the difficulties in
the way of accomplishing it in many cases, a
third indication advanced is the oblique and
transverse positions of the head, for which, and
to overcome the difficulties mentioned, I submit
the antero-posterior forceps curved on the flat.

In reply to objections made on the ground that
this would unnecessarily complicate the arma-
mentarium of the obstetric operator, I would ask
to consider one moment whether it is unneces-
.sary.

Does not the dentist possess a number of for-
ceps, curved on the flat and edge, and in all con-
ceivable angles, and does he not select that in-
strument which best enables him to seize and
extract the tooth ? He is guided in the selection
of the forceps by the position of the tooth, and
chooses the instrument that is curved in proper
manner to grasp it most securely. Is the respon-
sibility of the obstetrician less than that of the
dentist ? Is it not incumbent upon him to ascer-
tain positively, in everj' ca.se requiring artificial
delivery with forceps, the position of the head
and to adjust the forceps in such manner that he

can extract it according to the natural mechanism
of labor.

With the aid of anaesthesia and the whole
hand, if necessary, introduced within the vagina,
no excuse exists for failure to clear up any doubt
regarding the position.

Let me repeat what is stated in the beginning
of this communication : "Labor is absolutely a
physical act, accomplished according to a well
defined mechanism ; therefore, the laws governing
the application of artificial aid should be precise
and absolute." Only until these laws are estab-
lished and followed will there exist a uniformitj-
of practice in the use of the forceps.

The advice of eminent obstetricians that one
pair of forceps should be made to answer for all
operations has had, and still has, its evil influ-
ence. In no other operation, and in no other
special work, is the operator hampered by such
advice.

The surgeon has forceps, scissors, knives and
needles curved at different angles on both the flat
and edge, and he uses them to the best advan-
tage. Wh}' not tell him to discard all these, as
they unnecessarily complicate his armamentarium?
Tell him that one of each, with a proper curve,
will answer for all of his operations, and he
should learn to employ it onlJ^ I claim it equal-
ly unscientific to bind the obstetrician to a single
pair of forceps, with which he must accustom
himself to do all this class of work ; and I repeat,
"he should be equally expert with several, and
employ one or another, according to the circum-
stances of the case, alvvaj-s selecting that instru-
ment which best enables him to apply the blades
to the sides of the head."

THE CHOICE OF OPERATION FOR STONE
IN THE BLADDER.

Read in the Section of Surgery and Anatomy, at the Fortieth Annual
Meeting of the American Medical Association, June, iSSg.

BY A. T. CABOT, A.M., M.D.,

OF BOSTON. M.4SS.

In order to make the drift of this paper at once
clear, I wish to state at the outset the conclusions
I have reached by a stud)' of the results of others
in stone operations, and from the moderate expe-
rience I have had in these cases myself. Unfor-
tunately, residence in a region where stone in the
bladder is rather rare has made the accumulation
of personal observations slow, but, on the other
hand, my association with Dr. Bigelow has given
me unusual advantages in getting an understand-
ing of the operation which he devised and chris-
tened " litholapaxy," and of which I shall espe-
cially speak to-day.

In my opinion, we have in litholapaxy the op-
eration of choice for the removal of most stones.
While this is the rule, there are exceptions to it,

658

OPERATION FOR STONE IN THE BLADDER.

[November 9,

and the var3'ing conditions surrounding stone in
the bladder, will now and then lead us to choose
some other operation for their safest removal.
The surgeon who best appreciates these varying
conditions, and selects in each case the operation
which most surely avoids the dangers surround-
ing it, will arrive at better results than any advo-
cate of a special operation, however expert.

I realize that some objections have been urged
against litholapaxy, and that superior advantages
have been claimed for other methods of stone re-
moval. I shall tr)- to fairly consider these objec-
tions, and tojustly appreciate the strong points
of other operations. Before entering seriously
upon our subject, I wish to note one of these ob-
jections which seems to me to merit no extended
consideration, but which has received a certain
amount of weight from the unsupported assertions
of some of the German surgeons. It has been
urged b)' them that litholapax}' requires a special
skill for its performance, and should not, there-
fore, be commonly employed. Certainly, none
but qualified surgeons should undertake any op-
eration for stone in the bladder, and it seems to
me that the question to be discussed is, not which
operation is safest in the hands of a tyro, but
rather this : By what use of the different meth-
ods of stone removal can a competent surgeon
accomplish the best results ? In modern surgery
the test of merit is looked for in results. No
operation, however brilliant, can claim superiority
over rival methods if its death-rate is much higher
than theirs. The best operation is the one that
.saves the most patients, unless some serious inter-
ference with bodily function more than counter-
balances the gain in safety.

Let us examine the results of the various oper-
ations for stone, in respect to their rates of mor-
tality, their interference with bodily function, and
the completeness of cure which follows them.
We have, in general, three methods of operation
to choose among, namely : perineal lithotomy,
suprapubic lithotomy, and litholapaxy. Perineal
lithotomy may be again subdivided into median
and lateral lithotomj-. We have here several
wholly different rriethods, each of which has cer-
tain advantages over the others and each of which,
on the other hand, has its own difficulties and
dangers, to be recognized and avoided. The
cases for which these operations are to be consid-
ered and selected, also differ vastly in their con-
ditions and complicating surroundings, .so that
it may well be seen that each case should be stud-
ied for itself, and the operation cho.sen which best
meets the difficulties and avoids the dangers pres-
ent in that particular instance.

First, looking at the rates of mortality obtained
by these operations, we find at once that we can-
not properly compare the results in patients of
very different ages. The mortality in children
and young adults, after any operation upon the

bladder, is distinctly less than it is in advanced
age, and, as we shall see later, there are at differ-
ent ages changes in the organs concerned which
make marked differences in the manner in which
the various operative measures are borne. For
the sake of convenience in this study, cases maj'
be grouped in three categories :

Children, from birth to 14 years of age.

Adults, from 14 to 50.

Old men, from 50 upwards.

This division of the cases is somewhat arbitrary,
but the ages of 14 and 50 are selected as marking,
more or less accurately, certain epochs in the de-
velopment and decay of the genito-urinary organs.
At about 14 we look for the changes in the size
and sensibility of these organs which accompany
the arrival at pubertj' ; and at 50, senile changes
in the prostate and bladder begin to make their
appearance, which often interfere seriously with
the health}' performance of the functions of those
parts. In the collection of statistics those tables
have been used in which operators have published
all of their results, and reports of single cases are
not included. This is done to avoid the danger
of forming tables of exceptional results; for single
cases are more likely to be reported when success-
ful than when the}' resulted unfavorabh'. Fur-
ther, owing to the recent improvements in tech-
nique and to the influence which the general
adoption of antiseptic measures has had upon
surgical diseases, it is evident that the statistics
of old times cannot be accepted in settling the
present status of these operations; and, therefore,
only cases occurring since modern methods came
into vogue have been used in this studv.

Sl'PRA-PVBIC LITHOTOMY.

Operator or Re-

Children.

Adults.

Old Men.

(m

,

u..

. 1

**• .

.

porter.

u

a 4*

•a

V

■}(

s-g

■B

^¥

?.^

•a

Offl

S-

Q

^S

11

Q

s«

^5

r^

«

Sr.

4

4

Werewkin

24

17

Asseudelft

78

76

2

24

Cabot

I

.

Tremaine

I

I

J

1

I

Thompson ....

6

,s

I

Guyoii

a

s

^

Mikulicz

1

2

I

Walker

I

^

Garcia

4^

•!7

6

Recent foreign . .

.■iS

42

i.^

Recent British . .

33

33

-

^

~9

II

■

Total

240| 211

»9

12%

»7

27

s

4».i?£

Garcia, from a collection of 106 cases of all
ages, calculates a death-rate of 24.4 per cent.
Tuffier, from 120 cases without regard to age, has
a death-rate of 27 per cent. Dulles, among 231
adults, finds a mortality of 32.4 per cent., while
among 132 children there was a death-rate of 21
per cent.

1889.]

OPERATION FOR STONE IN THE BLADDER.

659

LITHOLAPAXY

Operator or Re-
porter.

Children.

Adults.

.1

Freyer. . . .
Keegan . . .

VanderVeer -
Kerr

Cabot"

Mass. Gen'l Hosp.

• v- ■J

^ o-f.\>

.1 .

4 3-5%] 149

Old Men.

S = o

69

5.3%1 1S8

68, I

8,3
7

31
57,_9

173 15

^"3

8%

' One from bronchitis and pneumonia.

Guyon had a mortality of 5.2 per cent, in 647
cases of all ages. Usigli calculates a mortality
of 4 per cent., while Tuffier places it at only 3
per cent.

PER1XE.\L LITHOTOMY.

Children. Adults.

Old Men.

■ 11 . l_ .

porter. ^_ V

oitk- °s

?,-?.

■?,

°s

gti

•c

0^

15 «

SS0JS5 |5

S"

«

Sla

X"

5

Srt

Freyer

14,^

143 . . .

Werewkin- ....

147

138 9 • •

Cabot

3 . , • •

. .|. .

I

I

Mass. Gen'l Hosp.

16

l6i- !• .

2 2

I

I

Carrow

46

44

2I. .

76 71

5

14

.3 .'. . ■

Rivington

. .

1 .

I

I . .

I

3

3.|. . .

Total

355

344' 1 1

3,i,%

79 73

1

6!7.6%

>9

16 3|>5-7%

' S^ven fistulie.

Freyer gives the following rates of mortality
after lateral lithotom3\ arranged according to age.
Thej' are calculated from 98 7 cases occurring dur-
ing the year 1883 in the Northwest provinces of
India :

Rate of mortality up to 20 years 5.1 percent.

" " " from 20 to 40 " 10.7 "

" " " above 40 " ... 31. 9 " "

Rosenthal, from a collection of 400 cases, de-
duces the following rates .

Mortality, from i to 5 years 3.5 per cent.

" 6toli' " 2.1 "

" " 12 to 16 " 8.4 " "

" 171029 " 15.7 " "

" " .^otoee " 38.8 "

These statistics probably give a more accurate
rate of mortality for old men than in my table, in
which so few cases occur at that time of life.

From these statistics we see that in childhood,
judging from the results as to mortality, there is
little to choose between lateral lithotomy and
litholapaxy. The death-rate in each is but little
over 3 per cent. Suprapubic lithotomy is more
dangerous, with a death-rate of about 10 per cent.
In adult life, the death-rates alter somewhat in
favor of litholapaxy. As the prostate and ure-
thra enlarge, and the parts about the neck of the
bladder become more vascular, the dangers inci-
dent to cutting through them increase. On the

other hand, the increase in the size of the parts
makes the performance of litholapaxj- compara-
tively easy and safe. Suprapubic lithotomy keeps
its place as a more dangerous operation than
either. In old age the rates of mortality are over-
whelmingh' in favor of litholapaxy. While the
dangers attending all the cutting operations have
increased very greatly, the mortality after crush-
ing is very little higher than it was earlier in life.

INTERFERENCE WITH THE FUNCTION OF THE
PARTS.

It is somewhat exceptional to see a serious loss
of function follow any of the operations for the
removal of stone. A litholapaxy, carefully per-
formed, should never cause any lasting injury- of
the genito-urinar>- organs. The suprapubic inci-
sion rarely causes any after-trouble, although oc-
casionally a fistulous opening remains which can-
not be closed, and is therefore a constant source
of discomfort to the patient. The perineal oper-
ations, entering as they do through the neck of
the bladder, are much more likely to cause serious
trouble. The position of the seminal ducts in the
lower part of the prostate, makes their injury by
an incision in the floor of the prostatic urethra
quite probable. The median operations ma)-
sometimes avoid this when the stone is small
enough to be removed by stretching the neck of
the bladder, but even then lacerations are likely
to occur. The lateral incision has the advantage
that, while giving more room, it endangers only
one of the ducts. The erectile tissue, known as
the caput gallinaginis, is also liable to injury, and
this may cause sterility. Incontinence is an oc-
casional result of the perineal incisions, owing to
their interference with both of the sphincters of
the bladder; and fistulfe, though rare, do some-
times occur, and may be very persistent and trou-
blesome. Injuries of the rectum during lateral
lithotomy are unnecessary and accidental ; thej-
still happen often enough in the hands of expert
operators, to make it worth while to take the
chance of this into account in deciding upon an
operation.

COMPLETENESS OF CURE.

It is a not uncommon experience to see a sec-
ond or a third attack of stone in the same patient.
In order to understand how far this reappearance
of a calculus is dependent upon the operation b)-
which its predecessor was removed, let us con-
sider the ways in which a recurrence of stone
may come about.

I. A uric acid stone may be followed by an-
other, on account of the persistence or reappear-
ance of the uric acid diathesis. The same may
be true, though less commonly, in the case of an
oxalic stone, and may even occur with a phos-
phatic stone due to phospaturia of constitutional
origin.
I 2. The successive escape of several stones from

66o

OPERATION FOR STONK IN THE BI^ADDER. [November 9,

the kidneys maj* give rise to several consecutive
attacks of stone in the bladder. These stones
raa5' be uric, oxalic or phosphatic.

3. A soft, phosphatic stone may be reproduced
after removal, if the chronic cystitis and alkaline
condition of the urine, which led to its original
formation, persists. This is not uncommonly
.seen in those cases where an obstruction to the
complete emptying of the bladder perpetuates
the fermentation of the urine.

4. Lastly, if a fragment is left after an opera-
tion, it may serve as a nucleus for another stone.
The danger of this mischance is greatly increased
by an}- obstruction to the flow of urine, such as is
caused by an enlarged prostate. The bladder, in
such a case, is often .'-acculated, so that fragments
are more likely to escape removal b}' the evacuator
after litholapaxj-, or b}- the lithotomy scoop and
forceps after lithotomy ; and if such a fragment
be left, it is very unlikely to be voided by the
natural efforts of the bladder, but remains in the
residual urine. A healthy bladder that complete-
ly expels the urine at each act of micturition
usuall}' frees itself of such small fragments.

It is plain that recurrences due to the patient's
diathesis, in which a new stone forms years after
the removal of a former one, cannot be laid at the
door of the operation, being as likely to follow
one method of removal as another. And the
same is true when successive escapes of renal cal-
culi from the kidneys give rise to recurrent attacks
of stone. Among mj- cases, 47 in number, I have
seen three instances of the recurrence of uric acid
stone due to the patient's diathesis, and have had
one case in which calculi of renal origin gave rise
to successive attacks of stone in the bladder.

Next, we have the cases in which a recurrence
is due to a persistent cystitis with consequent de-
position of phosphatic material. I have seen
four instances of this sort, all of them occurring
in patients with greatly enlarged prostates, and
in all of which I was able to satisfy myself con-
clusively that the recurrence was not due to the
retention of fragments. In such cases, the later
attacks of stone cannot be ascribed to incomplete-
ness in the operation, but rather to neglect in the
after-treatment.

It is obvious that to prevent this sort of
recurrence, it is important to entirely relieve the
cystitis before allowing the patient to pass from
observation, and then to .send him away with
a clear understanding of the importance of
immediately correcting any tendency to alkalinity
of the urine or to pus formation. When an ob-
structed urethra is the cause of the cystitis, the
obstruction should be relieved if possible. In
case of an enlarged prostate, the evils of retained
urine must be lessened as far as possible by sys-
tematic catlieterization. The moment that any
considerable amount of mucus or other evidence
of commencing fermentation appears in the urine

of one of these patients, thorough irrigation of
the bladder must be instituted and kept up until
the normal condition is again reached. If milder
measures fail to keep the urine in a fairly good
condition, or if the catheter causes pain and has
to be used ver3' frequentlj', a prostatotomy may be
called for to correct the obstructing condition. It
may sometimes seem well in these cases, if the
stone is a small one, to remove it by a perineal
incision, for the sake of the opportunity to at the
same time operate on the prostate and to drain
the bladder. Dr. J. P. Br>'son, of St. Louis, has
called attention to this occasional advantage of a
perineal operation for stone. A surgeon selecting
such an operation .should, however, bear in mind
that the perineal operation is about three times
more dangerous to life than litholapaxy, and
should balance the hoped-for advantage against
this certain risk. In one such case, the writer
did a combined litholapaxy and prostatotomy ;
first crushing and pumping out the stone, and
then, through a median incision, dividing the
middle lobe of the prostate. The operation was no
more severe than a simple prostatotomj^ and the
power of urination, which had been absolutely
lost, was restored to a very considerable extent.

Finally, a stone which has for its nucleus a
fragment of an earlier stone is obviously the re-
sult of an incomplete operation, and it has been
urged against litholapaxj' that such recurrences
are especially liable to take place after it.

In the early daj's of this operation such instances
of incomplete evacuation were more common than
now, and were due to a want of thoroughness in
the surgeons rather than to a necessary lack of
completeness in the operation itself. To guard
against such retention of fragments, many opera-
tors now make it a rule to alwaj's wash the blad-
der once or twice with the evacuator some days
after the operation, before the patient is dis-
charged. These washings cause but little dis-
comfort, and may usuall}' be done without anaes-
thesia. These washings, if successful in obtaining
debris, should be continued at intervals of a few
days until fragments are no longer obtained, and
in cases of cystitis, where the tendency to the de-
position of phosphates is verj^ great, it is a good
plan to give an occasional wash with the evacua-
tor up to the time that the urine becomes clear
and loses its alkalinity. In using the pump at
the time of operation, and in these subsequent
washings, the sacculated character of many of
the.se bladders should be borne in mind, and a
careful search should be made for fragments which
maj' be caught in pockets. The orifice of the
evacuating tube should be turned successively
toward each part of the cavity, to dislodge with
the current all such fragments, and, lastly, the
pouch which so often exists behind the prostate
should be searched in this way. For these ma-
noeuvres a straight tube is especially adapted and

1889.]

OPERATION FOR STONE IN THE BLADDER.

661

should, when possible, be used. With a careful
observance of these precautions, I confidently be-
lieve that a retention of fragments after lithola-
paxy need be of no more frequent occurrence than
after lithotomj'. Indeed, it has happened that
fragments left b)- lithotomj- have been subse-
quently removed by the litholapaxy pump.

SELECTION OF OPERATION.

/;/ Childhood. — As the statistics show, the mor-
tality after any operation for stone in children is
small. Lateral lithotomy and litholapaxy are
very nearly equal in this regard, and both are de-
cidedly safer than suprapubic lithotomy. The
crushing operation has the great advantage that
it avoids injury to the seminal ducts and the rec-
tum ; also that it does not give rise to fistula or
to incontinence of urine ; all of which are occa-
sional results of perineal lithotomy. An ample
experience has shown that the urethra and blad-
der of a child will tolerate a considerable amount
of instrumentation. It would therefore seem wise
to use litholapaxy for all small stones or stones of
moderate size (from i and i 'j to 2 centimetres in
diameter), and for stones larger than this to do
lateral lithotora3', except when they are very
large (3,'; centimetres and upward in diameter),
and then suprapubic cystotomy is to be resorted to.

The ease with which bimanual palpation can be
pracriced in children, with a finger in the rectum
and a hand on the abdomen, makes it possible to
judge, pretty closel}', the size of the stone, and so
to select intelligently the best operation for its re-
moval. The consistency of a stone is also to be
taken into account when litholapaxy is thought
of, and stones of considerably larger size than is
above indicated may properly be crushed if the}-
are soft and friable. The quality of a stone in
these regards maj' usually be determined with
some degree of accuracy by the sensation imparted
to the sound and by a knowledge of its probable
constituents, which can often be gained by an ex-
amination of the urine. Phosphatic stones are
usually soft, as are also pure uric acid stones.
The urates make a rather hard calculus, while an
oxalic stone is exceedingly hard and resi-stant.
Certain other conditions which would lead us to
emplo}' some other method than litholapaxy will
be spoken of in considering operations on adults.

In Adults. — Whether we consider the danger of
the various operations for stone in the adult, or
the likelihood of disturbance of function follow-
ing them, we are led to regard litholapaxy as the
operation of choice for stone removal. With the
efficient lithotrites and evacuator which made
" lithotrity at one sitting " possible, it is now
usual to remove stones of considerable size and
hardness, and practically it has been found that
under ordinary conditions in adults, any stone
which is suitable for lateral or other perineal lith-

otomy is suitable for litholapaxy, and that even
stones so large that they would require a supra-
pubic incision if they were removed by the knife,
may, when reasonably friable, be safeU- crushed
and pumped out. A number of instances are on
record in which stones between 2,000 and 3,000
grains iA weight have been successfully removed
in this manner.

The exceptional cases in which litholapaxy
cannot be used are as follows :

1. A very large and hard stone may resist every
attempt at crushing, especially if it is tightly
grasped by the spasmodically contracted bladder.

2. A stone may have as a nucleus a foreign
body such as a piece of necrosed bone or a bullet,
too hard to crush and too large to pass out through
a tube.

3. An encysted stone may be out of reach of
the lithotrite.

4. Some writers hold that stricture of the ure-
thra may prohibit litholapaxy. This cannot often
happen, for strictures, however clo.se, yield readily
to divulsion, which may immediately be followed
by the crushing and evacuation of the stone. I
have so often seen these two operations success-
fully done together on an etherized patient, that
I can but think this the best practice. While it
economizes time, it saves the patient much need-
less manipulation.

5. False passages may exist, which so interfere
with the introduction of instruments that the dan-
gers of the operation are greatly enhanced, and
the question of lithotomy is to be entertained.

6. The hip may be anchylosed in a position
which interferes with the use of urethral instru-
ments.

7. A .stone may be so lodged in the entrance
to the urethra, that it cannot be pushed back into
the bladder where it can be seized by the lithotrite.

In atiy of these exceptional cases in which lith-
olapaxy cannot be applied, we have to make our
choice between a perineal and a suprapubic inci-
sion. The danger attaching to the perineal inci-
sion is, according to present indications, decidedly
less than that after the high operation, so long as
it is applied to small or medium-sized stones; but
when large stones are dealt with, the facts are re-
versed, and the perineal operation becomes the
more dangerous of the two. Under ordinary cir-
cumstances, as has been said, litholapaxy disposes
of the stones of a size suited to perineal removal,
and these operations through the perineum have
therefore fallen largely into disuse for adult cases.
They find occasional application in cases of stones
of moderate size where false passages, anchylosis
of the hip or the presence of a foreign body make
litholapaxy impossible. They may also be u.sed
rarely when severe obstructive disease of the pros-
tate makes it desirable to combine prostatotomy
with the operation for the removal of the stone.
A stone impacted in the neck of the bladder, if it

662

OPERATION FOR STONE IN THE BI^ADDER.

[November 9,

cannot be dislodged, maj' properly be removed
through the perineum.

Suprapubic lithotomy is to be employed in cases
where the stone is too hard and large to be crushed,
or where an impervious urethra makes the intro-
duction of a lithotrite or staff impossible. In case
of an encysted stone the high operation is also the
best, as the thorough inspection of the bladder
which it makes possible enables us to treat the
condition intelligently. Occasionall3% cases are
met with in which the prostate is so large that
the bladder cannot be reached through the peri-
neum, and here, of course, one is driven to do a
high operation if a stone exists which it is not
possible to crush.

In Old Age. — The same indications are to be
followed as in the adult, except that it is to be re-
membered that perineal incisions are especially
dangerous 'in old men, and not to be undertaken
for the removal of stone without urgent reasons.
The suprapubic operation will therefore be called
upon to deal with most of the stones which are
unsuitable for litholapax}-, and even with this in-
cision, a prostatotomy or prostatectomy may be
done after the removal of the .stone if the condi-
tions require it. As was seen by tlie statistical
tables, it is in old men that the crushing opera-
tion has the most unmistakable advantage. The
urethra and bladder, in old age, are very tolerant
of the use of instruments, so that litholapaxy is
ordinarily well borne. '

In conclusion, I wish to say a few words about
my own experience with stone operations. I have i
operated forty-seven times, selecting the operation ]
in each case according to the principles I have set
forth above. There were forty- two litholapaxies,
nine of them in adults and thirty- three in old men;
three lateral lithotomies, all in children ; one me-
dian lithotomy in an old man and one suprapubic
lithotomy in an adult.

Of the cases of lateral lithotomy, two were
done before it was believed possible to do lith-
olapaxy in children. In the third case there were
two stones, one of which was firmly fixed in the
prostatic and membranous urethra. The median
lithotomy was done for a small stone impacted
in the prostatic sinus, and the suprapubic opera-
tion was done for a large, hard stone, in a patient
having a bad stricture of the urethra with false
passages about it. Among these cases there were
three deaths ; two following litholapaxy and one
after median lithotomy. Of the cause of death
in these cases I wish to speak briefly.

Case ! was a broken-down man of 69, for whom
litholapaxy was done for a phosphatic stone weigh-
ing 98 grs. The operation went smoothly and the
relief from it was complete. The urine cleared
up and, after a few days, was pas.sed normally
without ])ain or frequency. In short, he made a
perfect recovery from the operation. On the
fourth dav a chronic bronchitis that he had had

before entering the hospital became much aggra-
vated, led to pneumonia and of this he died on
the ninth daj-.

Case 2 was a patient 7 1 years of age, whom I
saw at Bennington, Vt., August 24, 1887, in con-
sultation with Dr. Leroy McL,ean, of Troy, N. Y.,
and Dr. Jennings and others of Bennington. He
had had trouble with his bladder for three or four
years, but had been able to keep about with it till
eight days before I saw him, when he had sudden-
ly been seized with an acute exacerbation of cys-
titis with retention, for which the bladder was
aspirated over the pubes. During one of the as-
pirations the needle touched a stone. When I
saw him he was suffering from great pain and
frequent painful tenesmus ; his puLse was rapid
and weak, his countenance sunken. The urine,
which had been abundant at first, had almost
ceased during the past twenty-four hours. The
general feeling at the consultation was that the
patient was in a dying condition, and that anj'
operation could only be looked upon as a last ef-
fort to give him some more chances of recovery.
With this understanding litholapaxy was under-
taken. The bladder contained 2 or 3 ozs. of thick,
bloody mucus, with almost no urine. The stone
was very hard (oxalic), and weighed i oz. The
operation was a long one. After the stone was
out, a catheter was tied in the bladder. There
was no reestablishment of the flow of urine and
the patient died on the following day.

In the first case death was due to a pneumonia,
and the bladder and kidneys were in good order.
In this series of forty- two litholapaxies we have,
then, but one death due to the condition of the
urinary organs, and even that could not fairly
be ascribed to the operation. Among the suc-
cessful cases were several in which there was dis-
tinct evidence of an alread)' existing interstitial
nephritis, and yet the patients bore the operation
well.

Case 3. — -The third death occurred also in an
old man (over 70 )-ears of age), broken down by
hard labor as a missionary in the tropics, who had
just recovered from a severe illness on his voj^age
home. He had a small stone lodged in the pros-
tatic sinus, which caused much pain with frequent
micturition. This stone was removed by a medi-
an perineal incision and at the same time the third
lobe of the prostate was divided with a probe-
pointed bistour\-. A drainage tube was fastened
in. After doing well for a few days he gradually
developed a septic condition of the wound which,
in his enfeebled condition, proved fatal. This
was the only case in the series of forty-.seven, in
which the fatal issue was distinctly the result of
the operation.

1889.]

SUMMER DIARRHCEA AND DYSENTERY.

663

SUMMER DIARRHCEA AND DYSENTERY
IN CHILDREN.

Jiead by title in the Section of Diseases of Children at the Fortieth

Annual Meeting of the American Medical Association,

June, iSSg,

BY N. GUHMAN, M.D.,

OF ST. LOCIS, MO.

Before I commence to read my paper I will ask
your patience and indulgence if I wander some-
what from the title. I think the propriety of the
digression will be apparent before I conclude.

During the summer months j-ou are all aware
of the prevalence of diarrhcea, d}-senter}- and dis-
turbances of the gastro-intestinal canal. I will
not take up j'our time in giving definitions of the
terms, or in detailing the pathological and physio-
logical changes which occur in the digestive or-
gans in these diseases, as you will find these
stated much better in your text-books than I can
describe them to you. What are its causes ? j
Atmospheric changes, heat, rainy and sultry
weather, warm during the day and cold at night,
impure air and water, insufficient clothing, a
badly nourished, fretful and overworked mother
or wet-nurse, imprudence on the part of the
mother or wet-imrse in the selection of food and
drink, over and too frequent feeding of indigesti-
ble food, or cooked food which has been kept too
long, perhaps in a patent unclean nursing bottle,
with a rubber or glass tube attached to it, or
which has been kept in an ice-box with various
kinds of vegetables, meats, cheese and butter. I
suppose most of you have drunk milk or water
or eaten butter which had been kept in an ice-
box in which strawberries, raspberries or cante-
loupes had been stored away to be kept cool until
used, and no doubt all of you have noticed the }
efifect of placing such articles in the same ice-box.
I look upon ice-boxes, in which there are placed
all sorts of decomposing and fermenting articles,
such as we generallj- keep for our table use, as
breeding boxes of bacteria and microbes and all t
kinds of germs. Of course I am aware that we |
cannot have a separate ice-box for each kind of i
food we eat. Another point to which I desire to j
call your attention is the use of ice in drinking
water. We should not put the ice in the water
we drink. It is far preferable and less dangerous
to cool the water by keeping it near the ice. You
all know that all the ice is not as pure and clean
as it should be. Ice-boxes need ventilation and
the use of care in selecting the articles which are
placed in them as much as our dwellings. These
points may be foreign to the title of my paper,
i)ut I consider them very important points for us
to remember. I have no doubt that bacteria and
microbes play an important part in these diseases.

Is dentition of children the onlj- cause of diar-
rhoea and dy.senter}' during the summer season?
I doubt it. During the winter months the moth-
ers come to your office with their babies and say:

' ' My baby has a cold and the snuffles ; ' ' and dur-
ing the summer, "dentition;" so that in sum-
mer they ascribe the trouble of dentition to
diarrhoea, and in wintei; to diseases of the
respirator}' organs. The question may be asked,
may not the irritable and swollen condition of
the gums, which we see existing in some chil-
dren, cause diarrhoea through a reflex action of
the nervous system? If you take notice you will
see that this condition of the gums occurs onlj'-
where a child is broken down more or less from
diarrhcea and deficient assimilation of food. You
do not observe it in healthy children.

What are the varieties, symptoms and charac-
ter of summer diarrhoeas and dysenteries, simple
and inflammatory or dysenteric diarrhoea ? The
above mentioned causes may produce either of
these troubles ; it all depends on circumstances —
in which direction it strikes. It may produce
cholera infantum under certain conditions. I
think these diseases are closely allied to each
other. In the beginning of the attack we first
obser\-e vomiting of indigestible food, curdled
and chees5' milk. I suppose man}' of you have
seen children vomiting a white coagulated mass
of cheesy material, tough like rubber, elongated
and moulded by the oesophagus as long and thick
as a thumb. It seems to me it would take some
time for the formation of such a mass, and much
longer to expel it from the stomach. The phy-
sician should be very careful not to make a mis-
take when he is called to a child which is vomit-
ing, or an empt}' retching symptomatic of, caused
by, or a forerunner of cerebro meningitis or other
brain lesion, where the former is caused by local
irritation and the V'omiting is easy, with very
little straining, while in the latter the eff'ort of
vomiting is preceded by a little hacking cough
and retching, with vomiting of a little mucus or
a yellowish-green fluid, although j'ou may have
the same condition in acute gastritis ; during
vomiting or immediateh' afterwards you have an
action of the bowels of indigestible food and faecal
matter of a more or less thin white, grayish color,
curdled and of an acid odor ; or the discharges
from the bowels may be of a greenish color, inter-
mixed with white lumps, casein; and then at last
comes the dysenteric form, tenesmus, with a little
mucus and streaks of blood, or a j-ellowish, slimy
mucus, with some faecal matter and blood of an
offensive odor. At this point I would draw your
attention to cases which may occur in summer as
well as in winter, where the child lies on its back,
legs drawn up, with a continued straining, and
9a.ssing nothing but red blood, mixed with a lit-
tle mucus and no faecal matter, and with scarcel}'
any odor. What might we expect in such a case?
Probably an invertion or intussusception of the
large or small bowel. It may be near the rectum,
or higher up. If it is in the lower part of the
bowel, we may be able, by a digital examination,

664

SUMMER DIARRHOEA AND DYSENTERY

[November 9,

to feel the inverted bowel in the lower part of the
colon; if higher np, we might make our diagnosis
with a flexible catheter or bougie, and if we are
in doubt about our .diagnosis I would give the
doubt the benefit.

What would be the treatment in such a case?
First elevate the child's pelvis so as to favor
gravitation towards the diaphragm and chest, and
fill up the bowels with warm starch water, with
a long or short flexible tube attached to a foun-
tain syringe, according to the location of the ob-
struction, whether low or high up, or the inflation
of air. If this is not successful I would advise
laparotomy, the same as in a grown person. I
do not know why the operation should not be
performed as well in a child as in an older per-
son, although laparotomy is not often performed
in children under such circumstances. We all
know that'a child in such a condition will die if
not relieved, and I do not see why laparotomy is
not as justifiable as tracheotomy in obstruction of
the larynx.

What treatment should we follow in case of
diarrhoea and dysenteric diarrhoea? First remove
the cause and make correction in the food and
drinks. Do not overload the stomach. Eet the
child have plenty of fresh air. Medication should
be very simple and mild, such as emollients, de-
mulients, antacids, antiseptics and peptonoids in
some form. Be careful of opiates where you have
fever or congestion of the conjunctiva, or the
least indication of brain lesion. Astringents
should hardly ever be used. I never derived anj-
benefit from them, and I have always regretted
their use when I employed them. If the fault is
in the secretions, small doses of hydrargyrum
cum creta or chloridum mite with lactopeptine,
which will promote and stimulate the secretions
of the digestive organs. If the diarrhoea is of an
acid odor, diluted lime water, bicarbonate of
soda with the chalk mixture ; and if there is any
indication for an antiseptic I add some listerine,
carbolic acid or creosote. In inflammatory or
dysenteric diarrhoea, if the stools are greenish,
slimy, mixed with mucus and accompanied or
preceded with pain and tenesmus, mj- favorite
remedy is lactopeptine added to a castor oil emul-
sion, with a little paregoric or McMann's elixir
of opium, if not contra- indicated, warm cloths or
hop and flaxseed poultices to the abdomen. I
always give my little patients enough to drink.
I instruct the nurse to get a large piece of ice,
wrapped in a blanket, put it in a large dish and
keep it in the sick-room, so as not to require
them to run up and down .stairs to the clean ice-
box, which I have described before. I order the
medicine, if it is fluid, lime water, some good
whisky or brandy, also a soda hottleful of rice,
gum arable and barley water in the dish near the
ice, to keep it cool. I always make it a rule, if
possible, to look at the stools before I prescribe. |

If they come to my office, I require them to bringj:
the last two diapers with them. I prefer to look
at them myself, rather than get an imperfect de-
scription from the mother or nurse. They will
not tell you of the indigestible food, such as po-
tatoes, meat, apples and all kinds of seeds from
fruits. They ver\' readily tell you the child is-
no better, and the medicine did not do any good.
Hold up the diaper and ask the mother if she
carried out your instructions. Of course she will
excuse herself — sa}' that the child picked it up-
from the table, or got it from its little brothers or
sisters.

Gentlemen, you are all aware that we have not
so many cases of summer diarrhceas and dysen-
teries, or any other disease, now as we had irt
former times. Why ? Because the public is bet-
ter educated in hygienics, they occupy better
houses and more room, our cities are better sew-
ered and drained, and sanitation is better in our
large cities than elsewhere. There is more clean-
liness all around.

Since writing my paper I read the report made
by Dr. Henry Tomkins before the British Medical
Association in Glasgow, on bacteriological re-
searches in connection with summer diarrhoea, as-
he had studied it in the town of Leicester, where
he resided, and published in the British Medical'
Journal, August 25, 1888. It will be very inter-
esting to all of you and I have no doubt that we
will all profit by it, and if the Chairman will
allow me to read it I will do so.

'' Bacteriological Researches in Contiectioyi With
Summer Diarrhtra. — Dr. Henrj- Tomkins brought
this matter before the British Medical Association
at its recent meeting in Glasgow. He alluded
more particularly to the subject as he had studied
it in the town of Leicester, where he resided
{British Medical Journal, August 25, 1888.)

" In approaching the subject two facts were to
be borne in mind: (i) That all diarrhoeas, not
some diarrhoeas, were often only a symptom' of
I varied morbid conditions, as pointed out at the
Cardiff" meeting of the British Medical Associa-
tion by Dr. Vacher ; but, after all due allowance
made, there undoubtedly remained a large residue
of cases of a specific or special nature, constitut-
ing a disease /><v .v, as much so as true Asiatic
cholera ; (2) that that disease was not a disease
of infancy or early childhood only, or even for
the greater part. Exact observation showed that
the bulk of sufferers from it where it prevailed
were of more mature years, though, owing to the
mortality occurring almost exclusively amongst
young children, this fact had often been over-
looked. Of all English towns Leicester was, par
excellence, the home of this di.sease, if its mortal-
ity was to be taken as a true criterion of its pre-
valence. During the past three years, since hold-
ing the office of Medical Officer of Health there,
Dr. Tomkins had paid special attention to the

1889.]

IS SENN'S GAS TEST INFALLIBLE?

665

subject. It was easy to disprove that many of
the reputed cases gave no satisfactory explanation
■of the disease. Many of these affect only the in-
fantile population, and aflFect these more or less
throughout the whole town, whereas the preva-
lence of the disease was confined to certain well
defined low- lying districts of the town and affect-
•ed all ages and occupations, etc., within those
districts. The cause must be something common
to every resident within tho.se districts, which
something was apparently absent in other parts
•of the borough. The onlj' things or conditions
common to all were food supplies, water and air.
The two former were the same throughout the
whole town ; there remained, therefore, only the
air. During the past three years Dr. Tomkins
liad undertaken a large series of observations on
the air, with special reference to the microbic
forms of life contained therein. The general re-
sult showed that the air of the diarrhoea district
■of the town contained three to six times as many
microorganisms and their germs as the air of the
non-affected districts. These microbes (or certain
of them) grew in a distinctive manner when arti-
ficially cultivated, and were capable of producing
diarrhoea ; or, perhaps more correctly speaking,
the products of their artificial cultivation were
■capable of producing diarrhoea in the human sub-
ject. At present Dr. Tomkins was endeavoring
to isolate and single out the particular form or
forms which were most concerned in this. The
•organisms and growths obtained from various
tissues, organs and intestines in fatal cases of
diarrhoea give like results, A very probable ex-
planation of the undue prevalence of diarrhoea in
Leicester, or rather in certain parts of the town,
was found in this excess of aerial microbes and
germs, and this excess might be satisfactorily
accounted for in the following way: Since 1850
(from which date the prevalence of diarrhoea ap-
peared to have commenced and increased) the
whole of the area of the "diarrhoea district" of
the town had been subjected to a pollution with
organic filth, more or less of an excremental
character. This, acted upon by the heat of the
summer sun, amply sufBced for an enormous pro-
duction of bacteria. Imperfect and filthy sewers,
containing much deposit, in the same way con-
tributed to like results. Meteorological observa-
tions during the summer months of 1885, 1886
and 1887 showed that as soon as the earth, at a
depth of one foot, reached about 62° F. , the dis
■ease broke out. At the time of writing (July 23,
1888J this subsoil temperature had not yet been
reached, and the outbreak had not yet commenced
for this year. In addition to the need for more
exact isolation and identification of the "diar-
rhoea microbe," it was of equal importance to
study how this and other bacteria acted in pro-
ducing disease ; whether it was probable by the
production of some poisonous material of an alka-

loid character, such as ptomaines or leuco-
maines. These inquiries were of supreme impor-
tance to the physician and clinical observer, as
well as hygienist, but could hardly be expected
to be carried on by an ordinary health ofiicer,
with multifarious routine duties to attend to.
Such questions as these required the whole time
and attention of specialists."

IS SENN'S GAS TEST INFALLIBLE AND

ALWAYS DEVOID OF DANGER ? TWO

CASES OF SHOT WOUNDS.

CONCLUSIONS.

Read before the Mississippi I'alley Medical Association, at its meeting
at Evansvilte, Ind.. September ii, iSSg.

BY H. C. DALTON, M.D.,

SUPERINTENDENT CITY HOSPITAL, ST. LOT'IS.

I report to-day one case of laparotomy for shot
wound, and another in which an operation ought
to have been performed, and would have been,
had I not been deterred on account of the failure
of the Senn method, being led thereby to believe
that the intestines were intact. It is not always
pleasant to report our failures, but believing it a
duty we owe the profession, in order that our
statistics may be reliable, I have made it a rule
to report all my failures as well as successes in
abdominal surgery.

It is true this course may subject me to criti-
cism owing to some sins of omission or commis-
sion, but as criticism will teach me wherein I
have erred, I shall still be the gainer. Should
the criticism be unjust, I trust it will proceed
from him only who has never made a mistake in
surgery. This apologetic prelude is written to
induce you to "be to my faults a little blind,"
when you listen to the "o'er true tale" of the
two following cases :

Case I. — B. J., colored, set. 35, laborer ; ad-
mitted to the hospital October 25, 1888 ; was
shot at a distance of twelve or fifteen yards three
hours before admission, after which he was un-
able to walk, and- soon felt a numb, dead sensa-
tion in the right leg, followed by pain in the ab-
domen.

Examination showed a shot wound an inch
and a half above and a little to the right of the
anus, the probe passing upwards and inwards
through the great sciatic notch into the pelvic
cavity. The urine was drawn and found to be
clear. There was absence of liver dulness to the
extent of two inches above the border of the ribs.
The patient was suffering from shock and intense
pain in the abdomen, referred to the umbilicus.
The extremities were cold, pulse 72 and respira-
tion 39, rectal temperature 96.6° F.

Assisted by Drs. Meisenbach and N. B. Carson,
and the hospital staff, I proceeded to make me-
dian laparotomy', using Senn's hydrogen gas test

666

IS SENN'S GAS TEST INFALLIBI^E?

[November 9,

before making the incision. A small hole was
made about two inches below the umbilicus, a
glass tube was put in and an ineffectual attempt
was made to ignite the gas. When the tube was
removed the gas escaped through the hole and
ignited readilj-. Upon enlarging the wound the
gas escaped with an audible sound. The bullet
was found to have entered to the right of, and
almost grazing, the iliac vessels. It then entered
the csecum a little to the inner side of the appen-
dix, and passed out an inch and a half above.
Twelve holes were closed by the interrupted Lem-
bert suture, iron-dyed silk being used, two in the
caecum (as described above), six in the small in-
testine, three in the mesentery, and one — the
hole of entrance — near the iliac vessels. The
bullet was not found, nor were we able to find it
post mortem.

After a thorough peritoneal toilet we attempted
to return the enormously gaseous, distended intes-
tines, but found, like Banquo's ghost, that they
would not down. It seemed our task was like
that of Sisyphus, for as fast as we would replace
one coil another would "bob up serenely from
below," until our patience, as well as our patient,
was well nigh exhausted. To make confusion
worse confounded, about this time, when we
thought our task almost completed, the intestines
being nearly all reduced, two or three sutures
gave way and the cavity was again flooded with
faecal matter. In the attempt to reduce them the
intestines were necessarily subjected to rather
rough handling and considerable pressure ; hence
the rupture. The sutures which gave wa)' were
those closing two holes which were ver>' close
together, and we found it difficult to locate the
exact spot from which the fceces escaped. We
accomplished it, however, by a very simple, but,
I think, important method suggested by Dr. Car-
son, /. ('. , allowing water from the irrigator to
play upon the part while making pressure upon
either side of the holes. The escape of the gas
elevated the water to perhaps a half inch, indi-
cating the exact site of rupture. An attempt
was made to get rid of the gas by washing out
the stomach and putting a cylindrical speculum
into the rectum to facilitate the escape of the gas,
but this much vaunted method failed utterly.

Here was a case where the Senn method not
only did no good, but absolutely did a great deal
of harm ; but more anon. The case also teaches
a valuable lesson in that it should caution us, no
matter how far away the wound of entrance may
be, to look out for abdominal injury if the range
of the bullet be in that direction. In a conversa-
tion with Dr. Senn, .some weeks ago, I informed
him of the above facts. He stated that he had
also been annoyed by the same thing, but it
could be overcome by elevating the hips and using
a large funnel-shaped towel to produce compres-
sion upon the intestines during their reduction.

I do not believe that it would have worked in
this case.

Case 2. — Wong Gau, Chinaman, aet. 25, laun-
dryman, entered the hospital at 7:25 p.m., October
II, 1888. One hour before admission he was
shot by a negro at a distance of ten feet, the bul-
let entering between the fourth and fifth ribs in
the left axillary line.

The assistant who examined him (I was absent
at the time) probed the wound and concluded
that it did not penetrate the abdominal cavity, a
very natural mistake, as there were no s}'mptoms
pointing in that direction, except that he had
vomited several times, the ejecta, however, con-
taining no blood. When I returned to the hospi-
tal, three hours after the injurj', the pulse had
gone up to 100, temperature 100° F., but there
was still entire absence of abdominal symptoms.
Suspecting, however, from the direction of the
bullet, that it had penetrated the cavity, I resect-
ed two inches of the seventh rib in order to in-
spect the diaphragm. A hole was found in the
same about three inches from the thoracic wall.
Through this hole I placed a glass tube and ap-
plied the hydrogen gas test, which gave negative
results, although the tube was moved in various
directions and removed several times to see if it
was unobstructed. The urine was drawn and
found to be clear. Having great faith in the gas
test I was satisfied that the alimentan,- canal was
intact. My faith has received several rude
shocks, and I am no longer an enthusiastic advo-
cate of the measure, except in certain cases. The
diaphragmatic and thoracic wounds were closed
with heavy chromatized catgut. Patient died
twent5^-eight hours after the injury.

BULLET HOLES

The above cut shows tlie relation of the food and bullet holes
to the stomach as revealed by the autopsy in Case 2. The arrows
show the course the gas would naturally take in passing up the
alimentary canal rather than to displace the food sufficiently to
gain e.xit through the bullet holes.

The autopsy revealed two holes in the stomach
and a large lacerated wound of the left kidney.
The holes were on the greater curvature, three or
four inches below the cardia. They were quite
close together (half an inch of septum), each

1889.]

IS SENN'S GAS TEST INFAI.LIBLE.

667

I

hole being about half an inch in diameter. The
stomach was one-third full of semi-solid food,
mostly rice, the consistence of which was so firm
that it failed to run out when the stomach was
elevated, nor did any escape ante-mortem. The
food plugging up the holes and overlying them,
accounts for the failure of the gas to escape. It
naturally sought the higher and unobstructed
portion of the stomach, and by its pressure plug-
ged up the holes still more securely.

During anaesthesia the patient came near dying
from interference with respiration, due to the
great gaseous pressure upon the diaphragm.
Had there not been large gaseous eructations,
partially relieving the pressure, I believe he
would have died upon the table. The case
teaches that extreme care should be taken in giv-
ing the anaesthetic during the gas test. It also
teaches that the test is liable to deceive us at a
very important juncture, and that we cannot
positively depend upon it in gunshot wounds.

In the above case I might have turned the pa-
tient on the right side allowing the food to gravi-
tate to the right, leaving the holes free for the
exit of the gas. But who would have suspected
such a condition as we found in the case, or
would have thought of the necessity of placing
the patient in such various positions? It is
certainly unusual to have a patient with both
stomach and kidney so badly injured without
.some blood being vomited, or being found in the
urine, and this assisted the Senn test to deceive
us in the case. I object to the use of the gas
test in shot wounds for the following reasons :

1. Because it is misleading, not being akvajs
reliable.

2. Because even if it give negative results, we
should operate anyway, as we are not sure that
the intestines are not perforated, and statistics
give but poor encouragement to those who adopt
the do-nothing plan, the recoveries in such cases
being less than 8 per cent.

3. Because even were we positive the intestines
were uninjured, there are other organs which are
almost equally important, such as the liver,
spleen, mesentery, etc., which might require
prompt attention.

4. Because I believe there is danger of the gas
forcing faeces through the wounds into the peri-
toneal cavity, thereby adding to the gravity of

Ithe ca.se. It is said this does not take place, but
'I am loath to believe it.

5. Because of the additional danger during
snsesthesia from interference with respiration.

6. Because of the liability of the sutured holes
to be torn open while handling the intestines,
especially during the eifort to return them to the
peritoneal cavity, as in case i.

7. Because after their return to the cavity, ow-
ing to their distended condition, and the conse-
quent pressure upon the diaphragm, it em-

barrasses respiration, and hence adds to the shock.
I believe this to be a valid and most serious ob-
jection to its use. He who can put his patient
to bed with the least shock, ccrtcn's paribus, has
the best chance of seeing him recover, for shock
is the cause of death in the vast majority of
cases ; and certainly' the liabilit}- to death during
anaesthesia, while not probable is more likely to
occur with the use of the gas than without it,
and hence should be taken into account.

Those who have attempted to close the ab-
domen over intestines distended by gas can fully
appreciate mj' statement. I imagine that a well
person with intestines so distended would suffer
from colic, and a feeling of oppression consequent
upon the great gaseous distention. Why should
we add such additional danger to our patient, al-
ready in such a perilous condition, when a
feather's "weight may turn the scale against him?
It may be claimed, and I grant it, that the gas
soon becomes absorbed, but why subject a patient
to an additional risk, even for a short time, at
such a critical period ? Then too, the preparation
and administration of the gas takes up valuable
time, it is true not a great deal of time, but when
one remembers that the saving of ever}- moment
in these cases is vitally important, he naturally is
anxious to get through at the earliest moment
consistent with the proper management of the case.

Senn reports a case of shot wound of the in-
testines in which, after sewing up all the holes
he could discover, he was enabled by the use of
the gas to find another, low down in the rectum,
which he could not have found without it. I
imagine such cases are very rare, and do not
counterbalance the harm which the gas maj^ do
in other directions. I would not leave the infer-
ence that I have di.scarded the gas test. I would
use it in shot wounds of the back, and low down
on the sides of the abdomen, where I could not
positively determine whether or not the peritoneal
cavity had been penetrated. In other words,
where we are in doubt as to the penetration use
it, and if we get affirmative results, operate. I
think the test is more appropriate to stab wounds,
for there we are often very much in doubt as to
whether or not the intestines are wounded.
When we are so uncertain we should use the gas
test ; if it give negative results we need not op-
erate, especially as we know that many penetrat-
ing stab wounds do not wound the intestines,
whereas it is quite the exception — in fact a very
rare occurrence for a penetrating shot wound to
fail to do so.

So I conclude that the fact that a shot wound
of the abdomen is penetrating, justifies lapar-
otomy, for, unless the ball be a spent one (a very
unlikeh' occurrence), we can be almost certain
that there is serious injury to the viscera. This
is a rule to which the exceptions are too few to
have any weight.

668

the; cunic.

[November 9,

The gas test then in this class of cases is un-
necessary. In penetrating incised wounds, how-
ever, the character of the injury is such that the
viscera may, and in fact often do, escape.

I believe that this question should be thor-
oughly discussed, and the truth evolved, not
only for the good of our patient, but also for the
medico-legal aspect of the case. Self-protection
demands that the status of the test be definitely
settled. I have not been able to find that any
one has controverted Dr. Senn's claim that "rectal
insufflation of hydrogen gas is an infallible test
in the diagnosis of visceral injury of the gastro-
intestinal canal in penetrating wounds of the ab-
domen." My experience will not allow me to
subscribe to the statement.

I propound the query " Is the question settled?
and answer in the negative, believing it to be still
siib judice. ' What say you after thoroughly
weighing the facts in the above cases ?

THE CLINIC.

THE CLINICAL HISTORY OF A CASE OF
CYSTITIS FOLLOWING TUBERCULAR
KIDNEY, THE CHIEF SYMPTOM
OF WHICH WAS CONTRACT-
ED BLADDER; TREATED
BY HOT WATER DI-
LATATION.
BY I. S. STONE, M.D.,

OF LINCOLN, VA.
MEMUER .^iMERICAN MEDICAL ASSOCIATION, VIRGINIA MEDICAL SO-
CIETY AND STATE BOARD OF MF-DICAL EXAMINERS; SOUTHERN
SURGICAL AND GY.N'ECOLOGICAL ASSOCIATION; FELLOW OF
THE BRITISH GYNECOLOGICAL SOCIETY, ETC.

Miss M., white, set. 22 years, came under my
care in April, 1885. She had for two 5'ears had
cystitis, for which she had been treated in Wash-
ington, D. C. She was somewhat ansemic, al-
though but slightly reduced in flesh. Her fam-
ily history was exceptionally free from suspicion
of tubercular disease, although her father had re-
cently died of supposed carcinoma of the liver
and stomach. The patient complained of pain
extending along the ureter to the bladder from
the right kidney. The pain was not constant,
but was increased by pressure over the kidney or
by severe exercise, as in riding or jumping, etc.
The urine had sp. gr. 1020, reaction neutral, vol.
24 ozs. per diem ; was heavily charged with pus
to nearl)^ one-third of its vol. Microscopical ex-
amination revealed abundant epithelium appa-
rently from the bladder, besides pus corpuscles
and abundant amorphous urates. No casts, very
slight amount of albumen.

The usual treatment for cystitis gave so little
relief that I .sought for the cause in the urethra

and found two small papillomata, the removal of
I which gave some relief She was passing urine
' every hour or two and was obliged to continue
this through the night, causing loss of sleep and
consequently loss of strength. The patient, in
September, 1886, passed from my care and en-
tered Columbia Hospital for Women, D. C,
where she steadily grew worse and was discharged
as incurable in December, after nearly two months'
residence therein.

I was again called to see the patient and found
her quite wretched and anxious to end her miser-
able existence. There was constant dribbling of
urine, great pain in region of the bladder, extend-
ing to both kidneys, although worse on the right
side. Her temperature was i02°-i03°, pulse no
to 1 20, attended by rigors and other septic sj^mp-
toms. Her kidneys were not supposed to have
to do with her condition ; no tumor or other dis-
ease having been discovered by those recently in
charge of her. Again hoping to benefit the patieut
by wise counsel, and to satisfy the demands of ur-
gent friends in Philadelphia, she was taken to Jef-
ferson Medical College Hospital and placed under
the care of Dr. S. W. Gross, January 15, 1887. His
diagnosis was "contracted bladder from cystitis
with some pyelitis," which latter he thought
i needed no special treatment. Accordingly he
prescribed hot water irrigation of the bladder, di-
latation of the urethra, and argent nitr. sol., xx
ad ,5j every five days. During the seven weeks'
residence of the patient at the hospital, her blad-
der increased its capacity for urine from zero to
3ij. The general condition of the patient had
greatly improved, and she was greatly encouraged
with the prospect of recoverj'. Dr. Gross failed
to detect any tumor or other disease of the kidney
— save the pyelitis — and doubted the expediency
of any surgical examination.

The patient was again brought under my care
in March, 1887, and the treatment instituted by
Dr. Gross continued. By increased pressure the
, bladder reached a capacity of 8 ozs. forced disten-
sion, with hot water. At this point, Dr. Gross-
suggested the stretching cease, but it soon became
apparent that contraction would again take place,
! and the stretching was continued until a capacity
of 19 ozs. was reached. This treatment was con-
tinued for many weeks and gave the patient great
j relief from the bladder symptoms. She could re-
I tain her urine for eight hours, although generally
• was called up twice during the night. The quan-
titj- of pus in the urine constantly diminished
until about }^ \iy volume remained. Sulphate of
morphia gr. '4 with sulph. atropia gr. jJ ,7, hypo-
dermatically, were always required to afford relief
from pain during the distension. The anodyne
was given only once in five days and a gain of
from .^j to .^j secured at each sitting. This in-
crease in capacity with morphia was sustained by
daily irrigation and distension by means of hot

1889.]

THE CLINIC.

66g

water, temperature 115° to 125° F., until the time
would again arrive for the administration of mor-
phia and renewed distension. H^-drochlorate of
cocaine was useless in mitigating pain, both from
-the distension, and that from the silver solution
(strong solutions of cocaine, 10 and 20 per cent.,
were used).

The galvanic current was used dailj' for six
weeks of this period of treatment, but an estimate
■of its value could not be made, owing to the con-
tinuation of other treatment. A ball syringe was
used to inject the bladder through a No. 12 soft
catheter. Various means were tried to estimate
the force required to secure an increased capacity,
but all failed ; moreover, the syringe gave entire
satisfaction. The amount of pain produced by
distension with hot water alwaj's proved a safe
o^uide, and no bad symptoms followed this treat-
ment, save slight haemorrhage which invariably
ceased when the bladder was allowed to contract.
This haemorrhage always resulted from the dis-
tension if any important gain was made in capa-
city. It would appear that the bladder was con-
tracted in folds which bled when separated. This
bleeding ceased when the bladder was fully opened
up to 18 or 19 ozs. Iodoform in sterilized muc.
acaciee was used with great benefit, so far as could
be estimated by the statement of the patient after
the treatment by distension ceased. The iodoform
mixture was thrown in the bladder with a syringe
on alternate days, and the bladder would retain |
some portion of this until the next injection.

This case furnishes additional evidence of the
amount of speculative knowledge of renal diseases
at the present time. Although the pain was not
characteristic of either calculus or malignant dis-
ease of the kidney, we know that in cases of renal
calculus the pain varies greatly in character and
intensity. I am fully convinced that all such
cases as the one being described should have a
surgical exploration made, and would have re-
sorted to it earlier in this one but for the advice
of counsel. I was confident that I had discovered
a tumor of the right kidney a year before this,
but as it did not continue to develop, concluded
that it was a temporary distension of the kidney
from an obstructed ureter. I

The microscope also failed to discover positive '
renal disease, as shown b)' Dr. Brown's examina-
tion of the sediment August 7, 1887 (Microscopic
Laboratory, Detroit, Mich.): "The sediment is
composed entirely of urates, pus and epithelium.
The kidnej's are apparently not at fault."

During the first half of the succeeding year I
was abroad and unable to continue the treatment
of the case, and she accordingly remained with
the nurse who had previously had charge of her,
and who continued the dilatations from time to
time. On my return she was again brought under
my care and I found her retrograding. There was
some loss of flesh, and a decided bronzing of the

skin. In September, 1888, during the Congress
of Physicians and Surgeons in Washington, I had
my friend Dr. Edwin Ricketts, of Cincinnati, see
the patient, who fully agreed with me as to the
necessitj' for surgical treatment of the kidney.
Accordingl5^ in November, 1888, I made the usu-
' al lumbar oblique incision, and on reaching the
' kidney found it very hard and firmly adherent to
its capsule, so as to render an examination of its
; pelvis verj' difBcult. A fine needle was thrust
in every direction through the mass without find-
ing a stone. The nature of the disease appearing
to be malignant, and the adhesions so strong, the
wound was closed for prudential reasons. She
soon recovered from this examination, and re-
turned to her home with poor prospect for life or
health. Intestinal complications occurred in three
months and the patient died of inanition in March,
four months after the exploratory operation.

Autopsy, twelve hours after death, disclosed
healthy left kidney double its normal size. Bow-
els distended by flatus. Right kidney also double
the normal size, densely adherent to everything,
including liver, intestines and spinal column, so
that a reckless dissection was necessarj' to obtain
a portion of the growth for examination. The
remains of the pelvis consisted of a collap.sed sac
lined with pyogenic membrane, and containing
some pus, which could be forced down the re-
mains of the corresponding ureter to the bladder.
No chees)' particles could be found in the remains
of the kidney, and the appearance strongly indi-
cated sarcoma.

The bladder was similar to those usual!}- found
following chronic cj'stitis, the walls somewhat
thickened, but free from any other appearance of
disease.

I sent a portion of the growth to my friend Dr.
Kemp, of the Hoagland Laboratoni% Brooklyn,
for examination, whose opinion was that the spec-
imen was indicative of tubercle.

I had frequently examined the urine for tuber-
cle bacilli without result, neither was there cough
or other evidences of tubercle elsewhere. Mj- ex-
perience in dealing with these cases of chronic cys-
titis goes to show an invariable causation outside
of the bladder. Exclusive of toxicant causes such
as the administration of such irritants as canthar-
ides, etc., there appears to be no such disease as
acute idiopathic cystitis. Cystitis is therefore
remediable so far as the cause is removable. I am
quite well satisfied in this opinion after consult-
ing convenient authorities such as Emmet, Thom-
as, Agnew, W. H. Baker (Vol. ii, Am. Syst.
Gynecology), Goodell (new edition), Reginald
Harrison ("Surg. Disorders of the Urinary Or-
gans," third edition), etc., also Morris and \V.
H. Dickinson, London.

It is plainly to be seen that the later writers
are acting upon this theory. The length of this
report prevents a greater discussion of the sub-

670

MEDICAL PROGRESS.

[November 9,

MEDICAL PROGRESS.

ject, save to say that in the three cases reported \ the same time utilized as fuel. If these views
by myself cystitis was the chief symptom, and ' should prove true we would have ample justifica-
that it was impossible to permanently cure the ' tion of the time honored practice of clearing the
disease because the kidney was involved. I would bowels and stimulating the action of the liver in
also urge earlj- resort to surgical exploration. the early stages of various diseases.

I The Relations of Tubercle Bacilli to

THE Cells. — A. Stschastny reports the results
of investigation in this direction made in Dr.
Hueppe's Laboratory in Wiesbaden. His ma-
terial was the spleen and liver of the marmot,
the liver of chickens and sparrows and the tuber-
culous tonsils of man. The results obtained were
similar to those of Metschnikoff, He finds that
the migratory cells, the blood and lymph chan-
nels eat the living and virulent tubercle bacilli ; that
in their migrations thej- deposit the bacilli, which
they have taken up, in the tissues, and thus pre-
pare the way for the development of genuine tu-
berculosis or tubercular infiltration. A portion
of the leucocytes with their bacilli are converted
into epithelioid cells and giant cells containing
bacilli. The reporter believes it possible that
giant cells also originate in fixed connective tis-
sue cells. The giant cells in animals subject to
tuberculosis may suffer a partial or total necrosis.
The giant cells of animals not subject to tubercu-
losis are lasting active structures without appa-
rent phenomena of necrosis, which, just as the
physiological giant cells, strengthen the defenses
of the organism as the result of a formative irri-
tation.— Cent, fi'ir Klin. Med., No. 33, 1889.

Ptom.\ines and Leucomaines and their
Relation to Disease. — Dr. Jos. LeConte
contributes to the Pacific Medical Journal an in-
teresting article under this caption. He reviews
briefly the germ theory of disease together with
its recent modifications of interpretation and its
outgrowths. With the discoverj' of toxic germs
of diseases, it was at first believed that all the
grave symptoms of a germ disease were due
directly to the presence and multiplication of
specific microbes. The first modification of this
idea was, that disease in these cases was not due
directly to the microbes, but to the accumulation
in the blood of a poisonous chemical substance,
a b5--product of microbian multiplication, id est
the ptomaines which may be regarded as alka-
loids of albuminoid decomposition induced by
the vital activity of microbes. The writer be-
lieves that we are now on the eve of another
equally important modification of the original
theorj' growing out of a recognition of the leuco-
viaines — the poisonous products of albuminoid
decomposition induced by cell life. The leuco-
maines, although formed by normal physiological
processes, are highly poisonous, and inimical to
health unless speedil3' eliminated by appropriate
organs. If now there should be a failure to
eliminate these toxic elements the result would
be diseases similar to those produced by disease
germs, except that they would lack the property
of contagiousness because they are not due to the
presence of microbes. The writer suggests that
in view of this conception light may be thrown
upon the etiology of some of those obscure
sporadic and apparently non-contagious forms of
fever which often puzzle the physician to classify
such as some varities of typhoid, malarial, typho-
malarial, continued fever, and perhaps also a host
of other indispositions of less severit}'. In the
elimination of the leucomaines, the writer be-
lieves with Schiff", that the liver is the organ
chiefly concerned. He believes further that this
process is accomplished by the splitting of
albuminoids (whether of food or of waste tissue)
into glycogen (which is immediately converted
into liver sugar and burned) and a nitrogenous
incombustible residue which is eliminated by the
kidneys as urea. Thus leucomaines (and per-
haps ptomaines) are rendered innocuous, and at

■ See Medical News, Jiine 26, 1886, for the first case.

Statistics of Pasteur's Inocul.^tions. —
Pasteur's method of preventive inoculation against
rabies has now been employed in 6,870 individu-
als, some of whom were severely- wounded. Proof
that the animal inflicting the injur}' was actually
rabid has been furnished in 80 per cent, of the
cases, either by experiment or h\ veterinary ex-
amination. The mortality among individuals,
bitten by animals which were certainlj' mad, and
treated by inoculation, amounts to i per cent.,
while the mortality of those who were not treated
was 15 per cent. The mortality of patients with
severe wounds of face and hands was formerly 80
per cent. , while in Pasteur's institute it has been
reduced to 4 per cent. The English committee
appointed to investigate the value of Pasteur's
inoculations, reports that Pasteur's method de-
serves to rank with Jenner's great di.scoverj' ; the
committee consisted of Sir Jas. Paget, Sir Jos.
Lister, H. Roscoe and \'ictor Horsley.

It is interesting to note that so far it has been
impossible to demonstrate the virus, much less to
isolate it and propagate it in artificial cultures.

Sulphur .\& an Antiseptic. — Semmola pro-
poses sulphur as the coming antiseptic, most ser-
viceable for use in derangements of the alimentary
canal.

1889.]

EDITORIAL.

671

Journal of the American Medical Association

PUBLISHED WEEKLY.

SCBSCRiPTioN Price. Including Postage.

Per Annum, in Advance $5.00

Single Copies 10 cents.

Subscription may begin at any time. The safest mode of remit-
tance is by bank check or postal money order, drawn to the order
of The JorRN-'\L. When neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
letters.

Address

Journal of the Americ.^x Medical Association,

No. 6S Wabash Ave.,

Chicago, Illinois.
All members of the Association should send their Annual Dues
to the Treasurer, Richard J. Dunglison, M.D., Lock Box 1274, Phila
delphia, Pa.

London Office, 57 and 59 Ludgate Hill.
SATURDAY, NOVEMBER 9, 1889.

EARLY DL\GNOSIS BETWEEN BENIGN AND MA-
LIGNANT NEOPLASMS OF THE LARYNX.

The editorial assertion of the British Medical
Journal, that lar3'ngeal neoplasms which origi-
nall}^ show no trace of malignancy ofteii assume
a malignant character in consequence of the irri-
tation produced by attempts at removal, will be
remembered in connection with the case of the
late Emperor Frederick the Third. The assertion
was apparentl}' based upon the opinion of Mr.
Lennox Browne advanced to this effect as early
as 1875, which position had been accepted as cor-
rect by Sir Morell M.\ckenzie and in part, but
only in part, substantiated by Dr. J. Solis-Co-
HEN, inasmuch as he qualified by "occasionally"
and " sometimes " in place of " often ;" " It oc-
casionally occurs that papillomata become trans-
formed into epithelial carcinoma, sometimes from
mere local irritation from cough and pressure, and
sometimes from irritation set up b}' repeated un-
successful attempts at removal by evulsion."
Later, Gottstein, Bosworth and Seller spoke of
the possibility of such transformations under trau-
matic influence, but without specifying intra-lar-
yngeal operations.

The subsequent discussion in the British Medi-
cal Joiunal, resulted on the part of Mr. Browne
in the substitution of the word "occasionally"
for "often " as expressed in his original opinion,
and in the inauguration, among all known lar-
yngologists, by Dr. Felix Semon, on behalf of
the Internationales Centralblatt fur Laryngologie,
Rhinologie, und venuandtc Wissenscha/teti of a

" Collective- Inquiry (Sammelforschung) relative
to the Transformation of Benign into Malignant
Neoplasms of the Larynx in consequence of Intra-
Laryngeal Operations."

The final results of the ''Sammelforschung^'
will be noticed in due time. Just now, it is evi-
dent, that to render reliable tabulations thus made
.special care is requisite regarding the correctness
of the original diagnosis — a malignant or a mixed
neoplasm, erroneously regarded early in the case
as benign, must not be entered up as a transform-
ation. Therefore, as essentially preliminarj' to
the main question and as a subject of importance
concerning the treatment of future cases, the Cen-
tralblatt discu-sses the early differentiation between
benign and malignant neoplasms of the larynx.

With what exultation and pride in the advance-
ment of medical science, as exemplified by the
dexterity of the laryngologist and the precision
of the microscopist, did we first learn that the
German Crown Prince suffered, not from carci-
noma, but from simple "pachydermia laryngis;"
and with what sense akin to chagrin did it finally
dawn upon the profession, that the Prince had
escaped the danger and mutilation incident to
laryngectomy, only to die," after all, of cancer of
the lar>'nx for which the radical operation had
been originally proposed.

It now appears that superficial papillomatous ex-
crescences are a common and earh' accompaniment
to deep-seated carcinoma of the larynx; or, in other
words, a mischgeschwulst may easily be present.
Evidently, the fault in such cases will be neither
in the dexterous extraction of a fragment, nor
necessarily in the microscopic examination, but
in the assumption that the part represents the
whole, and consequently in placing undue reli-
ance upon testimony thus secured.

The inadequate examination of mixed neo-
plasms has been the occasion of blunders, numer-
ous and deplorable. Even \'irchow confesses to
such errors in connection with fibromata, and
says : " Nothing is more deceptive than the fact
that certain parts of a tumor ma}' be formed com-
pletely- of fibrous tissue while other parts have an
entirely different structure, and unless one under-
takes a thorough investigation of all parts he is
liable to pronounce judgment according to the
part only which he has happened to examine.
This has occured to myself and I remember espe-
cially such a case, diagnosticated as simple fibro-

672 NEOPLASMS OF THE LARYNX. [November 9,

ma, in which only after relapse and on reexam- ' cerning only the fragment submitted to him, not of the
ination of the original specimen did I discover in | disease itself, unless he discovers in this fragment /o^zVzV^
• . ., 11 ^ X- ^ i ■> -r. indications of malignanc3'. The examination must not

It quite small spots of cancerous structure. Re- , ,• •. j * ■ 1 ^- u ^ u ,j

^ ' be hmited to a smgle section, but should embrace, ni

marks which, of course, are equally applicable— ! fine sections, the entire fragment submitted, unless the
tnidatis mutandis — to new formations other than diagnosis of malignancy is with certainty sooner deter-

fibromata.

mined. If necessary, the careful remoyal and micro-

KriEG, of Stuttgart, contributed to the Sam- scopic examination of fragments should be severaltimes
,j- , P ,- . . j reoeated, unless in the meantime clinical symptoms.

iiieiJorscint?ip-, as a case of transformation from i- x. -^-l. » , , . c . . ,

. which with our present knowledge of sj-mptomatology

a papilloma, one which he subsequently deter- are irreconcilable with benignity, establish with certainty
mined, by examination of additional sections I the malignant character of the neoplasm. In such cases
from the original fragment, to be a mixed neo- j a" otherwise indicated radical operation should not be
plasm : "In the oldest part there is pronounced I delayed for microscopic confirmation of the diagnosis."
pachydermia, /. e., marked proliferation of the! What, then, are the clinical symptoms which
epithelial coating with inter-overgrowth {Hincin- will aid so substantially in the diagnosis of cer-
-ivuchern) of vascular small- cell infiltrated con- tain cases? These have not yet received the de-
nective tissue' papillae. The connective tissue, ! tailed consideration which the gravity of the sub-

beneath the thickened epithelial layer, is thickly
beset with epithelial nests situated in the alveoli
of the connective tissue. There is present, there-

ject demands, but the Sammelforschung contains
data which materially enrich our literature.
The laryngoscopic aspect of a commencing ma-

fore, at the same time pachydermia and carcinoma." lignant laryngeal neoplasm is frequently that of
In a case of known primary carcinomatous infil- 1 a broad- based, semi-globular, or oblong wart. It
tration of the right half of the larynx which was | "^^y ^e situated at any point but is the more sus-
accompanied secondarily by superficial papilloma- ' picious when, in an elderly individual, it is found
tons excrescences, fragments which were twice "PO" the posterior third of the vocal cord. The
extracted and microscopically examined exhibit- ^olor of this wart varies fi-om white to reddish-
ed only the structure of papillary- fibroma. And ; gray. The surface, in exceptional cases, may be
to cite still another case from the many, in the ; q^iite smooth, lending to the tumor of reddish hue
Scmonische Fall the first pieces were microscopi- ' the appearance of a fibroma. More frequently it
cally tho.se of a papilloma, while fragments re- 's finely granulated like an ordinar}' skin-wart, or
moved only five days later gave unmistakable \ again, finely branched and villiform so that it is
evidences of epithelioma. ■ difficult to distinguish from a papilloma.

Now we have no desire to dethrone our little If benign, the wart would be wholly superficial,
God— the microscope, but wish merely to limit \ but being malignant it is accompanied by a deep-
his power to his own legitimate field of action. '^ seated infiltration which though not itself appa-
These limitations cannot be better formulated ' ''ent, yet occasions a relatively greater degree of
than in the concluding words of the author of ' ^o^i'seness or aphonia, of circumscribed conges-
the Sammclforschimg : jtion, and later, of impairment of mobility of the

.,_, . . , . . ^^ ,! vocal cord — the latter svmptom being of supreme

The microscopical examination of fragments removed • .„'.,.. ^

by intra-laryngeal methods in cases of doubtful laryngeal ' importance in the dliTerential diagnosis. These,
neoplasms, is a valuable but not infallible aid to clinical \ together with an age of over 50 years, the situa-
diagnosis. It should be used in all cases in which it is tion of the growth On the posterior third of the
possible. This, however, is not always the case, as e.g. . vocal cord, and the exclusion of syphilis, tuber-

in submucous infiltrating carcinoma, an intra-larvnsjeal .■ ji j j-_ - r i-_

° , ' , , - ° culosis, and lupus, render a diagnosis of malig-

extraction of fragments cannot always be made. Has "^ ° °

such extraction been accomplished," then one should ' *^a"t neoplasm in the early stage, almost a cer-

never forget; i, that the examination need not necessa- tainty.

rily yield results characteristic of any particular form of '-

tumor; 2, that, even when the examination presents ap- TenTH INTERNATIONAL MEDICAL CONGRESS.

parently characteristic results, the possibility of a mixed , _^^^ German Imperial Ministry of the Interior

neoplasm should be remcnibered; Darticularly so in cases , , , „ , ,

, • , ., , ...,.-.,, . . , ., has made a grant of 80,000 marks — 520,000 —

m which the new tormation is c/i/iicat/v suspicious while

the microscope furnishes apparent evidence of its iuno- towards the expenses of the International Med-
cence The microscopist can give an opinion con- 1 ical Congress, to be held in Berlin in 1890.

1889.]

AMERICAN ACADEMY OF MEDICINE.

673

A PHYSICIAN'S RESPONSIBILITY IN MEDI-
CATION.

The present area of medical advance is charac-
terized not only bj^ improvements in surgical ap-
pliances, but by numberless additions to the
armamentarium of the physician. In our eager-
ness to try the new, it would seem that some of
the cardinal points in drug administration are
lost sight of, or at least neglected. From a sum-
mary made from many thousands of prescriptions,
it would seem that physicians generally pay close
attention to dosage, and to physiological action
of medicaments in the abstract, but give entirely
too little attention to the factors which influence
the therapeutic physiological action of drug in a
given case, namely, the fugaciousness of action,
the term of maximum intensity, the rapidity of
absorption and elimination, and the fact that
drugs act very differently' in varj-ing doses.

It has become a routine practice to give quinine
in sthenic fevers, three or four grains at a dose
three or four times a daj', even in the early stages
of fever. Quinine has but little influence in
lowering the temperature when the cur\'e is up-
wards. It is only when the wave has reached its
height and is turning, that the drug gives a de-
cided answer and carries the ebb far below the
point it would have reached unaided. Again
quinine inhibits, in some degree, the rise of tem-
perature if a maximum effect of the drug can be
obtained before the commencement of said rise.
Such being the case, given the temperature record
of a patient, it can be seen at a glance when to
apply the remedy so as to obtain the greatest
effect with the smallest quantit}' of drug. No
general will spread his troop over a wide terri-
tory in straggling line, but endeavor. Napoleon
fashion, to mass his men and throw their weight
upon the weak point. We have not absolute
control of disease, but lead our patient's vital
forces to battle with it. Our drugs are auxiliaries.
In all forms there is usually a morning remission
of temperature. The time to give quinine is
after the maximum wan at midnight, and before
the morning rise. In this way, 10 grains of the
drug will accomplish as much as one-third more
of the drug given in divided doses through the
day.

Bromide of potash is exceedingl}' slow in its
action, attaining a maximum in six hours, and
not being all eliminated in twenty-four to thirty-

six hours. Now suppose a patient is taking 20
grains three times a day. By the time the first
dose is in full action, a second is ingested, and
again a third before the previous doses have been
eliminated. Therefore an epileptic taking the
above dose continuously has his vaso-motor
centres laboring under the impress of not 20-grain
doses, but two or three times the quantitj'.

In contrast, we have nitroglycerin, one of the
most fugacious of all the remedies used for con-
tinuous action. It attains its maximum in three
to ten minutes, and is all eliminated in from
thirty to forty minutes. In painful nerve affec-
tions, in local congestions and headaches, and in
spasm, to obtain a rational effect from it, we must
give it not two or three times a day, but almost
everj' hour.

Chloral begins its action fifteen minutes after
ingestion, and is mainly eliminated in from two to
four hours. When it is desirable to maintain a
sedative action over anj- extended period, either
the dose must be repeated or some drug given in
combination whose effect is more lasting.

There are many drugs that it would seem best
to use in full dose at commencement, and to ad-
minister from time to time such increments as
will make up the gradual loss bj- excretion and
thus keep the patient under a more or less con-
stant impression of the drug for hours at a time.
This, it would seem, is particularly true of opium
preparations.

Illu-strations might readily be multiplied, but
our object is not so much to illustrate as to call
attention to the fact, that the smallest part of a
physician's responsibility in medication is the ab-
stract dosage — that the question before him is not
how much of a drug is needed for a therapeutic
response, but how much is needed in the particu-
lar case before him to meet all its requirements,
and how should it be administered.

THE AMERICAN ACADEMY OF MEDICINE.
As announced elsewhere in this issue of The
JouRN.\L, the next annual meeting of the Acade-
my will be held in this city during this month.
The aim of the Academj' deserves to be better
known to the profession. It recognizes the fact
that one of the principal objects of the organiza-
tion of the American Medical As.sociation was to
aid in elevating the medical profession of the

674

EDITORIAL NOTES.

[November 9,

United States by every practicable means, and
thus securing better care for the public health ;
and the further fact that the investigations and
reports of its committees, especially those on the
education — preliminary- and medical — of medical
men, showed that it had done much to secure the
honorable standing of the medical profession in
the United States at the close of the first century
of American independence, as shown in the gen-
eral addresses delivered at the Centennial Inter-
national Medical Congress in 1876. With a de-
sire to supplement the work, so well begun by
the American Medical Association, the Academy
was organized during that congress with the de-
sign of securing the cooperation of those members
of the medical profession who themselves had
had the advantages of a liberal course of study
before entering upon their medical studies. Be-
lieving that the advantages which result from
the mental discipline gained by pursuing a clas-
sical or scientific course of stud3' enables the
medical student to prosecute his medical studies
more profitabh-, it encourages the most liberal
preparator>- training, and advocates ample pro- '
vision for theoretical and practical instruction by
medical colleges. By concentrating its efforts
mainly in the direction of securing frequent con- '
ference as to the requirements of the age, and the
best methods of fitting j^oung men for the study
of medicine and the most profitable manner of
pursuing their professional studies, it believes :
that its existence and its efforts serve a useful {
and an honorable purpose. It is at present en-
gaged upon an important investigation as to the
proportion of physicians now in active practice
in the United States who have had the benefit of
such preliminarv' training as it advocates. It in- i
vites the cooperation of all physicians who not
only desire, but who will aid in securing for those
entering the medical profession, and who are to
fill our places in it in the future, the best equip-
ment for it.

EDITORIAL NOTES.
HOME.
New Building roR the Phil.xdki.phia Poi.v-
CI.1NIC. — The contract for the erection of the new
college, hospital, and dispensary building of the
Philadelphia Polyclinic and College for Graduates
in Medicine, was awarded October 5.

The new structure will rest on a lot 96 feet by

143 feet, about three blocks from the present
temporary quarters, and will be of brick, sand-
stone, and terra-cotta. It will be four stories in
height, and will occupy at present only one-half
of the lot.

The important features of the building will be
the incorporation of the most modern accepted
plans in hospital con.struction.

The system of heating will be bj' indirect radi-
ation, and the ventilation that of sub-stratum
suction. All corners in the building will be
rounded to avoid the accumulation of dust. The
water-closets and bath-rooms will be in a separate
building easily accessible from all parts of the
building. The kitchen and laundr3' will be at
the top, separated from the lower floors by an
artificial stone floor. The clinic rooms will be
on the first floor in direct communication with a
spacious waiting-room.

The corner-stone was laid with impressive
masonic ceremonies on the 2d inst.

Dr. Carl Koeler, the discoverer of cocaine
anaesthesia, has been made instructor in Oph-
thalmology at the New York Polyclinic,

The American Academy of Medicine
which meets in Chicago on November 13 and 14,
will hold its sessioiK at the Leland Hotel. Dr.
Lester Curtis is Chairman of the Committee of
Arrangements. Dr. S. J. Jones is Chairman of
the Committee on new members, to whom appli-
cations for fellowship in the Academj' may be
addres.sed. A cordial invitation is extended by
the Academy to physicians to attend its meeting,
and especiall3' to those who are interested in a
higher standard of qualification for the medical
profession, beginning with the preliminarj- edu-
cation of students.

FOREIGN.

Dr. Phillippe Ricord died in Paris, October
2 1 . He was the world renowned syphilographer,
and was verj- often spoken of as the great Ameri-
can ph3'sician of Paris. He was born in Balti-
more, December 10, 1800. His father was a
native of France, and young Ricord went to
Paris in 1820, and took his medical degree in
1826. After a few j-ears he settled for life in
Paris, and went to the front rank in surgery. He
was Court-Surgeon under the third Napoleon,
and was the recipient of numerous decorations.
Notwithstanding his advanced years, he was until
quite recentlj- a prominent character in Parisian
medical societv.

1889.]

TOPICS OF THE WEEK.

675

TOPICS OF THE WEEK.

THE UNITED STATES CENSUS IN ITS RELATIONS TO

SANITARIANS.

From a paper presented bj- Dr. John S. Billings at
the annual meeting of the American Public Health Asso-
ciation held in Brooklyn October 25, we make the follow-
inij extract;

Theoretically we all agree that vital statistics are the
foundation of public medicine; but practically, the ma-
jority of sanitarians and physicians think that they are
not essential to the work of a health officer or Board of
Health, although they may be desirable. That the main
objects in sanitary work are to see that the water supply
is pure, that garbage and excreta are promptlj- removed
or destroyed, that no filth is allowed to accumulate in the
vicinity of habitations, that contagious diseases be con-
trolled by isolation and disinfection, and that plenty of
fresh air be provided in schools, churches, etc., and that
all this can and should be done whether death-rates are
known or not. Occasionally it is possible to get up a
cholera, or yellow fever, or smallpox or typhoid fever
scare, and to thus get a little money for sewerage or for
street and alley cleaning; but these spasmodic reforms
do not last long, and in most cases do not amount to
much. You have got to produce constant, undeniable
evidence that the work is needed and is useful ; evidence
that will convince the press and the majority of the com-
munity, and this evidence must be mainly death-rates, to
which should be added all the sick-rates that can be ob-
tained.

To give these death-rates you must have a complete
registration of deaths and a corresponding enimieration
of the population, and you ought to have a complete
registration of births.

Before this Association meets again the eleventh United
States census will be taken, and its methods, its complete-
ness, and the mode in which its results will be tabulated
and published, are of great interest and importance to
all who are interested in sanitary science or in public
health work in this country.

One of the most important questions, then, to be set-
tled before the census is taken, is; What shall be the
boundaries of the special districts of the city for which
a separate statement of the population is desired?

For about a dozen of our large cities it is proposed to
make a sj-stematic division of the area into sanitarv dis-
tricts having special relations to altitude, character of
habitation or of population, etc., and to have special
death-rates calculated for each of these districts. This
is being done in conference with the health authorities
of these cities, and it is hoped that in this way some very
interesting data will be obtained which will serve as a
foundation for sanitary work in the future. Such dis-
tricting has been arranged for Boston, New York, Brook-
lyn, Washington, New Orleans and Louisville, and the
work is in progress for other cities. In investigating the
details of the records of deaths kept in different cities I
have noted deficiencies in a few of them to which I wish
to call the attention of all who have to do with the regis-

tration of vital statistics. First, all deaths occurring in
hospitals should be charged to the ward or district of the
city from which the patient was taken to hospital, where
this can be ascertained. Otherwise the death-rate in the
ward in which the hospital is located will be too high,
and in the other districts it will be too low.

Second, the birthplace of the parents of the decedent
should be reported. We want to know the race of the
decedent — whether he was German, Italian, Irish or
American, and to give merely his own birthplace is not
sufficient.

Third. It is very desirable that in all cases of deaths
of colored persons it should be stated whether the dece-
dent was black or of mixed blood, such as mulatto or
quadroon.

One of the most important questions in the vital and
social statistics of this country relates to the fertil-
it}', longevity and liabilit3' to certain diseases of those
partly of negro and partly of white blood, and the only
way to obtain data on this subject is through the regis-
tration of vital statistics.

Under the provisions of the law providing for the cen-
sus, the living colored population is to be enumerated
with distinction as to whether such person is black, mu-
latto, quadroon or octoroon, and we need the same dis-
tinctions for all persons dying during the census year, to
enable us to calculate comparative death-rates. Wher-
ever there is a fairly accurate registration of deaths,
which now exists in several States, and in over 100 cities,
the next census will afford the means of calculating the
death-rates, with distinctions of color, sex and age which
will furnish important indications for sanitarj- work.

I have no authority to make specific promises, but I
believe that the reports of the next census, in which the
members of this Association are specially interested, will
be published as soon as it is possible to compile them,
and will be distributed to those sanitarians and physi-
cians who need them in their work and who make time-
ly request for them; and thus believing, I do not hesitate
to ask the cordial cooperation of all members of this
Association to make the data upon which these reports
are founded as full and accurate as possible.

CHANGES IN THE GANGLION CELLS AFTER STIMU-
LATION.

The theory has for a long time been held that the
change in activity in the central nervous system, that is,
the performance of its function by any nerve centre com-
posed of ganglion cells, was accompanied by some phy-
sical or chemical change in the cells. This theory has
at last received demonstrative evidence in its favor from
certain recent investigations. Korybutt-Daszkiewicz'
has attempted to solve the question whether the activity
of the central nervous system is accompanied by changes
recognizable with the microscope. His experiments
were conducted on two frogs of the same weight and sex.
One was kept as a control, in the other the eighth nerve
was stimulated by induction shocks for an hour. The
cords of both were hardened and stained by Gaule's
method with haematoxylin, nigrosiu, eosin, and safranin.

f .\rcliiv. f. inik. Anal., lS.Sg. p. 5:.

676

TOPICS OF THE WEEK.

[November 9,

The nuclei of the ganglion cells were the point of chief
interest. These stain red and blue, but he finds that
3.31 to 3.66 times more nuclei stain red in the stimulated
frog than in the unstimulated frog. Hodge, who has in-
vestigated the same subject, questions the accuracy of
this method, thinking that the red nuclei are more super-
ficial than the blue, and that the thinner the section the
greater the number of red nuclei. Hodge's method was
to stimulate one or more nerves on one side of the body,
and then remove the corresponding spinal ganglia on
both sides, keeping them together all the time in the
hardening and staining fluids, and making simultaneous
sections. The treatment is thus absolutely identical, the
only difference being that one ganglion has had its nerve
stimulated while the other has not. He finds that the
stimulated ganglion shows distinct differences ; the
nuclei in its cells are smaller, the outlines are jagged and
irregular instead of round, and there is a loss of open
reticular appearance with darker stain. The cell pro-
toplasm shows a slight shrinkage in size, it has a lessened
power to stain or to reduce osmic acid, and it becomes
finally granular and reticulated. The cell capsule also
shows a decrease in the size of its nuclei. These iuves-
tigatious are practically the first undertaken upon this
subject, and their importance as confirming the theory
of nerve action is great. They indicate, moreoverj the
importance of applying similar methods in the investi-
gatiou of so called functional diseases of the nervous
system, for they seem likely to render the old distinction
between functional and organic disease of no value. —
Philip Cooms Knapp, in Boston Medical and Surgical
Journal.

I

ship is full, the space set apart for the hospital is very-
apt to be used by the agents for berthing ordinarj- pas-
sengers. If the surgeon protests, he is snubbed, and if
he records the fact in his report, which ought, according
to regulations, to be forwarded to the Board of Trade
when the vessel returns, he is very likely to have the
document returned to him by the agents with the intima-
tion that the matter is one which does not come within
his province. It is within the powers of the Board of
Trade to compel the steamship companies to obey the
law as to the reservation of the ships' hospitals for the
use of the sick alone ; and it is not easy to understand
why frequent and repeated breaches of the law are
winked at by the oSicials. — The British Medical Journal.

STE.'^MSHIP S.\NITATION.

Among the subjects to be discussed at the meeting of
the American Public Health Association at Brooklyn this
month (October) is "Steamship Sanitation." The mat-
ter is one of considerable importance to the Eastern
States, and through them to the whole Union. Owing
to the supineness of the Board of Trade and the short-
sighted selfishness of the steamship owners, there is a
continual danger that whole shipfuls of passengers may
be landed at New York, Boston, or any other Eastern
port, bearing with them the germs of infection contract-
ed during the Atlantic voyage. The inspection of emi-
grants at British ports, though carried out, we believe,
as a rule, by the medical officers with the most conscien-
tious care which the circumstances permit, is little better
than a farce. The emigrants are gathered upon the
wharf and at a signal admitted on to a narrow gangway,
along which they struggle with their bedding and all the
small impedimenta for the voyage. As they issue from
the gangway they are hastily inspected, and any case
presenting obvious or suspicious symptoms is made to
stand aside for more careful examination. Even this
rough inspection is better than nothing, and a practised
eye will no doubt weed out most of the dangerous cases.
If the surgeon of the ship could always ensure the isola-
tion of the suspected cases, a very great step would be
taken towards the attainment of the desired end. Un-
fortunately this is by no means always the case ; if the

THE ESSENTI.\LS OF SUCCESS.

Sir .\ndrew Clark, who has achieved a professional
reputation which is world-wide, had occasion, in a recent
address, to give his views of what is required to make a
man a successful physician. In that address he uses the
following language :

Firstly, I believe that every man's success is within
himself, and must come out of himself. No true, abiding
and just success can come to any man in any other way.
Secondlv, a man must be seriously in earnest. He must
act with singleness of heart and purpose ; he must do
with all his might and with all his concentration of
thought the one thing at the one time which he is called
upon to do. And if some of my young friends should
say here, " I cannot do that — I cannot love work," then
I answer that there is a certain remedy, and it is work.
Work in spite of }»ourself, and make the habit of work,
and when the habit of work is formed it will be trans-
figured into the love of work ; and at last you will not
only abhor idleness, but you will have no happiness out
of the work which then you are constrained from love to
do. Thirdly, the man must be charitable, not censorious
— self-effacing, not self-seeking ; and he must try at once
to think and to do the best for his rivals and antagonists
that can be done. Fourthly, the man must believe that
labor is life, that successful labor is life and gladness,
and that successful labor, with high aims and just ob-
jects, will bring to him the fullest, truest and happiest
life that can be lived upon the earth.

THE LATE DR. JOULE.

Dr. James Prescott Joule, who died at Sale on Oc-
tober 9th, in the 71st year of his age, was one of tlie most
distinguished men of science which this country has
ever produced, and is entitled to be reckoned one of the
greatest of original workers in pure science. His great
achievement was his determination of the mechanical
equivalent of heat. The consequences flowing from the
working out of this problem, which was achieved by Dr.
Joule with the most consummate skill and admirable
completeness, are to be noted in almost every depart-
ment of science ; upon his demonstrations the whole
theory of the correlation of forces is mainly based. The
most important practical applications have been in the
mechanical arts, but even physiologj- is his debtor.

1889.]

PRACTICAL NOTES.

677

PRACTICAL NOTES.

THE DIGESTIBILITY OF BOILED MILK.

It is now verj' regularly recognized, both bj'
medical men and by the more highly educated
section of the community, that it is a wise pre-
caution to boil both water and milk before using
them as beverages, and the practice is becoming
very common. The growth of pathogenic organ-
isms in these fluids, especially in milk, is often
verj- rapid, and thus diseases may be transmitted
from one place to another. The temperature of
boiling water puts an end to the life of the mi-
crobes, and also to the danger of infection.
Another reason why boiled milk is so much used,
especially in infant feeding, is that it is supposed
to be more easily digestible than fresh milk. If,
however, we can draw correct deductions from
dogs to babies, it would now appear that this be-
lief in the superior digestibility of boiled milk is
founded on error. Dr. Randnitz, of Prague, has
recently published, in HoppeSeyler's Zeitschrift
fur physiologische Chcmie, certain very striking
experiments on this subject. He admit, what
anyone may confirm for himself, that milk that
has been boiled does not, on cooling and the sub-
sequent addition of rennet, form a large coherent
clot, as does fresh milk, but a flocculent precipi-
tate of ca.sein is produced instead. He shows,
however, bj^ analysis of the milk itself and of the
urine and faeces, that much less nitrogenous ma-
terial is absorbed from milk that has been boiled
than from the same milk when fresh. The di-
gestibility of fat is apparently unaltered by boil-
ing ; the following figures, however, illustrate the
fact just alluded to as to the difference of digesti-
bility of the proteid materials : In three days
15.6 grams of nitrogen were given in the form of
fresh milk ; of this quantity 13.3 per cent, was
found in the faeces ; the nitrogen of the urine ac-
counted for 77.3 per cent., so that 9.4 per cent.
was retained in store b)^ the growing animal.
The animal was next fed on boiled milk, and
10.4 grams of nitrogen were given in that form
for two days ; 18.6 per cent, of this was found in
the faeces, 75.7 in the urine, so that onlj- 5.7 per
cent, was assimilated. The belief in the superior
digestibility of boiled milk is, however, so wide-
spread, that we should like to hear of the confir-
mation of the above remarkable results before we
recommend mothers to leave off what is, from
other points of view, the ver}' praiseworthy cus-
tom of boiling the milk thej' give to their chil-
dren.— British Medical Journal.

TREATMENT OF DIABETES BY ANTIPYRIN.

Dr. Joseph S. Carreau, of New York {Med.
Record), cites three cases of this disease success-

fully combated by this remedy. He also states
the fact that Dujardin-Beaumetz, at a meeting of
the Academic de Medecine, April, 1888, praised
the happy effects of antipyrin in certain cases of
diabetes, especially when the two symptoms,
polyuria and nervous irritation, predominated.
Henri Huchard, at theSociete deTherapeutique,
February, 1888, said that he emploj'ed antipyrin
in a case of symptomatic polj'uria resulting from
meningo-myelitis, with good effects. He gave
from 4 to 6 grams daily, and the quantity of
urine was brought down from thirty-six litres to
four. He also reported a case of diabetes, where
he noticed, in a few days, the sugar diminish
from 735 to 271 grams a day under the use of
antipyrin — two to six grams daily. He also said
that the prolonged administration of antipyrin,
in his own experience, has never been followed
by albuminuria.

M. Panas reported two cases to the Academic
de Medecine, April, 1889, where great relief fol-
lowed the administration of antipyrin. A man
aged 38, passing 49 grams of sugar in twenty-
four hours, by taking 2 or 3 grams daily during
six days, had all traces of sugar in his urine re-
moved. A woman, aged 73, by taking 3 grams
daily for a few days, also received similar benefit.
— Canada Lancet.

SALICYLIC ACID IN TYPHOID FEVER.

Dr. Schakovski {Thera. Monatsh.) claims
great success from the use of salicylic acid in
malignant scarlatina. He has used it in 125
cases. The mortality is but 3^ per cent. The
following formula was used :

R Acidi salicylic! i part.

Aquse destillatee 75 parts.

Syr. aurantii cort 30 parts.

M. Sig. Give a teaspoonful every hour during the
day, and every two hours during the night.

The temperature falls very rapidly after taking
this mixture, so that in certain cases, inside of
forty-eight hours, the temperature has fallen from
105.8° F. to 100.4° F' All trace of fever van-
ishes by the tenth day. Nevertheless the author
advises the continuance of the remedy for some
time, in decreasing doses, to prevent a relapse.
All serious complications, such as uraemia, ana-
sarca and diphtheria, are avoided through this
treatment. The treatment is ineffectual only
when employed too late (after the fourth day of
the illness), or where grave complications already
exist. — Afedical Standard.

A REMEDY FOR NEURALGL^ WITHOUT MORPHINE.
R Antipyrin .5 iij-

Ex. cannabis lud

Ex. aconite aa gr. vss.

Caffein ,5 ss.

Hj^oscine hydrobrom gr. T.

Divide into 30 capsules.

678

SOCIETY PROCEEDINGS.

[November 9,

SOCIETY PROCEEDINGS.

The American Piiblio Health Association.

The American Public Health Association met
this jear at Brooklyn, N. Y., for its seventeenth
annual session. It occupied part of four days,
from October 22 to 25. In the number of its at-
tendance and the quality of the scientific results
the verdict, on the part of its /labituh, has been
that the meeting was a success. Not much time
was allowed to run to waste on outside entertain-
ments : the unwritten law of the Association
being distinctly in favor of giving the minimum
of time to excursions, collations and the like.
Three diversions were permitted at Brooklyn.

The first Was the exhibition of sanitarj' appara-
tus, food materials and the customary range of
inventions promotive of good health, that finds
place in this kind of exhibition. This is the first
exposition of the sort that has been attempted at
any annual session of the Association. It was a
modest show, tentative in extent, but sufficiently
attractive to make it probable that it will be tried
more fully at future meetings, when the local
committees shall see fit to give their time to it.
The present report is that the exhibition has been
self-sustaining ; an income having been derived
from the rental of floor space to the exhibitors.

The second diversion was a public meeting held
at the Academy of Music, on the evening of the
first day, in order to extend the freedom of the
city to the visitors. At this meeting, which the
citizens and especially the medical profession at-
tended en masse, addresses of welcome were de-
livered bj' the Mayor of the city, Mr. Chapin, Dr.
Alexander Hutchins, for the profession, the Rev.
Dr. R. S. Storrs and ex-Mayor Seth Low, who
has just been elected to the Presidency of Colum-
bia College, in New York City. These are four
speakers who, in their respective fields, are held
in highest esteem in the community. The ad-
dress of Dr. Hutchins was, in a marked manner,
approved and enjo3^ed bj' the medical members
present.

The third diversion was an excursion, by steam-
er, on the afternoon of the second day, to the
Quarantine Station on the Lower Baj- of New
York Harbor. The original plan of this excur-
sion included a visit to the islands in the East
River, on which are located the charitable insti-
tions of New York City, but lack of time pre-
vented the carrjnng out of that part of the pro-
gramme; the blustering weather, also, was rather
adverse to a prolonged sail after visiting the ob-
jects of interest in the harbor below. Two hun-
dred and twenty delegates and their friends took
the excursion. A collation, given by the citizens
of Brooklyn, was served during the sail. The

visit to the quarantine islands was upon the cor-
dial invitation of Dr. William M. Smith, for
many years the Health Officer of the Port of New
York. Dr. Smith sought this as a favorable op-
portunity of explaining the modus operandi of a
modern, non-stringent quarantine, and of making
better known to the official members of the Asso-
ciation some of the changes instituted by him in
recent years. With the exception of the fore-
going, the time of the Association was wholly
given to the consideration of scientific business.

The notable papers, prepared for the conven-
tion, included one \>y Dr. John S. Billings, U. S.
Army, who took for his subject T/ie Sanitary Re-
lations of the Federal Census ; one by Dr. George
M. Sternberg, also of the Army, who treated of
Vello-ii.' Fever and its Etiology, therewith present-
ing microphotographic illustrations by means of
the stereopticon ; one bj- Mr. Edward Atkinson,
of Boston, on The Economies of Cooking-, made
plain by the preparation and service to the audi-
ence of a hot supper, cooked in ovens invented by
himself, over two oil lamps, while his lecture was
in progress ; one bj- Dr. Salmon, of the National
Bureau of Animal Industr}', who gave an illus-
trated discourse on The Texas Cattle Plague; also
a paper by Prof. W. O. Atwater, of Washington,
on The Physiological Chemistry of the Dietaries of
various IVatio?is and Occupations.

The stimulating and instructive nature of many
of these addresses, as well as of others on the va-
rious problems vexing the medical officer of health,
was manifest in that they called forth a volume of
debate which was far in excess of the time appor-
tioned to the discussion of papers. If a full week
' had been the length of session, it would have been
none too long to have been occupied by the themes
that were ripe for consideration in the minds of
the members. The presiding officer had frequent-
ly to cut short an interesting subject by reason of
the preassignment of the time to other interesting
matters.

The Presidential Address of Dr. Hosmer A.
Johnson was cordially received by the popular
audience to which it was read (see Journal, No-
vember 2, 1889).

The Overshadowing ofourHotnes, by Dr. Thorn-
ton Parker, of Newport, was the subject of the
first paper of the first day. The contention of
this paper was adverse to the large or general em-
ployment of shade trees, as exemplified in the
towns of New England. Dr. Maxwell, of Flor-
ida, and others from the Southern States defended
the shade tree.

Infant Mortality occupied the afternoon session
of the first day very fully. Papers of excep-
tional value were presented by Dr. Jerome Walk-
er, of Brooklyn, and Alfred White, Esq., al.so of
Brooklyn ; the latter giving the results of a large
experience in the construction of improved tene-
\ ment houses. Dr. George Homan, of St. Louis.

1889.

SOCIETY PROCEEDINGS.

679

offered some suggestions regarding the compensa-
tion due to health officials.

On the second day, Dr. Billings gave an out-
line of the proposed studies in vital statistics to
be carried out under the coming census, inclusive
of new features to be introduced in regard to the
sanitary districting of ten or more of the larger
cities. His propositions elicited much discussion.
Dr. J. N. McCormack, of Kentucky, in this con-
nection, introduced a resolution instructing that
an effort be made to establish cordial relations
with Cuba and Mexico, in respect of the sauitar}'
departments and undertakings of tho.se countries.
Later this was adopted by the Executive Com-
mittee.

Dr. Ezra M. Hunt, of New Jersey, took up the
subject of Phthisis Pfeveiition and the Methods,
iyidicatcd by the latest Researches, to be employed to
that End. The discussion of this subject was de-
ferred until the following day, when it was opened
by Dr. J. S. Billings, who inclined to limit the
preventive official measures to precautions against
the aerial diffusion of dried phthisical sputa.

Dr. Gihon, of the U. S. Navy, introduced a
resolution declaring the sentiment of the Associ-
ation to be favorable to the adoption of preventive
means, as to the disease in question, so far as to
recommend the destruction of the tuberculous
.sputa.

The further discussion of the prevention of tu-
berculosis was taken up on the afternoon of the
third day, the papers introductory thereto being
presented by Dr. Iidward Playter, of Canada, and
Dr. P. H. Kretzschmar, of Brooklyn. The latter
speaker defended the doctrine of the heredity of
phthisis pulmonalis and laid down the following
propositions :

Fi?-st. If there are many children in a family,
those born after the sixth or after the seventh are
apt to develop pulmonary consumption.

Second. If the children in a large family are
Ijorn at short intervals, say one year, the younger
ones are apt to develop pulmonary consumption.

Third. If the offspring of healthy parents,
born under conditions named above, escape the
disease, their children are apt to develop pulmo-
nary consumption.

The discussion was animated on every point
bearing on the prevention of the spread of tuber-
culosis, and is destined to be renewed at future
meetings, many members not having had a full
freedom to express their views.

Prior to the midday excursion, on the second
day, remarks were made by Health Officer Smith
and Dr. Raymond explanatory of the conditions
and modifications of quarantine administration in
the harbor of New York. The remarks of Dr.
Smith dealt largely with details of construction
and will, when printed, have that value that be-
longs to a work of reference. It transpired later
that while, or about the time, these remarks were

being made, there was delivered at the morgue of
the quarantine hospital the body of a yellow fever
victim, a sailor who had died a few hours before
on a steamer coming in from a Central American
port. A few members only knew what the morgue
contained.

The morning session of the third day, October
24, was chiefly given up to papers and discussions
having relation to garbage disposal and the pol-
lution of streams. The chief papers were by Drs.
Martin and Kilvington, the Health Commissioners
of the cities of Milwaukee and Miinieapolis. Ac-
cording to Dr. Martin the cremation of city refuse
had not proved to be the success that it promised
to be in the Western cities. He said :

" Cremation as a sj'stem has had its day, and a
brief one it has been.

"The present system in the city of Milwaukee
is the Merz system, which, from June 1 1 last, has
given the best of satisfaction. The quantity of
garbage collected is 40 tons daily, which with
that brought to the works b}- the commission
dealers, wholesale men and grocers, brings the
total up to 50 tons, which is promptly disposed
of. The works are situated in the slaughter
house district, and the building is a two- story
frame, 62 by 1 10 feet. The garbage teams drive
up an inclined roadway to the second stor}-, where
the garbage is thrown on the floor to be scraped
into the driers, of which we have eight. The
time occupied in drying the garbage varies, of
course, with the quantity and amount of moisture,
but is usually from eight to eleven hours."

Another practical subject, the use of sulphur
as a disinfecting agent in the hands of sanitary
officials, was brought to the front by a paper by
Dr. Cyrus Edson, of New York City. Many
health officials participated in the debate on this
subject. The preponderance of opinion seemed
to be in favor of the value and efficacy of sul-
phurous fumigation when thoroughly performed,
and when the vapor of water was freely generated
in the apartment containing the infected materi-
als ; also that the wetting of articles with water
is not desirable, lest there be a bleaching process
set up and a damage to certain fabrics bj- sulphu-
rous acid gas.

On behalf of Dr. Ranch, of Chicago, the fol-
lowing motion was introduced and suitably re-
ferred :

WllERE.^S, Asiatic cholera, leavins; its usual restricted
bouuds, threateus to advance by the same lines that it has
followed in the last four epidemics, be it

Resolved, That the American Public Health Association
desires to call renewed attention to this fact, and to urge
that quarantine authorities on the Atlantic and Pacific
seaboards and boards of health throughout the country
make ever)' effort to prepare for this threatened danger.

The evening of the third day had two papers
finely illustrated by stereopticon views : first, a
paper on Sa/iitarv Disposal of the Dead, by Rev.
Charles R. Treat, of New York City ; .second, one

68o

SOCIETY PROCEEDINGS.

[November 9,

by Dr. Benjamin Lee, of Philadelphia, on The
Sanitary Reasons 7vhy Cuba should be Annexed to
the LJyiited States. The dangers from yellow fever,
small-pox and leprosy, under the present Cuban
Government, are such. Dr. Lee maintains, that
this country may lose, in a single season, by im-
ported infectious disease, more than the island of
Cuba is worth if it were bought outright from her
proprietors, at their own valuation. The illustra-
tions of leprosy, presented by Dr. P. A. Morrow,
of New York, were greatly admired ; the closing
one being a portrait of the late Father Damien,
the leper priest of Molokai.

According to the paper of Rev. Mr. Treat the
newly proposed plan of sanitary entombment will
bring down the cost of corpse disposal to about
$15 for each body entombed.

The morning of the fourth day, chiefl3' occu-
pied though it was by ofBcial reports and routine
business, was partly given up to a discussion of
The Causes of Infant Mortality, based upon a vig-
orous paper, prepared by Dr. R. O. Beard, of Min-
neapolis, and read by Dr. Gihon. Several health
ofiScers participated in the debate, who showed
the difficulties they have to contend with on ac-
count of the vague or misleading nomenclature
of the causes of death employed by many physi-
cians. Dr. G. C. Ashmun, of Cleveland, instanced
the use of the term " marasmus," by physicians
of prominence, to cover nearlj' everj' case of in-
fantile mortality, especially when the mortality
must be published in institutional reports. The
phrase indicates nothing that is useful for statis-
tical or sanitary purposes, and should be put in
the same categorj- with "debility" and "heart
failure."

Dr. W. M. Smith held that it should be the
duty of every health officer to decline to accept
certificates of death which evade, omit or vaguely
state the cause of death, not less with regard to
infant than adult mortality.

Growing out of this discussion, a motion was
made for the appointment of a special commit-
tee. Dr. Jerome Walker, of Brooklyn, to be chair-
man, to consider The Causes and Prevention of
Infajit Mortality, and report, from year to year,
at the discretion of the Executive Committee.

The convention closed about noon on the fourth
day, up to which time the attendance continued
creditably large. By some of the members it was
pronounced the most satisfactory in the past his-
tory of the bod)'.

The officers elected for the coming year are as
follows: President, Dr. Henry B. Baker, of Mich-
igan ; first Vice-President, Dr. Frederick Monti-
zambert, of Quebec ; .second Vice-President, Dr.
Jo.seph H. Raymond, of Brooklyn. The Secre-
tary, Dr. Irving A. Watson, and the Treasurer^
Dr. Berrien Lindsley, were reelected. The fol.
lowing elective Trustees will .serve one year : Dr
H. B. Horlbeck, of Charleston, S. C; Dr. L- T'

Salomon, of New Orleans ; Dr. Wm. Bailey, of
Louisville; Dr. Peter H. Bryce, of Toronto, Can-
ada ; Dr. J. F. Kennedy, of Des Moines ; and Dr.
Walter Wyman, of Washington, D. C. The time
of holding the next meeting, not definitely fi.xed,
will be early in November, 1890; place of meet-
ing, Charleston, S. C.

On motion of Dr. Plunkett, of Tennessee, a
special vote of thanks was tendered to Dr. J. H.
Raymond, chairman of the Brooklyn local Com-
mittee of Arrangements, for his arduous and suc-
cessful efforts on behalf of the convention then
drawing to a close. The daily papers of Brooklyn
and New York City were very cordial and appre-
ciative, reporting the proceedings very fully and
praising without stint the efibrts of the members
on behalf of the preservation of public health.

Obstetrical Society of Ptilladelphia.

Stated Meeting, September ^, i88g.
{Concluded from page 6^/.)
Dr. Joseph Hoffman reported

A SERIES OF abdominal SECTIONS, WITH
SPECIAL REFERENCE TO COMPLI-
CATIONS.

He said : The list of operations may be classi-
fied as follows: One strangulated ventral hernia;
one appendicitis and haematocele ; sixteen cases
of ovarian and tubal disease with adhesions, in-
flammation, and occlusion of the tubes, with one
death, the result of sepsis. Where the infection
came from, for a long time puzzled me. Months
after the death I learned that the patient had had
a miscarriage brought on instrumentallj', and the
mystery was solved. In other words, I believe
the tubes were septic, and gave rise to the
peritonitis.

By this case I believe there is sufficient learned
to warrant the practice of cauterizing the tubes
after ligation and section in all doubtful cases
where there is the least suspicion of infection.
If this is not done, they should be thoroughly
disinfected and the abdomen drenched. I have
had no other death from like cause, or from peri-
tonitis from an}' cause. Six cases of pyosalpinx;
one occurred during pregnancy, and the operation
was done to save life. The woman mi.scarried
the fourth day after the operation, but made an
excellent recovery, though her pains were very
great during miscarriage, and were only con-
trolled by the free use of morphia and atropia.
All cases of pyosalpinx recovered. They are all
working in comfort, save one, who has lately
died of tuberculosis. This last case is strongly
in support of Bernutz's view, that ]nis in the
tubes is a forerunner of general tuberculosis.

In two cases, the gonorrhoeal origin of the

1889.]

SOCIETY PROCEEDINGS.

681

pyosalpinx is well established ; in two, the history
points to post-puerperal origin ; in the remaining
two, the origin is doubtful, though in one of the
cases I strongly suspect a specific start.

On died of shock — never coming out of anaes-
thetic. She was a hard drinker.

In two cases the tumor removed was dermoid.
Both were small. In one of these cases the 1
uterus was rudimentary, though the woman had
for a long time worn a pessary for a so-called dis-
placement, introduced by a specialist in gyne-
cology.

There is sufficient commentary here on the use
and abuse of pessaries without further remark.
In two cases exploratory incision was made. In
both, the women recovered quickly. One of
these soon after died after tapping ; from what
cause, I do not know. I visited her for a day or
two after tapping her, and was told that the pa-
tient was feeling so well that no further visit was
necessary-. In a week, or thereabouts, I learned
of her death in the hands of another. The j
whole air of the matter was unsavorj', and I am
not sorrj^ to remain in ignorance concerning it.
The second exploratory incision was due to an
error in diagnosis, The uterus was retroverted,
a miscarriage having occurred a short time previ-
ously. There was a peculiar thickening of the
right broad ligament, which immediately led to
the blunder. I examined the patient on my table
soon after her recover}', and had I not known
that I had erred before, the condition was such
that I would have done so again. Two small
ovarian cysts ; both recovered. One case of
omental hernia, one case of extra-uterine preg-
nancy. One case of operation for adhesions due
to previous operation. The result has now a
greater measure of success than I hoped for a
short time ago.

The drainage tube was used in fourteen cases.
I believe I would have had a better chance of
saving one of my deaths had I used it. I have
never had a death from its introduction. I have
had but one fistula persisting after its use, and
this now gives everj- sign of closing. In only
one case has there been a discharge of the liga-
ture. The patients operated upon are now all
living but four. They are all able to do their
work comfortably save two. One ca.se, I believe,
is reported to have had another operation. She
was a most ungrateful baggage, and I trust she
will tarrj' a long while on earth for the experi-
ence she will bring to others. I have had one
case of hernia after simple section. The woman
was fat, and neglected her bandage. In two
cases where it existed previously to operation it
still is present. I did not really operate for its
cure. I have found drainage and flushing the
abdomen to be of the greatest service in cleansing
the abdomen of debris, and believe them indis-
pensable. Free saline purgation, or when the

salts are not retained, mercurial purgation, is of
the greatest benefit in severe wind-pains. These
are probably- more frequently the cause of pain
soon after the operation than inflammation,
though there is no doubt that here, also, these
purges are of undoubted value. In the question
of diagnosis, I find it is much easier to say there
is a lesion than to map it out exactly- or to define
it. I have found marked trouble in cases where
expert examination pronounced disease absent :
in others, where one thing seemed to be the
trouble, another was found present. So far as
pain is concerned, it does not always indicate the
spot of the lesion. I have found one side the
most diseased when it was freest from pain.

In the thirty-three operations recorded, two
deaths have occurred. No patient was operated
on by myself more than once. The first death
occurred early in the series. In the last twenty-
six cases there has been but one death. The
last eighteen cases have been without death.

Dr. Joseph Price reported

TWO OPERATIONS FOR EXTRA-UTERINE
PREGNANCY.

The first case I have to report is that of a white
woman, set. 35, nursing a child of 13 months.
Menses appeared on the fourth month of lacta-
tion, and remained perfectly regular at intervals
of twenty-seven days ; four days duration ; were
absent two periods, followed by paroxysms of
pain and collapse. At this point I saw her, and
operated immediately for ruptured tubal preg-
nancy. I found about a quart of clotted blood in
the peritoneal cavity ; tubal rupture left side ;
hydro-salpinx right side. Clean removal of both
sides ; irrigation ; drainage ; recovery.

The second case, occurring in a pure negress,
is of great interest. I am not satisfied, from the
microscopical appearance, that it is a true
ovarian pregnancy. Ovarian cysts are very rare
in true Africans. In the blood cyst, I found
something for all the world like placenta and
: membrane. I do not wish to put this on record
; as an ovarian pregnancy until I receive the report
I of Dr. Henry Formad, the pathologist. There
i also existed in this case a hydrosalpinx of the
other side — both demonstrating most beautifully
the causal relation of tubal disease to ectopic ges-
tation. One point of great interest in connection
with these cases that sur\-ive the rupture and go
into the hands of the surgeon, is the marked
difference in the character of the hjemorrhage
I from those that go into the hands of the coroner
— and they are numerous. In the latter cases,
the haemorrhage is overwhelming, and the ab-
; domen is found full of blood. The surgeon finds
probably one-fourth the blood. Dr. Formad, the
coroner's physician, tells me that in one case he
found the peritoneum deluged with blood, and
the little foetus sitting, or washed up on the pan-

682

SOCIETY PROCEEDINGS.

[November 9,

creas. Its object was probablj^ to try and escape

a possibility of electrical treatment.
Dr. J. M. Baldy reported a case of

FIBROCYSTIC TUMOR OF THE UTERUS.

Mrs. A., aet. 35 years, married, no children.
Has had a lump in her abdomen for fifteen years,
which remained quiescent until within the last
two years, since which time it has grown rapidlj\
Menses have gradually become irregular and pro-
fuse ; bowel and bladder sj-mptoms have become
severe ; pus has appeared in the urine ; abdomen
is constantlj- swollen, and verj' painful ; general
health had begun to suffer severely. Examina-
tion .showed a uterine tumor, and its removal was
advised, the dangers of the operation being fully
explained. Operation was eagerly accepted.
The tumor was removed one week ago last Tues-
day, and proved to be an extremely nodular
fibroid, which had undergone cystic degeneration
in part, and in other parts is quite oedematous,
as can be seen bj' the specimen which is here be-
fore you. The mass was firmly wedged into the
pelvis, and was delivered with the greatest diffi-
culty, leaving practicalh" no pedicle at all. The
case was treated bj' supra-vaginal amputation, a
wire ncEud being first placed around the lower
portion. The stump was treated by the extra-
peritoneal method, as advocated by Bantock.
After the tumor had been cut awa}-, there was
left a stump with a diameter of over three inches;
this was gradually trimmed awaj' until it was re-
duced to about an inch and a half in diameter.
The operation was altogether the most trying
and most difficult one of this kind I have ever
performed or seen.

This case presents the opportunity for a few re-
marks on the method of treating the pedicle in
hysterectomy, and on the use of electricit}- in
fibroid tumor of the uterus.

There are two methods of treating the stump —
the intra-peritoneal, as advocated by Martin, and
the extra-peritoneal, as advocated bj' Bantock.
All other methods devised or proposed are simply
modifications of these two, and are far from being
as good as the originals. A so-called half-way
method proposed by Kelly last winter has so
man}- objections for general application, that it is
hardly worthy of consideration, excepting for
picked cases ; and these nuist be cases of the
simplest kind, with a pedicle which can be easily
dealt with. In the AVrr York Medical /oiinial,
for July, Douglas has called particular attention
to the defects of this departure.

What we want are results, and in ([uestioning
different gentlemen who are experimenting with
the so-called improvements in hysterectomy, I
find almost universally that their losses amount
to from 30 per cent, to 50 per cent. The patients
who get well may do .so quickly, and the opera-
tions may be very beautiful, theoreticallv, but

the results are murderous 1 Until a larger number
of cases have been reported, and the results are
very decidedly better, I prefer to pin mj- faith to
one or other of the two original methods. Of
these two, the results obtained by the extra-peri-
toneal method are, at present, verj- decidedly the
best, and have proven eminently satisfactor}- in
my hands. Martin, by the intra-peritoneal
method, reports a series of eighty-four cases, with
twenty-five deaths. Later, he has thirtj- cases,
with three deaths ; and still later, he has "another
series with good results ;" and last, a series with
bad results." And so, after an experience of
much over one hundred and twenty-five ca.ses, he
ends up with a series so bad that he does not
publish it. In contrast with this stands Bantock's
record, by the extra-peritoneal method, of fifty-
seven cases with only twelve deaths, and his re-
sults continually getting better to the end. He
now has a run of thirty or forty cases without a
death. These figures speak for themselves.
After all his experience, Martin ends by saying,
" So I think we must wait for a larger number of
cases before deciding this question."

Of the twenty-five deaths met with by Martin
in his first eighty-four cases, fifteen died of
"bleeding, embolism, and collapse," all of which,
of course mean hcemorrha-ge. Now bj' the extra-
peritoneal method, these would all have been
saved, as bleeding cannot possibly occur if the
wire does not slip or break. Again, ten of
Martin's cases died of sepsis ; this also is much
less likely to happen by the extra-peritoneal
method, as all cut surfaces are oiitside the peri-
toneal cavity, in plain sight, and under perfect
control.

When Martin has finished his operation and
drops the stump, as I have seen him do, the ap-
pearance to the naked eye is simply perfection,
and one carries away the feeling that everything
is cleaner than the stump of an ovariotomj-. On
the other hand, when the stump is left outside,
as I was taught by Bantock, the after-treatment
is often tedious, and the convalescence prolonged.
If the stump is not perfectl}^ dry it is apt to sup-
purate, and, at best, it is an unsightly affair.
But Vv'hen we contrast the results, there can be
but one choice, if we give proper consideration to
the safety of our patients. Not onl}- are Martin's
own results bad, but in the hands of less expert
and experienced operators the mortality- is very
high. Even Bantock has lost four out of five
cases by the intra-peritoneal method. By the
extra-peritoneal method, five or six of us here in
Philadelphia can now put on record twenty- or
more cases with only about two deaths in the lot,
and those were cases in which there was ex-
tensive cancerous involvement of vital organs.
In fact, our mortality is about as good as that in
ovariotonij'.

The use of electricitv in fibroids is not without

1889.]

FOREIGN CORRESPONDENCE.

68-,

its dangers and impossibilities. Such a case as that the brains of human beings change in size,
that before you is wholly beyond the reach of Taken at different times in the same individual
this palliative agent. To have done any good to , the length of the head varied ^\ inch, the width

that tumor it would have to be punctured, and
this large cyst which you see, emptied. To
have done so in this case would have required a
puncture four or five inches deep : the needle
would have to have penetrated the whole length

^ inch, and the length as much as ^2 inch. The
variations were not due to head growth. They
sometimes showed reduction of size to the extent
of 6 per cent.

In a recent discussion upon ' ' Poisoning by Ar-

of the tumor. Dr. Massey punctured one of these senic," it was generall}^ admitted that acute cases
•cystic tumors (if I recollect correctly) last winter, j followed by urgent symptoms and death were best
and the patient verj- promptly died of sepsis. At , known in the practice of forensic medicine, but
the June meeting of this Society Dr. Price pre- 1 arsenic could be administered as a slow poison,
sented two specimens of fibroid tumors. One was and death might occur six weeks after the victim
a large cedematous myoma, containing blood ves- had ceased taking arsenic. Nevertheless the
sels as large as the iliacs, and. as he then said, symptoms are much the same in both cases, var>"-
one might as well have tried to dissipate the iliacs ing onl)- in the time of development. There are
themselves as those vessels ; a puncture of any first troubles of the digestive organs ; secondly,
one of them would have meant tremendous hjem- catarrhal bronchial irritation and eruptions on
orrhage. The .second specimen was a fibrocystic the skin ; thirdly, loss of sensibility, numbness of
tumor with nothing but a thin membrane between | the lower limbs, cramps, acute pains, followed by
the cyst cavity and the uterine cavity, the mem- j local insensibility ; and the fourth and final stage
brane being lined with a mass of blood-sinuses as ' is indicated by paralysis. The case was men-
large as one's little finger. An attempt to punc- ^ tioned of a woman who was poisoned at Havre,
ture that case would have meant almost instant ' and whose hair was cut and analyzed. One bun-
death. And so it is with many other specimens : dred grams of her hair yielded i milligram of ar-
on record. The fact is plain that there is a large ' senic. It was thought that there should be no
class of fibroid tumors totally unfit for the elec- difficulty in detecting arsenical poisoning if the
trical puncture ; and to make the danger in these bones and especially the cancellous tissue was
all the greater, they cannot always be differen- 1 analyzed.

tiated. ■ For instance, the fibrocystic character! During the long vacation just ended many jour-
of the specimen before you was not even suspected nals have taken the opportunity to warn intend-
during life, although repeated examinations were ing students of medicine that the ranks of the
made. There is plenty of material here for ear- profession are at the present time tremendously
nest thought, and it ought to be a warning overcrowded, and that it was impossible for them
against blindly rushing into the use of electricity all to make an adequate livelihood. For the last
in all cases, simply becau.se the enthusiastic ad- five years an average of 1,921 entering medical

vocates of this treatment fail to bring out its dan-
gers, and, in fact, only too universally hide them.

FOREIGN CORRESPONDENCE.

LETTER FROM LONBOX.

IFROM ot:r o\\'>* CORRESPONUEN'T.)

Some Interestmg Facts about the Brain — Poison- [
ini^ by Arsenic — Tlic O'cercroicding of the Medical
Profcssio7i — Statistics 0/ Admission to Scottish Lu-
natic Asj'tums — The Mode of Treatment at Aix\
Ics Bains — The Anglo-American Vienna Medical'
Association — Miscellaneous Notes.

students have annually registered their names,
which shows if competition has been severe in
the past, it is certainly to be more so in the near
future. At his opening lecture Dr. P. S. Abraham,
at the Westminster Hospital, referring to the
progress made in the medical profession, said the
' ' barber surgeon ' ' was long since extinct and the
hybrid medical tradesman was becoming obsolete,
and that Voltaire's oft- quoted dictum that a med-
I ico " was a man who poured drugs of which he
I knew little into a body of which he knew less "
was not quite so true now as it was. He pointed
, out the fact that London was the healthiest city
in the world, as a concrete result of the attention
paid to the advice of sanitarians. He admitted
that in recent years the State had more and more
recognized its obligations to the public weal and
had done much for the science of health, but a

There has been published the result of some
measurements of the heads of students in the
Cambridge University, showing that although it great deal was still left to private effort and gen-
is pretty well ascertained that in the masses of erosity. They had to await the initiation by his
the population the brain ceases to grow after the Royal Highness the Prince of Wales and bis
age of ig or even earlier, it is by no means so " Damien Committee " of a much needed crusade
with University students, and that the men who of investigation against one of the most terrible
obtain University honors have larger brains than scourges of mankind, and they had to leave gaps
the average. Further careful experiments .show in their knowledge of an important therapeutic

684

DOMESTIC CORRESPONDENCE.

[November 9,

agent until an enlightened Indian prince came
forward and handsomely defrayed the cost of its
re-examination.

Statistics of admission to Scottish lunatic asy-
lums indicate an unmistakable seasonal variation.
The Report of the Commissioners contains a table
showing the numbers for each mouth of the eight
years 18S0-18S7. The average monthly total is
1,699, but during the three months of May, June
and July that average is exceeded by 628, while
in the four months of October, November, Decem-
ber and January the admissions are 462 below the
mean. These two periods of maximum and mini-
mum are the extremes of a regular annual rise
and fall. A steady increase is perceptible through
Februar}-, March and April, and after the culmi-
nation in June there is a similar fall from July to
the autumnal equinox. Similar figures collected
for the years 1S65-1874 reproduce exactly the
same periodical change, differing only in the
length of the maximum in early summer. An-
other fact which points to the same conclusion is
revealed by the statistics of suicides, for Mr. Bu-
chan and Dr. A. Mitchell showed long ago that
self-murder was most common in just those very
summer months in which lunacy is most rife.

Many patients are now returning from Aix-les-
Bains. The patient at this health resort has to
go through a somewhat curious course. He
walks down — unless rheumatics have crippled
him too much — to the bathing establishment in
the morning. There he is shampooed and mas-
saged, but he is not allowed, as in most places, to
go home in his own clothes. He is wrapped up
in blankets, is then deposited in something re-
sembling the old sedan chair, is carried by two
stout porters back to his room and put to bed.
There he has to remain for some time perspiring
copiously and, if possible, sleeping. In some
cases there is a renewal of the massage. The
patient at Aix-les-Bains is nearly always tired
and always depressed, but people who have tried
the place for many years describe its results as
miraculous.

In Vienna some English and American phy-
sicians have resolved to found a society to be
called the Anglo-American Vienna Medical Asso-
ciation. The society is founded with a view to
giving information and moral support to the Eng-
lish and American doctors and students of medi-
cine who come to the Vienna University. As a
rule there are but few students of medicine from
England and America, but a great number of
doctors of medicine. In the last half year 105
American doctors and several lady doctors were
on the books.

At a meeting of the Society for the Study of
Inebriety, held in the rooms of the Medical So-
ciety of London, Dr. Norman Kerr, the President,
stated that though he had known arsenic, iodine
and similar substances to make a permanent im-

pression on the nerve centers, and taken habit-
ually to excess, he could not class arsenic eating
alongside of alcoholism or morphinism as a true
narcomania or inebriety. It was resolved to ask
for a Parliamentary committee of inquiry into the
Inebriates Acts, with a view to amend legislation.

The many Americans and others who winter in
Venice will be pleased to hear that the town is
to undergo a complete sanitarj' rehabilitation.
The works to be commenced with this object will
spread over ten years, and the first provisional
estimate of the outlaj' amounts to some four and
a half million francs. In conjunction with this
purely hygienic undertaking a plan for remodel-
ing the citj^ architecturally will also be carried
out, for which a period of thirty years is com-
puted to be necessary.

Lady Milne has died at a dentist's in Edin-
burgh whilst under the influence of gas for the
purpose of having a tooth extracted.

G. O. 'M.

DOMESTIC CORRESPONDENCE.

Tetaiiiis Caiised by Intestinal Irritation.

To the Editor. — Whilst looking over The
Journal of September 7, 1889, I noticed a letter
from P. B. P., of New York, giving a synopsis
of a paper on ' ' Tetany in Infancy and Early
Childhood," read hy Dr. J. Lewis Smith at the
last meeting of the New York County Medical
Association, which alleged that there is no re-
corded instance in which lumbrice or ascarides
caused tetanic contractions : but Gowers refers to
three cases cau.sed by tapeworms. This state-
ment of Dr. Smith's brings to my mind the case
of Sarah Shelton (colored), aged 12 years, which
occurred in mj- practice a few years since, I was
summoned during the month of February' to see
this patient, who was suffering with the most
violent attack of tetanus that I had ever seen. I
found her resting upon her head and heels in a
state of complete opisthotonos, with the jaws
firmly closed and the head drawn to the left side.
Everj' muscle in her body seemed to be rigid ex-
cept those employed in deglutition. Her arms
were forcibly flexed, and the muscles of the ab-
domen were as hard as a brick. After a careful
examination I found that there was no traumatic
injury, and I at once suspected that worms in the
alimentary canal were the cause of the trouble,
and calomel and santonine were given in decided
doses, followed by castor oil and turpentine. Her
bowels were obstinately constipated and refused
to respond to this treatment. Enemas were then
given, upon which she pas.sed a large ball of lum-
bricoids containing about thirty worms, half of
which were dead. Her muscles would relax onlv

1889.]

NECROI.OY.

685

when under the influence of chloroform adminis-
tered by inhalation. The bromides, chloral, In-
dian hemp and morphia were also used, but they
gave onl)' temporary relief. Finally I gave .her
the tincture physostigmatis, prescribed a generous
diet with stimulants, and an occasional laxative.
She remained in this rigid condition more than a
month, but she is now as healthy and well devel-
oped as any young woman in this county. I
was fully convinced then, and am now, that this
species of worms was the specific cause of her
condition. If you consider this case of sufScient
interest j'ou have mj^ permission to give it a place
in your excellent journal. Respectfulh',

B. A. Duncan, 'm.D.

West Point, Miss., October 11, 1S.S9.

NECROLOGY.

One Cause of Sickness and Discomfort
Ijargely Preventable.

To the Editor: — Owing to the drouth, fires,
especially in swampy places, are numerous, and
the atmo-sphere is unusually smoky and irritating
to the eyes, head and air-passages. Some dis-
eases are aggravated,' sleeplessness, nervous dis-
turbance, general discomfort and, I believe, other
serious troubles not commonly recognized, as due
to this cause, result, because the atmosphere is
to a considerable extent unfitted to properly sus-
tain life. One apparent change in the atmosphere
is to lessen, below the normal limit, the active
ox3'gen, and this is especialh- true during the
nights ; thus, during the week ending October
19th no ozone whatever could be detected in the
atmosphere at Lansing on any night except one,
^Vednesda3^ A sense of want of air, even ap-
proaching sufibcation, and a weakness of the cir-
culation, in some approaching heart failure, has
been noticed.

The object of this note is to ask attention to
the fact that much of this discomfort and danger
to health could easily be prevented if all persons
would refrain from setting fire to rubbish until
after this bad condition of the atmosphere has
passed. On some evenings dozens of such fires
have been set in one small city in the interior of
this State. " As the wind goes down with the j
sun," nearly all the irritating smoke and bad air j

Moi-se K. Taylor, M.D.

Morse K. Taylor, M.D., late Surgeon U. S. A.,
died at his residence in San Antonio, Texas, on
the 20th of October, 1889, after an illness of two
weeks.

Dr. Taylor was born in Watertown, N. Y., on
May 14, 1823. He subsequentlj- moved into Mich-
igan, where he commenced his military life as Sec-
ond Lieutenant in the First Michigan Cavalry, and
served through the war with Mexico with credit
and was honorably discharged in July, 1848. Af-
ter his discharge he commenced the stud}' of med-
icine and graduated from the medical department
of the Universitj' of Michigan at Ann Arbor in
1852, and soon commenced the practice of his pro-
fession in Galesburg, 111. On the organization of
the Chicago Medical College, then called the Med-
ical Department of Lind University, in Chicago,
1859, he was appointed to the chair of Physiolog\'
and Hygiene in that instition. He discharged the
duties of that position with ability and to the sat-
isfaction of both faculty and students, but onlj-
two years later, 1861, the war for the preservation
of the Union commenced, and he was offered the
position of Colonel of the Fourth Illinois Infantrj'.
This he declined and accepted the office of Sur-
geon of the Twenty-sixth Illinois Infantry in Au-
gust, 1 86 1. The next year he was commissioned
Surgeon of United States Volunteers, and served
in that capacity until October, 1865, when he was
honorably mustered out, having been promoted to
the rank of brevet Lieut. -Colonel for faithful and
meritorious services, The war having closed he
settled in Keokuk, la., and commenced practice.
In May, 1S67, however, he was commissioned
Captain and Assistant Surgeon in the United
States Arm}', and was assigned to active duty on
the Western frontier. He continued in active
service in different places in the West until 1879,
when he was transferred to New York, next to
Detroit, and afterwards to Fort Sill, in the Indian
Territory, where, in 1884, his wife died, to whom
he had been married at Clinton, Mich., April 25,
1849. In June, 1882, he was made Surgeon with
the rank of Major, and on the 14th of May, 1887,
he was retired from active service, having reached

from such fires built in the evening remain in the 1 the age of 64 years, and ordered to San Antonio,

cit}' or village, and must be breathed by' the in
habitants.

If such fires must be made, it would be verj*
much better to build them in the morning, be-
cause the movement of the atmosphere then
usually increases until 2 p.m., and that maj- carry
the foul and irritating air from such burning rub-
bish outside the city or village.

Henry B. Baker, Secretary.

Office of the State Board of Health, Lansing, Mich.,
October 23, 1S89.

Texas, the place he had chosen for his residence.
Here he identified himself with all the more im-
portant interests of the community, social, educa-
tional and religious, and won the respect of all.
He was a phj'sician of marked ability and sci-
entific attainments ; an active member of the Am-
erican Medical Association, and an accurate writer.

■ During the week ending October 19th, tonsilitis increased 50
per cent., pleuritis 33 per cent., inflammation of the brain 25 per
cent., and membranous croup 2.S per cent. Probably other causes
than the one here mentioned had influence, but the other atmo-
spheric conditions were not such as to account for such increase.

686

MISCELLANY.

[November 9, 1889.

A correspondent at San Antonio says : ' ' He had
in process of completion a work on the cHmatologj'
of Texas, which for scope and detail is wonder-
ful." His son, Dr. F. M. Taylor, has been inti-
mately associated with him in his more recent
literary and professional work, and it is hoped
that he maj' complete the same for the public.

N. s. D.

Tlios. SnoM-den, M.D.

Dr. Thomas Snowden, a resident of Peekskill,
N. Y., died in New York City October 11, ast.
64 years and 8 months. He was an alumnus of
the College of Physicians and Surgeons, New
York — a member of the class of 1849.

MISCELLANY.

CoMPARATi\E Obstetrics. — A girafie has beeu born
in the Cincinnati Zoo, the first delivery of this kind that
ever took place in this country. It is said to have been
a head presentation and to have been a long labor, the
baby being nearh' 6 feet from tip to toe when dropped.

The .\meric.\n Academy of Medicine will hold its
thirteenth annual meeting at the Leland Hotel, Chicago,
111., on Wednesday and Thursday, November 13 and 14,
1889. Papers will be read as follows.:

"Object, Scope and Mission of the Academy," Drs.
Traill Green, of Eastou, Pa., Edward Jackson, of Phila-
delphia, and R. Lowrj' Sibbet, of Carlisle, Pa. " Literary
Degrees as they Interest the Academy," Dr. Richard J.
Dunglison, of Philadelphia, Pa. "Preliminary Require-
ments of American Medical Colleges of the Present
Time," Dr. John H. Ranch, of Springfield, 111. "Instruc-
tion by Recitation," Dr. Henry M. Lyman, of Chicago.
" Methods of Teaching Jledicine," Dr. Wm. F. Waugh,
of Philadelphia. " Medical Harmonv, as Influenced by
Preliminary Training," Dr. F. C. He'ath, U. S. M. H. S.,
Detroit, Mich. " Professional .Integrity vs. the Code,"
Dr. S. N. Benham, of Pittsburg, Pa. "The Institutes of
Medicine; the Necessity of Their Being Taught in Our
Schools." Dr. J. Cheston Morris, of Philadelphia, Pa.
"Gymnastic Medicine," Prof. E. Hitchcock, Jr., M.D.,
of Ithaca, N. Y. "Vice and Crime," Dr. J. A. Thacker,
of Cincinnati, O. "The Moral Treatment of the Insane,"
Dr. Gersham H. Hill, of Independence, la. "Sulphonal
in Hysteria," Dr. Andrew C. Kemper, of Cincinnati, O.
' The .Physiological Action of the Typhoid Fever Poi-
son," Dr. N. S. Davis, Jr., of Chicago. "Malignant Tu-
mors of the Mammary Glands, with Cases," Dr. E. F.
Wilson, Columbus, O. " Improved Operation for Vari-
cocele," Dr. E. Wyllis Andrews, of Chicago. "What is
the Proper Function of American Medical Colleges of
the Present Time?" Dr. Samuel J. Jones, of Chicago, 111.
Reports will be read from various special and standing
committees; among the latter, one by Dr. Justin E.Emer-
son, of Detroit, Alich., on "Preliminary Requirements
of Medical Colleges," and one by the Secretary of the
Academy, Dr. Dunglison, on "Laws Regulating the
Practice of Medicine."

The President's address will be delivered by Dr. Lear-
tus Connor, of Detroit.

The annual collation will take place at the Lelaud
hotel on Wednesday evening, November 13th.

Richard J. Dunglison, M.D.,

Secretary.

Official List of Changes in the Stations and Duties of
Officers Serving in the Medical Department, U. S.
Army, from October 26, iS8g, to Xovetiiber i, i88g. •

Major Jlorse K. Taylor, Surgeon U. S. A. ^retired 1, died
October 20, 1889, at San Antonio, Texas.

Major Robert M. O'Reilly, Surgeon, par. 3, S. O. 24, Oc-
tober 16, 1889, from this office, is so amended as to
grant him leave of absence for six months, with per-
• mission to leave the United States, by direction of the
Secretarv of War, to take effect November i, iSSg. Par.
6, S. O. '252, A. G. O., Washington, October 29, iSSq.

By direction of the Secretary of War, so much of par. 2,
S. O. 44, October 16, 1S89, from this office, as relates to
Lieut. -Col. Anthony Heger, Surgeon, is amended to
read as follows: Lieut. -Col. Anthony Heger, Surgeon,
is relieved from further duty in the Div. of the Atlan-
tic, and will at once report to the Major-General com-
manding the Army for duty in this cit)-. Par. 3, S. O.
252, A. G. O., Hdqrs. of the Army, October 29, 1S89.

Major Joseph R. Gibson, Surgeon U. S. .A. , granted leave
of absence for seven days, to take effect from date of
being relieved from doty at Ft. Sheridan, III. Par. 9,
S. O. 249, A. G. O., October 25, 18S9.

By direction of the President, Major Wm. H. Forwood,
Surgeon, is detailed as a member of the .^rmy Retiring
Board at St. Paul, Minn., convened by War. Dept. or-
der dated January 12, 1S89, published in S. O. 10, Janu-
arj^ 12, from Hdqrs. of the Army, vice Capt. Edgar A.
Mearns, Asst. Surgeon, who is herebv relieved. Par.
12, S. O. 254, A. G. O., October 31, 1889.

By direction of the Secretarv of War, so much of par. 10.
S. O. 242, A. G. O., October 17, 1889, as directs Capt.
Louis M. Maus, Asst. Surgeon, to report in person for
duty at Ft. Stanton, N. M., to relieve Capt. Marcus E.
Taylor, Asst. Surgeon, is revoked, and Capt. Taylor
will proceed to Boise Bks. , Idaho Ter. , as directed in
said order, as soon as medical attendance shall be pro-
vided for Ft. Stanton. Par. 10, S. O. 249, .\. G. O., Oc-
tober 25, 1S89.
By direction of the Secretary of War, Capt. Wm. C. Gor-
gas, Asst. Surgeon,- is relieved from temporary field
duty in the Dept. of the Missouri, and will join his
proper station (Ft. Barrancas, Fla. 1. Par. 2, S. O. 25,
A. G. O., October 28, 18S9.
Capt. Louis M. Maus, Asst. Surgeon U. S. .\rmy, granted
leave of absence for two months on surgeon's certificate
of disabilitv. Par. 11, S. O. 249, A. G. O., October 25,
1889.
First Lieut. Julian M. Cabell, .\sst. Surgeon I". S. \..
granted leave of absence for two mouths, on surgeon's
certificate of disabilitv, to take eff'ect about November
10, 1S89. Par. 7, S. O". 249, A. G. O., October 23, 1SS9.

APPOINTMENTS.

First Lieut. Charles Willcox, Asst. Surgeon U. S. .\., to
rank from October 29, 1SS9.

First Lieut. Harlan E. McVa\-, Surgeon U. S. .\., to rank
from October 29, 1889.

First Lieut. E. B. Frick, Surgeon U. S. .A.., to rank from
October 29, 1S89.

By direction of the President, the Army Retiring Board
convoked at Vancouver Bks., W. T., by War Dept. or-
der dated December 15, 1888, published in S. O. 292,
December 15, 18SS, from Hdqrs. of the Army, is dis-
solved. Par. I, S. O. 230, A. G. O., Washington, Oc-
tober 26, 1889.

Official List of Changes in the Medical Corps of the U. S.

Navy for the Week Ending November 2, iSSg.
P. A. Surgeon F. S. Nash, detached from duty in Bureau

Med. and Surg., and to the "Petrel." November 14,

1889.
Medical Inspector E. S. Bogert, ordered to examination

preliminary to promotion to Medical Director.
Asst. Surgeons O. D. Norton, I. W. Kite and E. P. Stone,

ordered to examination preliminary to promotion to

P. A. Surgeon.

THE

Journal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.
PUBLISHED WEEKLY.

Vol. XIII.

CHICAGO, NOVEMBER i6, 1889.

No. 20.

ORIGINAL ARTICLES.

ADVANCES IN OUR KNOWLEDGE OF
SOME CEREBRAL, OCULAR, AND IN-
TRA-ORBITAL LESIONS; WHICH
FACILITATE THE DIAGNOSIS
AND TREATMENT OF IM-
PORTANT DISEASES.

Read in the Section of Ophthalmology, at the Fortieth Annual Meet-
ins af the American Medical Association. June , iS8g. j

BY HENRY W. WILLIAMS, .\.U., M.D., I

OF BOSTON.
PROFESSOR OF OPHTHALMOLOGY IN HARVARD UNIVERSITY.

In offering a short paper to the Association I
assume that knowledge independently acquired in
a special department of practice may be a useful
contribution to the general store ; especially if
illustrating the importance of an adequate theo-
retical and clinical training in order that the
value of local phenomena, and their relation to
coexisting conditions of other organs and of the
general system, may receive due estimation.
Much of our information, on points to which I
am to refer, is of so recent date, that I trust a
brief epitome of some personal observations may
not be unacceptable.

INTR.\-CRANIAL GROWTHS.

When we remember that less than forty years
ago the existence of intracranial growths was
usually but dimly suspected from the existing
symptoms, and only rarely demonstrated at au-
topsy ; and that we are mainly indebted for the
first and most positive recognition of their pres-
ence, to the disclosures revealed through the me-
dium of the ophthalmoscope, with which we were
endowed in 1851 by Helmholtz, we may well con-
gratulate ourselves on the brilliant advances in
cerebral pathology and cerebral surgery which
his invention has done so much to render possi-
ble ; as well as on the vast increase of our knowl-
edge of intra-ocular lesions obtained through its
assistance. These results afford a striking in-
stance of the direct application of purely scientific
investigations to the benefit of man.

But while being thus enabled to assert the ex-
istence of intra-cranial growths, we did not at
once recognize the full therapeutic importance of

this newly acquired knowledge. Unable at first
to discriminate between those specific formations
which are often amenable to constitutional treat-
ment, and those of local origin, or to determine
accuratelj- the position of the lesion, we often
looked on helplessly while the disease went on to
its sad termination.

I offer a few instances from my own experience
as a contribution to the symptoms and history of
early recognized cases which were uninterrupted
in their course and were verified b}' autopsy.

Soon after the addition of the ophthalmoscope
to our optical resources, I saw in consultation a
gentleman in middle life, on account of loss of
vision. The diagnosis of cerebral tumor was
made. As the disease advanced the senses of
taste and smell were also gradualh^ abolished, and
death occurred about six years from the invasion
of the disease. The tumor, which was shown to
me, was of about the size of a man's fist. Not
long afterwards, another gentleman of similar age
came under nn* care, in whose eyes the condition
of the optic disc and retina justified the same
prognosis, and led me to predict a probable even-
tual failure of other senses, in addition to the loss
of sight — which result slowly ensued. Two dis-
tinguished New York confirrcs confirmed my
opinion. Despairing of aid from our profession,
the patient was induced to place himself in the
hands of charlatans, whose sanguine promises of
relief were followed by no other results than the
copious depletion of his purse, and at last he
came again under the care of his family physician.
The autopsy disclosed an enormous cerebral tu-
mor, slowly formed during the six years' continu-
ance of his disease, and which I had an opportu-
nity to examine.

A middle-aged clergyman was brought to me by
his physician, on account of failure of vision with-
out marked cerebral or other symptoms. Surprised
at my prognosis of a fatal result, as indicated by
the ophthalmoscopic evidences of optic neuritis
caused by cerebral tumor, his attendant asked
what might be expected as to the duration of life.
I said six months seemed to me a probable esti-
mate, although it wa.s impossible to predict with
certainty. Death occurred three days beyond the
above named period.
I In the case of a stout middle-aged woman whom

688

CEREBRAL LESIONS.

[November i6,

I saw from time to time for six months, the diag-
nosis was made verj- early, but there were no se-
vere S5'mptoms until a short time before the fatal
termination. At the post-mortem we found a tu-
mor no larger than a filbert, at the base of the
brain, surrounded by softened cerebral substance.

A co7ifnre came a long distance to see me, ac-
companied b}- his phj-sician. He had only mod-
erate pain and lessened vision, but no diminution
of intellectual or physical ^■igor to any great ex-
tent ; although, when I made the diagnosis of
optic neuritis caused bj- intra-cranial growth, per-
haps in the cerebellum, his friend agreed with me
that this explained his symptoms better than any
other theor)'. The patient returned home, seem-
ingly little fatigued by his journeys, but died
three weeks aftenvards. The tumor, found in
the cerebellum, was sent to me for inspection,
and was of the size of a pullet's &%%.

I have seen but one instance in which the mor-
bid ophthalmoscopic appearances were monocu-
lar : a case of a young gentleman from a Western
city, who complained of lessened vision in his
left eye, with a moderate degree of pain about
the left temple and supraorbital region. The
ophthalmoscope disclosed optic neuritis, associ-
ated with retinal htemorrhage in the left eye ; the
right eye remaining normal. These phenomena,
with the localization of the pain, led me to make
a diagnosis of tumor between the left ej-eball and
the optic chiasma. Little increase of symptoms
or change of ophthalmoscopic appearances oc-
curred for some weeks ; until, about a fortnight
before death, the pain became greath" aggravated
and extended to the eyeball itself with much de-
preciation of vision. At the post-mortem I found
a tumor of the form and size of a large olive,
which, lying upon the supraorbital plate, had
graduall}' caused its erosion and, at last, perfora-
tion ; so that the tumor had come to press upon
the eyeball, and thus to occasion the sudden in-
crease of pain and loss of vision. There is rea-
son to believe that had cerebral surgerj' been at
that time in vogue, my patient might probablj-
have been saved, and possibly his vision im-
proved, by an earh' trepannation.

I cite some of these cases, in which post-mor-
tem verification was obtained, as showing the va-
rj'ing character and course of the symptoms of!
intra-cranial tumors. The details as to their mi- [
croscopic structure and the relative frequency of
the different forms, as well as the coexisting func-
tional disturbances which aid in determining the |
localization of the morbid growths, have been
fullj^ set forth in the results of the admirable re-
searches of V. Graefe, Allbut, Ferrier, Hughlings
Jackson,, Gowers, Bramwell, Horsley and other
observers. The.se frequently enable us, by a com-
parison of the indications afforded by the existing
local signs, the appearances seen with the oph-
thalmoscope, and the varied derangement of ner\-e

action, to designate with great accuracy the posi-
tion of these intruding growths, and to estimate
their development ; and thus, in a large propor-
tion of cases, we ma3- obtain data which enable
us to decide whether the conditions are such as
to justify operative measures, or whether thefee
would be inexpedient ; or if reabsorption of mass-
es having a specific origin may not, perhaps, be
obtained bj- constitutional remedies.

We have seen that the S3'mptoras in different
cases varj- greatlj' in intensity ; not always cor-
responding with the size or rapidity of growth of
the neoplasm, but rather with its situation and
its relations to important parts. Cases now and
then occur where these sj'mptoms are very slight
or even absent, and the lesion is only discovered
after death. The same is true, exceptionally, as
regards the characteristic ophthalmoscopic signs.
Although, when present, these peculiar forms of
optic neuritis and retinal apoplexy afford perhaps
the most conclusive evidence of cerebral tumor,
yet these are occasionallj' lacking, where other
indications of tumor exist ; or their stage of acute
engorgement may subside, to be followed by atro-
phy of the opticus and of the retinal vessels.
Even where these changes are observed in a
marked degree vision is not alwaj-s materially or
permanently affected. But though so valuable in
disclosing the existence of morbid intra- cranial
growths, the ophthalmoscope seldom affords a
clue as to their position, which must be deter-
mined by the concurrence of other local and gen-
eral symptoms ; such as limited headache, as
tenderness on percussion of the skull, vertigo,
paralysis or paresis of motor nerves of the e3'e-
ball or other cranial nerves — which often indicate
with great exactness the situation of the neo-
plastic growths.

Doubtless cerebral surgery- will become more
and more precise and the proportion of successful
operations larger, as experience determines with
j'et greater exactness what intra-cranial growths
are and what are not amenable to surgical treat-
ment, and what improvements may give the best
results in the removal of what would be otherwise
invariably fatal lesions.

INTRA-OCfL.'^R CONDITIONS HAVING IMPORTANT
REL.\TIOXS WITH OTHER DISEASES.

Onl}- a generation ago the suggestion that we
should look into the depths of the eye to detect
the presence of Bright's disease, meningitis, ma-
laria, lead poisoning, of .syphilis, of a tendency
to apoplectic effusion, of albuminuria in preg-
nancy, or of post-partum pyoemia, would have
been deemed in the highest degree chimerical ; —
but these, as we know, are but a few of the manj'
lessons we maj' read in the retina, the optic disc,
the choroid and the vitreous, by means of Helm-
holtz's ophthalmo-scope. Not the least of the
brilliant services of this instrument is its afford-

1889.]

CEREBRAL LESIONS.

689

ing the proof, through its revelations at the fun-
dus of the eye, that myopia, or near-sightedness,
is not merely an inconvenient infirmitj-, but, in
its higher degrees especialh-, a serious disease,
having progressive tendencies and a disposition
to hereditary transmission ; and, moreover, that
this is a disease of civilization, created or en-
hanced by inordinate use of the eyes in minute
work. It is to be hoped that the profession may
at length be able to induce ambitious parents to
accept their advice as to moderation in regard to
continued close application of the e}-es of their
children, as the only means of safety ; and thus
to prevent the too frequent impairment and even
the ultimate loss of vision as a sequel of excessive
study during the growing period, to which is so
often sacrificed the most precious of the senses.
In these cases, unfortunately, the victim has no
other warning than our admonitions. This makes
it the more important that the educated and the
educating public should understand that preven-
tive advice is the onlj- resource at our command,
and that grave alterations in the retina, choroid
and vitreous, once induced, cannot be removed
b}' treatment.

I was the first to propose, in 1853, the system-
atic substitution of early and continuous dilata-
tion of the pupil by means of mydriatics in cases
of iritis, in place of the indiscriminate adminis-
tration of mercury which had been previously re-
garded as the only method of preventing occlusion
of the pupil by plastic deposits in cases of this
disease. I showed, in a report of more than sixt\'
cases, that the effused lymph was reabsorbed,
within a brief period, without the use of a parti-
cle of mercurj', provided that adhesions of the
margin of the pupil to the anterior surface of the
crystalline had been prevented by free and con-
stant dilatation ; but that no amount of mercuri-
alization would produce absorption, if these ad-
hesions were allowed to form in default of the use
of mydriatics. This method of treatment, of what
may be regarded as to a large extent a self-limited
disease where complications from effusions have
been averted, has been largeh' accepted by the
profession ; to the great relief of thousands who
in consequence of a rheumatic diathesis are sub-
ject to repeated attacks of iritis, and who are now
spared the liability to persistent sialogical effects
which so often rendered the mercurial remedy
worse than the disease.

There is reason to believe, moreover, that this
demonstration of the possibility of dispensing
with a potent agent which had been regarded as
absolutelj^ indispensable in a frequently recurring
disease, has had an influence in lessening the lav-
ish resort to mercury as a panacea in almost every
affection of the system. The report of Dr. Hughes
Bennett, of Edinburgh, chairman of a committee
of the British Medical Association to investigate
the action of mercury on the secretion of bile, |

showed, as the result of experiments on dogs,
that the flow of bile was not increased, as had
been supposed, by the administration of mercury;
but was, on the contrary, lessened. The pub-
lished results of my experience were quoted by
Dr. Bennett as affording evidence that the vaunt-
ed powers of mercury^ in promoting the removal
of plastic effusions, which had for a long period
been accepted as unquestioned, had, to say the
least, been exaggerated ; and he suggested that
two cherished beliefs as to the modus operandi
of this powerful drug in so very general use were
perhaps without adequate foundation.

PHLEGMONOUS INFL.A.MM.\TIONS OF THE ORBITAI,
TISSUES AS A SEQUEL OF FACIAL ERYSIPELAS.

The last subject to which I ask attention, is the
insidious formation of deep-seated intra-orbital ab-
scesses ; especially as a sequel of facial erysipelas.
Until 1 88 1 I had not seen nor read an account of
a case of this sort ; although Graefe had already
mentioned its occurrence. In that year I saw in
consultation a confrere who was convalescing from
a severe attack of erysipelas, affecting the scalp,
forehead, neck and face. The lids of left eye
were still much tumefied and two abscesses had
formed in the upper and one in the lower lid. A
deep-seated abscess also formed in the cheek, near
the ala nasi. These I opened, and there was a
rapid lessening of swelling of the lids and of the
serous chemosis which had formed upon the globe.
All was apparently going on well, and vision was
tested daily and found perfect. For two weeks
there was gradual improvement, so that the lids
opened and everything promised a speedy recov-
erj\ Suddenly I found one morning, at our visit,
the chemosis more marked; the globe was rotated
with difficulty, and vision, which had been good
the previous daj% was found to be wanting. There
was a sense of discomfort in the region of the
outer canthus. The ophthalmoscope showed
slight indistinctness of the optic disc, a slight
lessening in calibre of the retinal vessels, and a
faint yellowish-gray aspect of the fundus of the
eye. Without other indications than these men-
tioned, I expressed the opinion that a purulent
nidus must have formed in the post-ocular cellu-
lar tissue, probabl)^ towards the outer side of the
orbit. It was agreed that, after etherization, punc-
ture should be made in the region most com-
plained of I accordingl)' made two punctures
with a long and narrow Graefe knife, going care-
fully to the posterior wall of the orbit, a depth of
more than 2 inches, without finding pus. No
further attempts were thought then to be proper.
On the following morning, the indications con-
tinuing as before, three more deep exploratorj^
punctures were made; from the last of which pus
was reached Drainage was established, and a
moderate flow continued for three or four days.
Recovery was favorable as regarded a normal as-

690

CEREBRAL LESIONS.

[November 16,

pect and movements of the eye, and with no no-
ticeable atrophy of orbital cellular tissue ; but
there remained absolute loss of vision. The graj^-
ish-^-ellow aspect of the fundus, which at first led
me to apprehend a possible supen-ention of sup-
purative choroiditis, slowly gave place to a slight-
ly atrophic look, but the disc did not assume a
chalky white appearance, as in ordinarj' atrophy
of the opticus.

M3' presumption was, that the inflammatory'
processes, terminating in infiltration and abscess,
must have compressed and partially obliterated
the retinal vessels in their passage from the optic
foramen through the orbit, and previous to their
entering the optic nerve to go to the retina. The
earl}- evacuation of the abscess prevented the pus
from making its way backwards through the for-
amen or from so far protruding the ej-e fon\'ards
as to cause sloughing of the cornea and phthisis
bulbi ; but was not in season to admit of restora-
tion of the retinal functions.

As sometimes happens with unusual cases, this
first instance seen after man}' 3'ears of practice was
succeeded bj- several others grouped within a brief
period; in all of which, taught by this experience,
and having the good fortune to see them earl}-
after the invasion, I was able to evacuate the pu-
rulent deposit before vision had been permanently
damaged or other serious results had ensued.

Soon after my first case was seen, a historj- of
seven cases was collected and published by a Ger-
man observer ; of which five were fatal to life,
from meningitis following infiltration into the cra-
nial cavit}'.

One of my cases was interesting as having oc-
curred during convalescence from erj'sipelas in a
boy g years of age, whose vision had already be-
come so far affected when I saw him in consulta-
tion, that objects appeared red to the eye on the
implicated side. Evacuation of the verj' deep-
seated pus was followed b}' recover^' of normal
vision.

An interesting case of deep orbital abscess, not
preceded by erysipelas, was ascribed by a patient,
a vigorous man of middle age, to exposure to in-
tense cold during sleep in the open air. When
seen late one evening I was enabled to determine
the diagnosis, but the abscess was not reached by
an exploratory' puncture, although considerable
relief from tension was obtained. A repetition
of the incision on the following day was effectual,
and rapid recover}-, without damage to vision, fol-
lowed the establishment of drainage.

Gradual accumulation of pus in the orbit, as a
sequel of necrosis of the orbital parietes, offers
less acuteness of the symptoms ; and this, as well
as the idiopathic and partial phlegmon of the or-
bital cellular tissue not ver>' rare in j-oung chil-
dren, involves less danger to life and to vision
than the acute attacks above de.scribed as super-
vening upon erysipelas, or than such as are due

to pj'semic infection of the circulation, which usu-
ally terminate fatallj-. Purulent inflammation
within Tenon's capsule is usually severe, and
maj- result in loss of vision, but does not involve
other dangers, as the pus generally tends towards
the surface, between the insertions of two of the
recti muscles. It is fortunately rare, and if early
detected should be at once evacuated to afford a
chance of preser\'ing vision.

The urgency of an early diagnosis and of
prompt operative interference in cases of orbital
phlegmon cannot be too much insisted on. Of
fort\'-four cases collected from all countries bj' Dr.
A. Schwendt, of Basle, loss of vision, from amau-
rosis or from phthisis bulbi, occurred in about 80
per cent., and the proportion of fatal cases was 25
per cent, of the whole number, including the more
benign cases resulting from orbital caries.

Dr. Knapp, of New York, said that there was
a considerable literature on the orbital cellulitis
and that he had collected it on the occasion of a
typical case which he published in the Archives
of Ophthalmology. The case was observed from
its beginning. When the orbital tissue was com-
pletely infiltrated, the eyeballs protruded and
were totally immovable, the ophthalmoscope dis-
covered the veins large, tortuous and black, the
arteries apparently absent, in realit}' invisible be-
cause of being empty, and verj' numerous dark-
colored retinal hsemorrhages. In less than a
week the orbital tissue became less hard, the reti-
nal arteries were visible again and there was a
new set of haemorrhages, which were light red.
The contents of the black veins showed the grad-
ual conversion of the black thrombi into white
ones, which appeared first in white sharp-cut
lines, interrupted by dark red ones, which also
became white, and the termination was atrophy
of the optic disc, the retina and choroid, with the
retinal vessels as white lines. The supposition
that the ophthalmoscopic picture is best explained
b\' compression of the orbital vessels, became
much more plausible when we learned that the
micrococcus erj'sipelati^ (Fehleisen) invades by
preference the lymphatics, in particular the peri-
vascular h-mphatic spaces.

I would like to point out two kinds of optic
neuritis that give a relatively favorable prognosis.
I mean that in children, and that connected
with disseminate (alveolar) choroiditis. In the
latter varietj* it commonly appears as a neuroreti-
nitis, but in some cases the ])icture of choked disc
is marked, and apt to alarm us.

Dr. Chisoi.im reported a case of marked papil-
litis occurring in a young person set. 22, whose
case was diagnosed brain tumor and treated as
such bj' a skilled -specialist and confirmed b}' a
second, who measured the prominence of the con-
gested infiltrated disc. By these two gentlemen
the most serious prognosis was given, and early

]

EXAMINATION OF MINERAL WATERS.

691

death expected. The most conspicuous sj'mptom
was severe pain in the head, increasing on use of
the eyes. No benefit or change in the discs oc-
curring from active treatment, the case came un-
der my care six months afterward. I found woolly
discs, but no other evidences of cerebral trouble.
There was some astigmatism and, believing that
this irregular refraction might be the cause of the
constant headache, cylinder glasses were pre-
scribed for constant use and the use of the eyes
permitted. Recovery was complete. I have re-
cently seen the patient, after three j-ears' interval.
Her health is perfect, her eyes give her no trouble
whatever. Her discs are still woolly, but no di-
agnosis of brain tumor is now believed.

Dr. Chisolm also reported a case of blurred
vision following a case of facial erj'sipelas gen-
eral to the head, accompanied by severe pain in
the head, and for a short period by coma. Upon
restoration to sensibility hearing was abolished
and sight was much impaired. At no time was
there any exophthalmos or indication of orbital
cellulitis. Hearing has been restored. The sight,
which was good before the attack of erysipelas,
has never been restored. The ophthalmoscope
reveals a normal fundus, nerve and retina. I
deemed the case functional and expect benefit
from treatment.

Dr. Leartus Connor said with reference to
the inflammation of the meninges in cases of optic
neuritis accompanying cerebral tumor, he had ob-
served two cases. In case first marked papillitis
was attended by the evidences of cerebral tumor.
He had seen three cases of cerebral tumor in
which no meningitis was to be found post-mortem
to account for the disease of the optic nerve.
Case first was a lad set. 16 years.

BACTERIOLOGICAL EXAMINATION OF

NINETEEN AMERICAN MINERAL

WATERS IN THE. BOTTLED

STATE.

jRead in the Section of State Medicine at the Fortieth Annual Meeting
of the American Medical Association, June, tSSi).

BY GEORGE MINGES, M.D.,

OF DUBUQUE, 10\V,\.

About a year ago there appeared in the Wiener
Medizinische Wochenschrift (Vol. xxxviii, p. 749)
an article by Dr. Reinl, of Franzensbad, giving
the results of his bacteriological examination of
a dozen bottles of each of four of the most popu-
lar European carbonated mineral waters, the de-
duction being that those waters in the bottled
state contained too many bacteria, and that the
latter had probably gained admission during the
manipulations of filling and corking. Not being
able to find anj' records of similar experiments
made on our native mineral waters, I began in-
vestigations on a more extended scale about the

beginning of the present year, and continued
them up to the present time. I examined 144
bottles of mineral water, including nineteen dif-
ferent varieties, as follows :

1. Saline naturally carbonated : Congress, Em-
pire, Excelsior, Geyser, Hathom, all from Sara-
toga, N. Y.

2. Carbonated table waters : Bethesda, Silu-
rian, Arcadian, Henk, White Rock, all from
Waukesha, Wis., and all charged with artificial
C0„ ; also water from the sparkling spring of
Manitou, Col., the natural CO., of which is first
collected and afterward forced back into the same
water, and water from the Salutaris spring of St.
Clair, Mich., which is charged with artificial CO,,
after its own natural carbonic acid has been al-
lowed to escape. The Bethesda I also examined
in the non-carbonated state.

3. Sulphur water from Blue Lick Springs, Y^y.

4. Virginia Buffalo Lithia and Rockbridge
alum waters.

5. Chalybeate water from Columbian spring,
Saratoga, N. Y.

6. Saline non-carbonated from Colfax spring,
Iowa, the Castalian water, and that from Crab
Orchard, Ky.

I know that I run some risk of being consid-
ered a bacteriomaniac, but the tendency of the
day is to judge of the purity of drinking water
more from its bacteriological than from its chem-
ical examination, and I think that most of you
will admit that dyspeptics and convalescents, for
whom these mineral waters are more especial 1}'
intended, and whose stomachs are already weak-
ened in their antizymotic powers, should not in-
gest more than a certain maximum of bacteria.
Besides, we must also bear in mind the remote
possibility of infection with pathogenic bacteria.

Bacteriological examinations of a number ot
European mineral springs would seem to indicate
that at the source they are generally practically
free from germs, especially when they contain
much free carbonic acid. I know of no similar
examinations of our native springs in situ, but
suppose that most of them are as pure as those of
Europe, on account of the great diversity in the
number of germs shown by different bottles of
the same water, probably filled at about the same
time. When, for example, we find that one bot-
tle of Empire water contains six bacteria to the
cubic centimetre, another 410 mould fungi, and
.still another over 9,000 bacteria, the conclusion
becomes quite forcible that the microorganisms
were not originalh- contained in the water, but
gained entrance by .subsequent contamination.

Reinl found that the bottled water from the
Franzensbader Stefanie Quelle contained, on an
average, 152 bacteria to the cubic centimetre,
that from the Apollinaris spring 214, that from
Giesshiibler Konig Otto Quelle 1,620, and that
from Krondorfer Kronprinzessin Stefanie Quelle

692

EXAMINATION OF MINERAL WATERS.

[November 16,

2,526. It has seemed to me more correct to com-
pare the different waters, not by the average
number of bacteria given by several samples, but
by the number of bottles containing more than a
certain maximum ; and I have, therefore, consid-
ered all those bottles contaminated which con-
tained more than 250 micrciorganisms to the
cubic centimetre. Viewed in this light, the first
of the above European waters had two bottles i
contaminated out of a dozen, the second three, j
the third eleven, and the fourth ten. By using
the average number of bacteria in making com-
parisons we would do great injustice to several
mineral waters, for example to the Hathorn,
where the average of 28 germs to the ccm., as
shown by the examination of five samples, is
raised to almost 70,000 by the addition of a sin-
gle contaiiiinated bottle, while the Blue Lick
water shows up fairly well with an average of
1,922 germs to the cubic centimetre, although all
the bottles are contaminated.

I am aware of several sources of error in my
examinations which I could not avoid. In no
case could I determine the length of time a water
had been bottled ; but we know that the bacteria
in water multiply with almost incredible rapidity
for a time, after which they again slowly dimin-
ish in number. A representative of one of the
Saratoga waters told me that they kept their bot-
tles on an average about six months after filling
before they shipped them. It would also have
been well to allow the colonies to develop for the
same number of days in every case ; but this was
impossible, as in some cases the gelatine was
completely liquefied in twenty-four hours, while
in others the principal growth did not begin until
three or four days had elapsed. Again, I can
understand that the amount of C0„ must vary
more or less in bottles of the same kind of water.
Thus, the last bottle I examined, one of Manitou,
seemed to contain almost no CO,,, and this bottle,
perhaps for that reason, was contaminated.

All the bottles containing carbonated water
were well corked by machine and wired. The
still waters were stoppered more loosely, but the
corks of Buffalo Lithia and Rockbridge alum
bottles were secured with circular paper seals.
The bottles containing Castalian and Crab Or-
chard water were stoppered quite loosely with
conical medicine corks. I wrote to all the springs
whose waters I examined for information as to
the manner in which bottles were cleansed and
the carbonic acid introduced. In most cases I
received verj' courteous replies. The Salutaris,
Manitou, White Rock and Hathorn companies
use the " Hoyt lightning bottle washer." The
bottles for Excelsior, Bethesda and Geyser waters
are cleansed by hand ; those for Colfax by hand
with a brush ; those for Congress, Columbian and
Empire waters bj' hand with a chain and gravel ;
at Blue Lick they use shot, and the Crab Orchard

and Buffalo Lithia bottles are used onlj^ new and
are merely rinsed. Essentially all these methods
amount to the same thing. Boiling or steaming
is nowhere resorted to.

In making the examinations the following
steps were taken : To prevent any impuritj- from
falling into the bottle during the pulling of the
cork, the latter was first wet, after which the
dirt was removed from the edges with a penknife.
The cork was then wet again and wiped dry.
The bottle was violently shaken for several min-
utes immediately preceding its opening to insure
an equable distribution of the germs throughout
the water. With a pipette carefully sterilized in
an alcohol flame and quickly cooled, two samples,
one of I, the other of '.^ cubic centimetre, were
taken from the center of the bottle and transferred
to two tubes of liquefied meat- water-peptone gela-
tine. To prevent any germs which might have
collected around the edge of the cotton plug seal-
ing the tube from falling into the gelatine, the
plug was pushed in flush with the mouth of the
tube and the latter heated in the flame until the
cotton was singed before adding the water to the
gelatine. Before plating out the mixture the
neck of the tube was again sterilized by flame
until the whole length of the cotton was singed,
and the pouring was done as soon as the tube
had become cool. Covered glass dishes were
used instead of the ordinarj' plates, to reduce the
possibilit}' of contamination to a minimum, and
these had been previously sterilized in the kit-
chen oven from before breakfast until after the
noon-day meal. A number of these coated plates
were put into a wet-chamber and allowed to hatch
at ordinary office temperature for varj'ing periods
of time, according to circumstances, as above set
1 forth. The colonies were counted directly when
there were not more than about 500 ; only when
I there were very many was their number arrived
I at by calculation. When there was a marked
' discrepancy' between the number of colonies de-
I veloped from the two samples taken from the
same bottle, the result was not utilized; otherwise
the average of the two results was taken.

An examination of the following table shows
that, on the whole, the number of bacteria in a
' water diminishes inversely with the amount of
COj it contains. It also shows that the microbi-
cide action of artificial CO„ is as great as that of
I the CO., naturally contained in a water, contrary'
i to the deductions of Leone and Hochstetter ; for
i although the Henk water contains large quanti-
ties of bacteria, the Arcadian, Bethesda and Salu-
I taris are among the purest on the list. Sohnke
i claims that the addition of sodium chloride and
bicarbonate neutralizes the inhibitory influence
of CO, on bacterial multiplication, but we find
that the White Rock water, which is thus pre-
pared, has only one-third of its bottles contami-
nated, while two of Reinl's natural waters show

1889.]

EXAMINATION OF MINERAL WATERS.

693

respectively ten and eleven bottles out of twelve
infected. The germ-destroying influence of COj
is best shown by comparing with each other the
Bethesda aerated and non- aerated waters.

Name of water.

No. bottles
contaminat-
ed out of 12.

No. ccm. of CO2 to
the gallon of water

Average No.

microorganisms

to I ccm.

Arcadian ....
Bethesda ....
Congress ....
Salutaris ....

Geyser

Silurian

I
I
I
2

2

2
2

2
2

3
4
4
5

ID
10
12
12
12
12
12

Artificial

Artificial

392-239

Original CO2 al-
lowed to escape,
and artificial CO2
substituted . . .

454 02

Artificial

52
85
93
59

85
100

Rockbridge Alum

Hathorn

Empire

"White Rock . . .

Excelsior

Manitou

Colfax

Henk

Blue Lick .

863

68,290

1.407

2,2l8

8,417
886

17,103

25,000

1,922

2.973

3.505

40.189

150,000

375-747

344-669

Artificial

250

Recharged with its
own CO2

Artificial

Columbian . . .
Bethesda ....

272.06

Non-aerated. . . .

Crab Orchard

As a number of these mineral waters are highly
extolled as table waters to be used in large cities,
on the supposition that the water supply is there
verj- impure, and as some of the well-to-do people
of my native city use one or the other of the
Waukesha waters exclusively at their tables, it
is worth while to examine the drinking water of
Dubuque bacteriologically. The latter is derived
from various sources. The city water works sup-
pl}^ a large part of the town from a clear spring
on the top of the bluffs. A sample of water drawn
from the hj'drant in my own ^-ard was found to
contain 86 germs to the cubic centimetre. We
have also a number of artesian wells. A sample
from one of these contained but 20 microorgan-
isms to the cubic centimetre. The well and cis-
tern water varied, according to the locality from
■which it was taken, from 14 to 3,200 germs to
the cubic centimetre. As those people who have
access to the purest supply of their own city are
precisely those who use the mineral waters, fur-
ther comment is unnecessary.

In order to still further satisfy myself about
the role played by the manipulations of bottling
in contaminating the mineral waters above exam-
ined, I made a few control experiments.

Two bottles were carefully' washed by hand
•with shot and hydrant water and rinsed three
times with changes of clean water from the same
source and allowed to drain, in an inverted posi-
tion, in a room free from dust. A third bottle
was boiled for an hour and allowed to drain in
the same way. The three bottles were then filled
with hydrant water which had been boiled for an
hour and allowed to cool while well covered.
Bottle No. I was loosely stoppered with a conical
medicine cork ; into the other two large boiled

corks were driven with a corker. All three were
allowed to stand in a warm room for five days, at
the end of which time their contents were exam-
ined by the method above described. No. i con-
tained 100,000, No. 2 500,000 germs to the cubic
centimetre. The tighter cork of No. 2 had not
prevented contamination. The bacteria had,
therefore, probabl}- been in the bottle, and did
not enter along or through the cork. No. 3 con-
tained 725 microorganisms to the cubic centi-
metre; as I had carelessly dropped the cork upon
the floor, the contamination was accounted for.
I repeated the experiment with a fourth bottle,
which was treated precisel}- as the third had
been, except that I was more careful with the
cork, and examination at the end of six days
showed 66 germs to the cubic centimetre.

resume;.

1. The bacteria in bottled mineral waters are
probably not derived from the spring, in the ma-
jority of cases, but are due to contamination from
the bottles and corks, the cleansing methods now
in vogue being insufficient to destroy them.

2. Carbonic acid in a bottled mineral water
has a powerful inhibitorj^ influence on the devel-
opment of germs, whether the gas is natural to
the water, or has been artificially generated and
added to it. When the proportion of CO, is 350
cubic inches or more to the gallon, the retarding
influence of the gas is ver}^ great. It is much
less when the proportion is only 250 cubic inches
to the gallon. But among every dozen bottles
of even the most highl}' carbonated waters there
is at least one which contains more than 250
microorganisms to ever}- cubic centimetre, and
ten even out of twelve bottles maj- be thus con-
taminated. When the water is charged arti-
ficially some time may be given for contamina-
tion before such charging is accomplished.

3. Sulphureted hydrogen gas, in the propor-
tion contained in mineral waters, probably has
some inhibitory influences on the development of
germs, but not to the extent which might be a
pfiori expected.

4. As regards freedom from bacterial contami-
nation, most of our native carbonated mineral
waters are superior at least to several of the most
popular European waters of the same kind.

5. The non-aerated so-called table waters are
probably verj' inferior to ordinary hydrant water.

6. The strongly saline non-carbonated mineral
waters are so badly contaminated as to be wholly
unfit for internal administration in the form in
which they are at present put up, unless the
germs are previously destroyed by heating (for

j two hours at 70° C. — Reinl).

7. In order to bottle at least a non-carbonated
mineral water in such a way that it will remain
bacteriologically pure for an indefinite period,

1 the bottles should first be boiled or steamed, kept

694

EXAMINATION OF MINERAL WATERS.

[November i6,

in an inverted position in a place free from dust
until cool, then immediately filled and closed
with boiled corks.

CONGRESS.

d

«, .1

&■= ' No.
■o S ' germs
o g to I cm.

Character of Colonies.

Morphology' of Micro-
organism.

T

13

2
2
3
3
3
3
4
3
4
4

5

2
2
7

32
3
8

i8
460
223

240

3

^

S

TO

II
12

Mostly black, opa<^ue,
rounded and elliptical
colonies.

Principally very small,
circular, transparent ,
almost in\'isible colo-
nies.

Short bacilli with straight

ends, i-i^^ tn. long and
about I m. broad ; some
again as long , the shorter
almost square.

HATHORN.

16
hrs

3

3

4

409,600

93

Many liquefying colon's

Bacteria

Bacteria

Two of b. subtilis, oth-
ers mould fungi,
sarcinas; 2, dark cir-
cular discs.

Majority are sarcinae.

Bacilli 1.65-3.35 m- long and
.S3-1.25 m. broad, with
rounded ends, some point-
ed, others clubbed, single
and in twos, slightly mo-
bile.

GEYSER.

51 2

6| 6

16
29

44
13

Solid, yellow to brown,. Very- sm. bacilli with round-
well-defined, circular ed ends, 1.65 m. long and

discs, almost homoge-
neous.

Liquefying colonies.

half as broad, but some no
longer than broad, single,
ver^- rarely double, no
large chains, motionless ;
about 10 per ct. b. subtilis.

Mostly sarcina, but also
some b. subtilis.

Sarcina

B. subtilis, sarcina, and di-
plococci

B. subtilis .

ARCADIAN (Aerated).

4

37

4

7

3

10

4

11

4

7

.■)

10

3

3

2

■ 334

4

13s

4

37

3

16

2

22

Sarcina and moulds.
Mostly moulds . . .

All moulds .
Liquefying .

HENK (Aerated).

About
15,000
About
25,000

40,500

45»ooo
27.500

Moulds

Small, circular .

Small, circular, yellow-
ish-gray, bountled by
sharp outline, shadeil
with short lines.
Small, circular and
lemon-shaped, well
Refined, greenish yel
low. verj' faintly gran-
ular. 2. Large, super-
ficial, grayish, kidney-
shaped.

Same as 4

as 3, also some of 4-2

Strongly cur\-ed. active ba-
cilli, 2'.^ to $}4 m. long and
^i m, broad, with rounded
ends, variously distorted.

1. Small motile bacilli . . .

2. Bacilli ijs m. long and J^
m. wide, single and in
twos, motionless.

Same as 4.

EMPIRE.

•o ^

No.
germs

4 ,
3^j

410

38

9,689

29

132
45

342

51

6

125

6,103

Principally mould fungi
Bacteria

Character of Colonies.

Mostly solid, some lique-
fying.
Bacteria

Light green, circular., .

Almost all mould fungi

Mostly small yellowish

circular colonies, with

sharply defined out

line.

Morphology of Micro-
organism.

Curved bacilli, alone,
in twos and threes.

Slightly curved bacilli with
rounded extremities, iH"^
m. long, alone and in twos.

EXCELSIOR.

34

5 About
50,000

Elliptical colonies.

20 per cent, mould, re-
mainder sarcinae.

Mostly round, solid dark
colonies.

Sarcina. also dark colo-
nies of slightly irregu-
lar outline.

Mostly sm. round white
colonies, greenish-yel-
low under microscope.

Sluggish, plump bacilli, gen-
erally in twos, round ends>
1.65 m. long.

Irregular cocci, single, in
zoogloea ; also in short
chains of two and three.

Diplococci of large oval
cocci.

Very small, verj* active ba-
cilli, rounded or pointed
ends, in twos and threes,
not equally stained.

Plump bacilli, 1.65 m. long,
in twos and threes, slug-
gish motion.

BETHESDA (Aerated).

fi

87
50
So

4
5

■^

Mostlv sarcina, a few

moulds.

4

6

4

Irregular, not well -de-
fined, superficial, col-
orless, transparent.

Bacilli, almost cocci, mostly
iu twos, sometimes three
of varying shapes and
sizes in one chain, some
rounded ends, some point-
ed, some wide at one end
and pointed at the other.

5

5

106

Small, circular, also a
few sarcina;.

Bacilli 2-2'-t: m. long, S as
wide, in twos and threes.

fi

5

50

Solid, round, brownish.

7

3

373

Brownish , coarsely

granular, without
sharp boundary.

Large bacilli, 3-35-3-75 ^■
long and 1.25 m. broad,
single and in twos.

K

4

26

Sarcina

<)

4

43

Sarcina

TO

4

2S

Sarcina

11

5

23

Yellow, circular

Bacilli with rounded ends,
2.3 m. long and half as
broad, some not much
louger than broad.

12

6

155

Liquefying

Very mobile, short, diplo-
bacilli.

SILURIAN (AERATED).

4

5

4

28

3

22

3

5

507 j

34 '

Round, finely granular.

Sarcina . .
B. subtilis .

Bacilli.

SALUTARIS.

267

4
15

Brownish -yel low,
lar, granular.

Moulds and sarcina. .

Sarcina

Sarcina and moulds. ,
Sarcina and moulds. .

Bacilli resembling b. subtilis
in shape, size and motion,
but not growing to such
long filaments.

B. subtilis.

1889.]

EXAMINATION OF MINERAL WATERS.

695

WHITE ROCK (Aerated).

•OS

No.
germs
to I cm ,

33

114
10,678

, 15
About

Character of Colouies.

Morphology* of Micro-
organism.

jSarcina

10 per cent, moulds. . . Majority sarcina

Mostly very transpar'nt,

almost colorless, circ'r.l
Almost all large, circu-; Mobile bacilli, growing into

lar, brownish colonies long threads.

without well -marked'

border, but having

short hairs projecting

into surrounding gela-
tine. " I

.Sarcina

Much of gelatine lique-'

fied. I

MANITOU.

4

About
i.Soo

5
4
3

74
About

2,500

5

■25

3

141

5
2

2
3

10

3,414

17

76S

Liquid .

Bacilli. S3 m. long and al-
most as thick ; rounded
ends, generally as diplo-
cocci, quite mobile.

Mostlv sarcina lutea ....

I. Great majority sharp-^Iotionless bacilli. 1.66 — 2,35
Iv-contoured yellowish! m. long and .85 m. thick,
discs. 2. A number ofi with rounded ends, some
double-contoured colo-j not much longer than
nies with radiating, thick, single an'd in twos;
lines. I very minute, active bacilli.

Small, circular, liquefy- Short, plump bacilli, with

ing j rounded ends, in twos,

rarely longer chains ; also

some threads: swim rap-

I idly through field.

Yellow and brown, slow- Short, plump, diplo bacilli.

ly liquefying. I with rounded ends, centre

often unstained, not very

I active.

Sarcinae

Moulds ........'

Solid colonies & moulds.

ROCKBRIDGE ALUM.

3

26

4

26

2'A

88

2>4

19

.S

18

.S

About

5,000

Half moulds,
one liquid.

half solid.

Liquefying .

Manj- sarcinie aurantiacse .

BLUE LICK.

4

3

488
2,267

4

4,o83

2
3

1,000
1,767

Elliptical, somewhat ir-
regiilar.

About half as in 2 ; the
other half similar col-

Many liquefying . . . .•
Mostly small, white,
round colonies, green-
ish-yellow under mi-
croscope.

Plump, somewhat mobile
bacilli, in twos and threes,
forming zooglcea.

Same as 2 ; streptococci in
chains of 2-S links.

Plump bacilli, 1.66 m. long,
in twos and threes, slug-
gish ; also quite a number
of sarcinEC.

COLFAX.

2,491

141

2,200

789

Bacteria and moulds .

Principally granular,
yellow to brown , circu-
lar discs.

irregular brown solid
colonies.

Brownish discs and ir-
regular colonies.

Bacilli with rounded ends,
mostly single, rarely in
twos, never in longer
chains.
Half sarcina, other half Bacilli, somewhat curved,
about size of tubercle ba-
cillus, with clubbed e x-
treraities, single and i n
short chains, extremely
active, some shorter and
thicker.

Both kinds of colonies con-
sist of short bacilli, not
much longer than thick,
generally in twos, so ac-
tive that their shape can
hardly be distinguished in
hanging drop.

BUFFALO LITHIA.

No.

- s

germs

to 1 cm.

I

2;M

^

20

2 3'A

41

3 5

142

4

6

21

.S

4

61

6

3

312

Character of Colonies.

75 per cent, are moulds.
25 per cent, are moulds.
Liquefying

Morphology of Micro-
organism.

Some sarcina and b. subtilis
Mostlv sarcina

Probablv all sarcina .

COLUMBIAN.

9,225

3.066
2,700

6S4

441

Solid, almost circular. Bacilli, slowly mobile, slight-
well defined, some-' ly curved, ends generally
what darker in centre, pointed, 1.66-3.35 ^u- long
and .85 m. thick, in chains
of two and three.
Same as i; also same'Same as i; very small, active
number of similar col-; bacilli, almost cocci, i n
twos and also iu chains of
two and three; also some
b. subtilis.

onies.

About 1 per cent b. sub-
tilis. the others round
and elliptical colonies.

[Solid, superficial, green-
ish-yellow, circular.

iSame as 5

Bacilli in twos, t.66 m. long
and half as wide, slowly
mobile.

Same as 5

CASTALIAN.

S.136
76.275
36.156

Bacteria

Moulds and bacteria .

CRAB ORCHARD.

About
150,000
About
150,000

About
250,000
About
150,000

About
100,000
About
100,000

Solid .

Majority are sharply de-
fined, circular, granu-
lar, brownish colonies:
also many large super-
ficial, greenish, irregu-
lar colonies.

Same as 2

I. Circular, finely gran-
ular colonies, darker
in center than at edge,
slowly liquefying. 2.
Ver^- light circular col-
onies, showing fine
concentric lines. 3. Re-
sembling pus corpus-
cles. 4. Resembling
typhoid colonies.

First two varieties of 4,

Same as 5 Same as 5

Short shuttle-shaped bacilli,
of^en in twos, but rarely
in longer chains, often
with an unstained spot in
the center.

Same as 2

I. Bacilli 1.65 m. long and
half as thick, in twos. 2.
Bacilli much finer than
preceding^. 4. Large ba-
cilli of uniform size, 2.5 ni.
long and 1.2 m. thick, sin-
gle and in twos, and also
in threads of two or three
bacilli.

First two varieties of 4 . . .

BETHESDA (Non-Aerated).

About iLiquefied

3.000 I

2.750 Great majority coarsely Motionless threads.

granular brown colo

I nies, circular, with

roughened on 1 1 i n e s;

manv not bacilli.

2,237 Root-shaped bacillus . .

2,400 [Many of root bacillus . .

3,000 Root bacillus

8,644 Many colonies of root
. I bacillus

2-5-t>-5

m. long and J2 ui- broad.

SuLPHOLEiNic Acid has been called " poly-
solve" by Mr. H. Wilson, of Manchester. This
product is produced by the action of sulphuric
acid upon any kind of vegetable oil, and when
concentrated is a yellow viscid liquid. It is capa-
ble of dissolving a large number of organic and
inorganic substances, 2 per cent, of sulphur, 3
per cent, of iodoform, 25 per cent, of camphor,
etc. — Pharmacetitical Jour, of New South Wales,

696

MANAGEMENT OF LARGE HERNIA.

[November 16,

THE MANAGEMENT OF LARGE HERNIA.

Read in the Section of Surgery and Anatomy, at the Fortieth Annual
Meeting of the A ?nerican Medical Association, June, iSSq.

BY J. COLLINS WARREN, M.D.,

OF BOSTON, JMASS.

The interest at present felt by the surgical
world in the radical cure of hernia is so great,
and so many methods of treatment are being
brought forward, that it has occurred to me that
the grouping together of a number of examples
of the extreme degree to which hernia may attain,
and to relate mj" experience in their management,
might not be without interest to the members of
the Association.

The very large hemiae appear to have a raiscvi
d' ctrc in each case ; that is, the patient usually
suffers from some form of disabilitj- which pre-
vents him or her from exercising that control
over a hernial tumor which an able-bodied and
intelligent person is usually capable of doing. In
a large number of cases obesitj- is a predisposing
cause, especially in umbilical hernise in women.
A stout, middle-aged, swag-bellied woman who
has borne children is particularh- liable to this
form of hernia. An examination of the abdom-
inal parietes of such an individual will show a
large semi-lunar fold running in a sort of festoon
across the abdomen and containing at its centre a
depression, marking the umbilicus. The size and
weight of this fold of skin and adipose tissue
must exert a strong traction upon the cicatricial
tissues of the umbilicus, and the abdominal pari-
etes at this spot must, therefore, be disposed to
yield to pressure, especially if weakened b}^ the
distension of numerous pregnancies. In a labor-
ing and ignorant woman a tumor once developed
is not likely to grow any smaller, and .soon be-
comes irreducible. If the intelligence of the pa-
tient is at all impaired, the conditions for the de-
velopment of a large hernia become unusually
favorable.

The type of man usually afflicted with a large
scrotal hernia is two-fold. Either he is a middle-
aged active business man, so engrossed with his
work or of so careless a temperament as to have
neglected his disease until driven to treatment by
fear of permanent disabilitj- ; or he is an old and
feeble individual, or so obese as to be unable to
manipulate the parts so as to effect a reduction,
or with insufficient intelligence to apply and keep
in place a truss.

Finally we have children with congenital her-
nia, whose position in the social scale is so lowly
that the little patient has never been able to re-
ceive proper care, and an unusualh^ aggravated
form of hernia is the result.

The cases which I shall present to you for your
consideration represents fairh- well each of these
types of this affection. No special plan of treat-
ment has been adopted applicable to them all, but
each case has received such treatment as the

special conditions governing it seemed to call for.
Most of them have, however, had this in com-
mon, that a preliminary treatment was applied in
all, consisting of pressure, with rest in the invert-
ed position ; that is, with the hips raised and the
shoulders lowered. The object of this position is
to reverse the conditions under which the gradual
formation of the tumors occur ; that is, pressure
and gravity combine now to return the intestine
and omentum to the abdominal cavity, as thej^
had before combined to protrude them through
the ring. The so-called inverted position is pro-
duced \)y raising the foot of the bed and so ar-
ranging pillows and mattresses as to make the
ring the highest point af the abdominal parietes.
Pressure can be made \>y sand or shot bags, or by
the rubber band or special apparatus devised for
the purpose. Usually, however, the position
aided h\ sand bags so greatlj- reduces the size of
the hernia that it can be reduced readily "by taxis
under ether. \\'hen it was not possible to retain
the hernise by any form of apparatus after consid-
erable trial, the radical cure was then attempted.
Case I . — Large scrotal hernia, tioenty-five years''
standing. — H. H. R.,' 45 years of age, had devel-
oped a small hernia during college life, but as it
increased very slowly, had used no truss, nor had
at first made any systematic attempt to reduce it.
At the time I saw him he was exceedingly stout,
his greatest weight reaching 340 pounds. The
enormous size of the scrotum, a portrait of which,
sketched bj- the patient himself, giving the exact
size, I here show you, measuring 17 inches from
the base to its most dependent portion, caused,
after active exertion, the development of a trouble-
some eczema. After a hard week's work he
would go to bed on Saturdaj' and give the scro-
tum a chance to recuperate itself until Monday
morning. Unsuccessful attempts at reduction had
been made in Paris, London and New York, on
at least one occasion under ether. On explaining
the method of reduction by pressure to the pa-
tient, who was a skilled architect, he entered
heartily into the plan and a bed was made of
special strength and a frame work built around
it by his carpenter, with an apparatus for hoisting
the hips or body, as might be desired. The foot
of the bed was raised, the scrotum was held verti-
cally in a hard rubber splint made for the pur-
pose, and pressure was exerted by shot and sand
bags. A rubber bag that could be inflated rigid
externally but flexible internally, and exerting a
sort of uterine pressure, was made for this ca.se
by the Davidson Rubber Company. By the time
this bag was ready for use the tumor had been
reduced to one-quarter of its original size. The
bag having been fitted over the hernia and held
in place by bandages, pres.sure was exerted by
water introduced into it, and, at the end of eight
weeks, the hernia was reduced. The opening in

' Boston Medical and Surgical Journal, March 18, iSSo.

1889.]

MANAGEMENT OF LARGE HERNI.E.

697

the ring had a length of four finger breadths.
The patient was not able to use a spring truss,
but the hernia was retained with ease by a buckle
and strap apparatus. The patient led a most
active life after this, going up and down ladders
and traveling great distances without any local
trouble. He died about five years later of Bright's
disease.

Case 2. — Large scrotal hernia, twenty years^
standing. — This patient was about 40 j'ears of
age, the proprietor of a large factory, and an
active business man. The tumor was about the
size of an infant's head of six months and irre-
ducible. It was chiefly omental, the amount of
intestinal contents being small. A six weeks'
rest in the recumbent position, with the foot of
the bed raised and pressure with sand bags and
occasional use of the rubber bandage, reduced the
tumor so much that only one or two large nodules
of omentum remained that could not be forced
through the ring. Ether was accordingly given,
and by vigorous manipulation the lumps were
reduced. A truss fitted by Dr. Green, of Leach
& Green, has held the hernia perfect!}-, and the
patient has since, during a period of eighteen
months, been activel}- engaged in business.

In neither of these cases did it seem advisable
to attempt a radical cure. In case No. i the
large size of the ring, its great depth below the
surface, owing to the presence of large masses of
fat, and the existence of Bright's disease, were
sufficient grounds for not advising an operation.
In case No. 2 suture of the rings might have been
attempted, but unless I could guarantee a result
which would make a truss unnecessar}-, it seemed
to me preferable to trj' the treatment by reduction
with subsequent use of the truss. This has
proved so satisfactorj' that the question of opera-
tion has not been raised since.

The following cases show some of the difficul-
ties to be met with in dealing with large umbili-
cal hernise :

Case

-Umbilical hernia ; reduction by taxis. —

Mary L. , 43 years of age, entered the hospital on
November 6, 1883. She is ver\' stout, weighing
over 200 pounds. A lump has existed at the
navel for over ten years. It has increased in size,
slowly diminishing at times, but never entireh' dis-
appearing. She has now a hernia the size of a
small cocoanut, which emerges through an irreg-
ular opening apparently just below the umbilicus.
Pressure by weight in the recumbent position en-
tirely reduced the hernia, so that a truss could be
fitted which held the hernia comfortabh'.

Case 4. — Large umbilical hernia ; operation for
radical cure. — Mrs. Rice, 45 3'ears of age, mother
of a family and a verj' large and stout woman,
noticed a bunch about the size of a marble pro-
truding from the navel. This gradually increased
to the size of a fist, but could be put back. For
the last five vears the tumor has been irreducible

and has increased considerabl}' in bulk, and the
patient has suffered from frequent attacks of ab-
dominal pain, nausea and constipation. On ex-
amination a hernia the size of a child's head (8
inches in diameter) was seen bulging from a broad
abdominal fold. It was tympanitic and evidently
consisted chiefly of intestine. By rest in bed
with the foot raised for a month and pressure
with sand bags the tumor gradually grew smaller,
and finally was reduced by taxis, without ether,
through an opening admitting three fingers. The
patient was sent home to try the value of a truss.
Three months later she entered the hospital for
radical cure, as no truss or support could hold the
hernia.

Case 4. — Before operation.

A median excision about six inches long laid
open the sac. There were numerous bands and
adherent masses of omentum, between and around
which protnided the intestines. The appendix
was adherent to the right wall of the sac and also
a portion of the colon. These were dissected off,
the bands were divided and portions of the omen-

698

MANAGEMENT OF LARGE HERNLE.

[November 16,

turn removed. The edges of the ring were
brought together with six silk buried sutures,
and the opening in the sac was then closed with
superficial silk sutures, a small portion of it hav-
ing been excised. The wound healed by first
intention, with the exception of a small tube
sinus, which closed at the end of two months.
The patient remained in the hospital one month
and then returned and kept her bed one month
longer. At the end of three months she showed
herself and a photograph was taken. A hard, in-
durated mass covers in and closes the site of the
old hernia. There is no expulsive motion in
coughing, and the cure appears to be complete.
She has worn no retentive apparatus.

Case 4.~Si.v momhs after operation.

Twelve months after the operation she was
sent for and reported that she had been in perfect
health and actively at work — never better for
many years ; had used no apparatus. A slight
return of the hernia was found, of the existence
of which the patient was unaware. Since that
time has worn an abdominal belt, which prevents
the hernia from increasing in size.

Case y. — Large uiiibiliail hernia ; operation for
radical cure. — E. S., 60 years old, married, young-

est child 25 years old ; stout and unwieldy ;
mental standard not a high one. Entered hospi-
tal with an umbilical hernia considerablj^ larger
than a child's head. First noticed a rupture at
the umbilicus thirty-five years ago, after jumping
from a carriage. On examining herself, found a
tumor about the size of a fist. Used at times a
truss and a swathe. Five or six years ago it be-
gan to be very painful, and during the past year
has increased rapidly in size. It has never been
reduced. Has a history of epileptiform seizures
at night. The circumference of the abdomen at
umbilicus is 42 inches. The hernial tumor is lax
and soft when patient is lying down, and the
skin over it at points exceedingly thin. It meas-
ures I3'.>xi4 inches. After a week's rest in bed
with sand bags over tumor the patient was ether-
ized, and after three quarters of an hour's taxis
the whole mass was reduced through the ring,
; which was large enough to admit four fingers.
The ring was padded and supported with a large
' adhesive plaster swathe. During the next two
I weeks the hernia was controlled by bandages, but
it was evident that no truss would hold it, and
the patient was accordingly etherized again and
the sac laid open. In the interior the bowels
j were found nested in a large number of pouches.
A considerable portion of the ascending colon,
with the vermiform appendix, was found pointing
I in front, with a large portion of small intestines
behind it. The appendix was so adherent that
it had to be excised, in order to reduce the colon
and its appendages so that they would remain
without tension within the abdominal cavit\-.
Many bands were divided and fragments of omen-
tum excised. The edges of the ring were then
brought together and sutured with six coarse silk
.sutures. The integuments were then brought to-
gether with silk sutures and two drainage tubes
inserted. The wound healed apparently by first
intention, and there was but slight pyrexia.
There was considerable mental disturbance fol-
lowing etherization, and the patient tried to get
out of bed the first night. This condition, how-
ever, soon passed away, and the wound had ap-
parenth' healed when an abscess formed in one
' of the mucous pouches. This was opened, but
the fistula has not yet healed, six months since
the operation. The patient is about with a large
pad over the umbilicus, at which a tumor about
one-quarter of the original size presents. An ex-
amination shows that the .stitches in the ring have
yielded.

Case 6. — Double congenital hernia : MacE<ven' s
operation. Chas. Green, 11 years old, small of
stature and below average intelligence, entered
the hospital April 2,S, 1S88. Six years before
had been advised by me to wear a truss, which
had been used from time to time with slight suc-
cess. The photogiaph gives an inadequate idea
of the hernial tumor, which reached one-third of

1889.]

MANAGEMENT OF LARGE HERNI.^.

699

the distance to the knees when fully distended.
The rings were so large that the first finger and
thumb of one hand could be introduced into the
rings and made to meet easily in the abdominal
cavity when the hernise had been reduced. On
May ist the right hernia was operated upon by
MacEwen's method for congenital hernia, /. e. a
portion of the sac was left behind to form the
tunica vaginalis. The wound was closed with a
continuous catgut suture and healed bj- first in-
tention. Three weeks later the other side was
operated upon in the same manner. A small
sinus remained for a few weeks, which had healed
hy July 1st. Was di.scharged without a truss
August I St. On his removal from the convales-
cent ward he had a urethral calculus and reten-
tion of urine at his home, which put the cicatrix
to a severe strain, but he went through the ordeal
successfull)'. Examined by me nine months after
the operation, a slight return of both herniae had
occurred as the result of falling down the cellar
stairs backwards. He still wears no truss, but
the hernial tumors are small and do not trouble
him. His family having removed to Providence,
I have been unable to see him a second time.

Case 7. — Large scrotal hernia in an old tnaii. —
The photograph of this case, which I show you,
gives a type of a certain class of cases of hernia,
easily reducible, but which have been allowed to
grow to an enormous size owing to the mentally
or physically feeble condition of the patient.
The present case is an Italian who does a certain
amount of work, but is unwilling to buj' a cheap
apparatus or put himself permanently under treat-
ment. The hernia is quickly reduced by the pa-
tient bj- catching it between the thighs, which
give diffused pressure, when reduction is finalh'
effected by the hands. For this class of cases I
am in the habit of advising a large suspensory
bandage made of jean cloth, which effectually
prevents increase in size, reduces considerably
the size of the hernia, and gives the patient a
comfortable sense of support. The large size of
the ring renders strangulation extremely improb-
able. These herniae sometimes are subject to
attacks of local peritonitis, but the use of the
support is a good prophylactic against this acci-
dent.

Case 8. — Large incarcerated hernia reduced by
Dr. Warren's method, by C. IV. Calloupe, M.D.,
Harv. 1883, of Lynn, Mass. — My patient is a
large-boned, hea\'y man, 46 j'ears of age. At the
age of 17, while in the act of lifting a cask weigh-
ing 825 pounds into the rear end of a wagon, his
foot slipped a little on the snow, and he felt a
sudden stinging pain in the left groin. This
pain continued, and at the end of a week or ten
daj-s he noticed a swelling in the groin as large
as the end of a thimble. He kept constantly at
work, however, until at the end of two years his
father noticed that he seemed weak and disin-

clined to lift. He then explained the cause of
his laziness, and at that time examination dis-
closed a bunch the size of a hen's egg.

An iron truss was applied bj- a countrj' prac-
titioner, which was discarded the next dav on
account of the pain it caused. In five j-ears from
the date of injury it had dropped down into the
i bag, and he was then fitted to a knitted bag,
j which acted as a suspensory. The rupture had
increased constantly- but slowly up to a year ago,
when it was about the size of a cocoanut. At
that time he jumped from a horsecar and felt a
sudden yielding, while the rupture doubled in
size in an hour's time. Since then it has steadily
increased and has prevented him from doing any
active work. There has been but little pain, but
a constant pull and drag that has made him an
invalid and has led him to indulge freely in alco-
holic stimulation.

At the time I first saw him, March 28, i88g,
the hernia measured 25'_. inches in circumference
around its base, 30 inches around its largest part,
and its length from pubes to center of perineum
■was 17 inches. It was of the left inguinal varie-
ty, but on account of its size, and the fact that it
had dissected up the skin from the lower part of
the abdomen and from the upper part of the
thigh, the ring could not be felt nor the contents
mapped out. He was placed supine on a hard
bed with the foot elevated 10 inches, the bowels
evacuated and the diet restricted to concentrated
and digestible foods. At the end of fort\--eight
hours the oedema of the scrotum had sub.'iided
sufficiently to disclose the nature of the contents
of the sac. The upper portion contained many
coils of gut, while the lower part and the part
next the ring were solid and nodular. Efforts at
reduction were made and a considerable part of
the gut returned. A cotton bandage was then
applied in circular turns to form a pedicle to the
mass, and three sand bags, of 3 and 5 pounds
weight, laid on the top, while a broad sling over
the shoulders and around the neck held the mass
vertical. On the fifth day the intestine could be
all reduced, and the mass measured 21 inches in
circumference b}^ 14 in length. The residue was
omental, the chief obstacle being a hard, solid
cake 4 inches in diameter and 2 inches thick.
The ring could be felt easily, admitting three fin-
gers. From the outset the cotton bandage was
applied once or twice daily, and after a few days
a rubber bandage outside the cotton. No attempt
was made to exert pressure by bandaging across
the top, as the effect of this was to gradually
squeeze the mass out under the ring of bandage
and cause the whole apparatus to slip off. For
the same reason the sand bags were of but little
value, the chief reliance being placed upon dailj'
manipulation to break up the omental lumps and
dilate the ring, while the tight circular bandage
caused an internal tension which constautlj- tend-

700

TREATMENT OF INSANITY.

[November i6,

ed to squeeze out the contents of the sac. No
pain was felt at any time unless the rubber ban-
dage was too tight. If applied directly to the
skin it would roll up and cut in uncomfortably,
so that the following plan was adopted : Ten
j-ards of cotton bandage, 2 inches wide, were
wound around close to the abdomen, including
the penis and testicles, each turn being wound
still closer, so as to form a hard constricting col-
lar about 4 inches wide ; outside of this was
wound the rubber, being worn about three hours
at a time.

On April 14th, the seventeenth day of treat-
ment, while squeezing the omental cake, it
seemed to separate on one edge and open out to i
form a crescentic mass, which was insinuated by !
its smaller end into the ring and by dint of steady ]
pressure was wholly reduced, exposing an open-
ing through the abdominal wall which easily ad- j
mitted four fingers. A graduated compress and
spica bandage retained the hernia, and two days
later the patient was up and around the room
with a water-pad truss on. Much diiSculty has
been found in getting a truss which would retain
the omental lumps, but no intestine has escaped
since the first reduction. The patient is attend-
ing to his daily work and has gained considerable
fat since he got up, while the scrotum has shriv-
eled very greatlj' and the ring has closed up
about one-half.

An incarcerated hernia of this size was not a
very promising case to undertake, more especially
as it had proved itself unyielding to many phy-
sicians during the past twenty or thirty years ;
but having had the satisfaction offending a num-
ber of such cases under Dr. J. Collins Warren, in
the Massachusetts General Hospital and in pri-
vate practice, I was encouraged to try it by his
method of treatment. The result shows the value
of his method, and the freedom from pain and
danger will make the patient readily consent to it.

I regret to say that I have not yet succeeded
in effecting a radical cure in any of these cases ;
but I may add that all the patients have been
fully satisfied with the result of their treatment.
I would recommend strongly the method of grad-
ual reduction by pressure to the members of the
Section. I do not advance it as a new method,
for it is in reality exceedingly old, but I don't
think physicians generally realize how much can
be accomplished by it.

In the large umbilical herniEe the failure to get
a permanent cure is due, I think, to the neglect
to excise the edges of the ring before suturing.
In order, however, to bring the different layers
of the abdominal walls together, as in a laparoto-
my, the amount of dissection necessarj- would
have greatly prolonged the operation and might
have increased the danger. On another occasion,
however, I think I should attempt it even in as
complicated cases as these were.

ADVANCEMENT OF THE TREATMENT
OF INSANITY DURING THE NINE-
TEENTH CENTURY.

Wi'f/i Notes upon the History of the Treatment of

the Insane in Louisiana, 7ip to the Close of

the Year iSjp.

BY JOSEPH JONES, M.D.,

PROFESSOR OF CHEMISTRY AND CLINICAL MEDICINE, TUL.\NE
VNIVERSITY OF LOUISIANA, ETC., NEW ORLEANS, L.A.

THE ADVANCEMENT IN THE TREATMENT OF
THE INSANE 'DURING THE NINETEENTH

CENTURY.

Dr. Benjamin Ward Richardson, of London,"
in a recent article, entitled, "Medicine Under
Queen Victoria," dated July 25, 1887, has clearly
shown by indisputable facts, that this first great
advancement in the science of medicine com-
menced practically in the year when Queen Vic-
toria ascended the throne half a century before,
and consisted in the adoption of the 7nethod of
treating the insane withoiit violetit physical
restraint.

What the practice of medicine in the treatment
of the insane had been previous to 1837, it is in
this day almost impossible to conceive.

Dr. Benjamin Ward Richardson says :

' ' There was in it no science and certainly no
humanity. I remember perfectly as a youth,
climbing the wall of a bam in order to look
through a small grated window at a poor lunatic,
who for twenty-five years had been chained in
one corner of the place, and in that condition had
been retained and kept by his relatives as a dog,
or other savage animal might have been. He
was bedded down in straw just as other animals
were, and except that it was put for him on a
platter his food was given to him as might have
been given to a dog. He took his food in his
hands and tore it with his teeth, the idea being
that it was not safe to let him have a knife or a
fork, or anything more than a wooden spoon as a
help for feeding. The people who had this man
in charge were not more cruel than the rest of
mankind. The)- labored under the idea that it
was for the safety of them.selves, and on the
whole for the benefit of the insane man that he
should be kept as he was kept. Had he been
set at large he would have done some mischievous
or dangerous thing for which he would have been
punished, and for which they would have been
responsible. It is true, they might have sent
him to a madhouse, but there he certainly would
not have been better cared for than at home. He
would have been under the rod of strangers, and
might have been exhibited as a show to those

> The Asclepiad : "A book of original researches and observa-
tions in the science, art and literature of medicine, preventive and
curable." By Benjamin Ward Ricliardsou, M.I)., F.R.S. Third
quarter, 1SS7, page 207. Longmans, Green 6c Co., Paternoster Row,
London : J, Ulakiston, Son ^: Co.. Philadelphia, V. S, A.; Cupples,
Upham & Co., Boston, U. S. A.

1889.]

TREATMENT OF INSANITY.

701

who were curious for strange sights. He might
also have been irregularl}- fed or imperfectly
clothed to meet the various seasons. As it was
he was kept out of mischief ; he did not com-
plain, he gave little trouble, and he was not
merely safe himself, but was a safeguard to the
lonely home or lodge attached to the barn in
which he was domiciled. For strangely enough
the poor helpless creature was a terror to the
superstitiousl}- wicked, to the prowling vagrant,
the thief, the burglar, and the incendiary,-. When
he cried or howled or laughed maniacally, the
wicked were alarmed into flight. The notion in
those days was also common that the insane at
particular times were under the influence of the
moon ; that lunacy was a lunar problem was in-
deed a belief as absolute as that the moon itself
appeared monthl}" in definite quarters, and that
she governed the tides. This belief is not efl"aced
yet, but so strong was it at the period of which
I was speaking — the latter part of the last reign
— that the brother of the lunatic, to whom ref-
erence was made above, would make his calcula-
tions as to the states of mind into which the luna-
tic would pass b)- reckonings of the moon, and
sometimes it reall3' seemed as if his* predictions
were correctly cast.

"As an illustration of the barbarities which
were practiced in these institutions, my late
friend, the distinguished George Cruikshank,
gave me this engraving, which he etched in his
time from an original drawing by G. Arnald,
F. R. A., of a man named William Norris, an
insane American, who was riveted alive in iron,
and was for manj- years confined in that state by
chains twelve inches long to an upright massive
bar, in a cell in Bethlehem Hospital.

' ' I have no personal recollection of the state of
asylums at the first period of the present reign,
but I have heard from others much that excites
the surprise of the present generation when it is
told. The asylums were conducted on the worst
and cruelest of syslems. All government, if
such it may be called, was by force and fear.
The insane were looked upon as endowed with
superhuman strength and craft, as human ma-
chines of great power, cunning and viciousness,
uncontrolled by reason or anj' attribute of com-
mon sense. It was but therefore, to keep them
at all times under restraint, and to make in some
cases the form of restraint unchangeable, perma-
nent and irresistable.

The system of pinioning the insane in .so de-
cisive a manner as Norris was pinioned, was
probably exceptional, but pinioning in a milder
manner was the rule rather than the exception.
Manacles attached to the limbs and secured by
chains to the bunks or beds in which the insane
slept were in common use, and what was called
the straight waistcoat by which the upper limbs
were kept under bandage, was so universal that

it remains b}- name a word of reproach towards
the violent until the present hour. ' He ought to
be put in a straight waistcoat,' is still a frequent
vulgar declaration.

"The centrifugal and the centripetal treatment
on a wheel were other methods followed out for
the management of the insane up to the latter
part of the period preceding the Victorian. It
had been ingeniously' surmised that the amount
of blood supplied to the brain could be increased
or lessened by placing a living human body on a
horizontal plane attached at a right angle to the
axis on a large revolving wheel. If the head of
the sufl^erer were placed on the circumference of
the wheels, then it was assumed that the blood
in the body would be forced into the brain as the
wheel went swiftly round. If on the contrarj-,
the sufferer were placed with the head to the cen-
tre and the feet to the circumference, the brain
would be emptied of blood as the wheel revolved.
One of the medical friends of my early days saw
this machine in motion, and made inquiries as to
the eSect it produced. His record in respect to
it was, that if the prayers of the sufferers not to
be put upon it, their screams on it, and their
giddiness and sickness when they came off' it,
were to be accepted as signs of improvement,
then the treatment might be considered to have
been of value ; but that he could trace out no in-
stance whatever in which any insane person had
been cured by the experiment.

"The Rev. Dr. P., is a verj- learned man, who,
in my first days of practice, was a patient under
m)' care, told me that in a great asylum of which
he was at one time a governor, the attendants
were detected in the act of dressing the insane
under a sj'stem of the most astonishing kind,
called by them 'the long stocking quietner.'
When a patient was to be dressed in the morning,
the attendant went to the bed or bunk of the
victim, passed round his neck a long, soft stock-
ing, and gently, but firmly, twisted the stocking
until the throat was sufficiently compressed to
produce a temporary a.sphyxia and insensibility.
Then another attendant came, and while this
rough anaesthesia was sustained, dressed the
semi-suffocated body for the day. The plan on
being exposed, was not without its defenders,
who urged that the process gave no pain, that it
was attended with no bad results, that it saved
hours of possible suffering, and that it was hu-
mane, because it did away with all necessity of
chastisement, with stripes and struggles, and
with injuries to the dressers as well as to the
dressed.

"These various modes of government of the
insane were not confined to those of the insane
who were poor, and, if it be fair to use the term,
friendless. The rich were shut up in separate
houses, large or small, and were subjected to the
1 caprice which the unwatched powerful, almost of

702

TREATMENT OF INSANITY.

[November i6,

necessity extend to the unprotected weak. Even
royaltj- itself did not escape. From the moment
when the unfortunate George III betrayed his
insanity in his speech at the opening of parlia-
ment : ' My Lords and gentlemen, and wood-
cocks cocking up your tails,' he shared with his
subjects the servitude of the insane. There are
some pictures of him extant, showing him during
the period of his insanity, which are simply ap-
palling in the miserj' thej- exhibit. Thej' are
pictures of fear concentrated and abiding, as well I
as of a mind weakened and feeble. The story so I
often repeated, that the king while in confine- j
ment at Windsor, was chastised into obedience, I
was largely credited, and was excused as a neces-
sary part of the treatment of the insane. The
exhibition of the king by his keepers for gain (
was not considered at all a detestable measure, ;
and that he received hard usage is, I fear, but
too true. While visiting a large asylum in i860,
the proprietors brought to me a man of advanced
life, who had been engaged in his zenith as a
younger or assistant keeper of the poor king dur- '
ing the pitiful and painful Windsor period, and \
this man told us that he himself had seen his 1
majesty knocked down for his obstinacy, j

"Such is the background of the picture of in-
sanity and its treatment previous to the present
reign. I should rather say it is a portion of the
background only, for to fill it up entirely would
indeed be a task impossible.

" For some time previous to the Victorian era
there had been a few good and humane efforts to
relieve the insane of a certain amount of the op-
pression to which they were subjected. Their
names in connection with this effort deser\'es
special mention : Pinel, of the Bicetre, in Paris,
the Elder Luke, in the retreat of York, and Dr.
Charlesworth, in the city of Lincoln, Lunatic
Hospital, in which institution the grand final
and triumphant experiment of entire freedom of
the insane was carried out." i^T/ie Asclepiad, 3d
Quarter, 1887, pp. 207-209.) Dr. Benjamin Ward
Richardson concludes his valuablfe obsen^ations
on, "The First Advancement, The Treatment
of the Insane," in the following words :

" There is nothing more striking in the course
of medical science than the improvement of the
insane by the abolition of restraint. It may be
considered as a complete conversion, extending
throughout all our wide confine. It has planted
us first among all nations as physicians of mental
disease, and has yielded the best literature on in-
sanity that has ever been produced.

"Strangest fact of all, we have obtained, as an
outcome of the system of treatment under the
love that casteth out fear, a literature of the in-
sane by the insane, edited, printed I believe, and
published by the inmates of the Morningside
Asylum in Edinburgh, is one representative of the
literature which alone would suffice to illustrate

the success of the instalment of practical medi-
cine in the historj' of the people living under the
sceptre of Victoria. ' ' ( The Asclepiad, 3d Quarter,
1887, p. 214.)

TREATMENT OF INSANE IN LOUISIANA.

Much has been accomplished in the alleviation
of the condition of the insane of Louisiana, but
much remains to be accomplished, and many
abuses, such as those which we have described in
the preceding pages, remain to be rectified. We
will give no fancy sketches, but will present au-
thentic facts as revealed in official reports, which
we have obtained after much careful research.

TREATMENT OF THE INSANE IN NEW ORLEANS,.
LOUISIANA.

New Orleans was founded about one hundred
and seventy- one years ago, but what was the fate
of the unfortunate insane during the dominion of
France and Spain, and during the early occupa-
tion of the United States in the early part of the
nineteenth centur>^ must remain in doubt and
obscurity.

After a careful search we find no authentic
records of the^early French and Spanish Hospital
in New Orleans ; they appear to have been re-
moved together with other archives to the re-
spective foreign governments. The following
facts are of importance in the light which they
throw upon the history of the Charity Hospital
of New Orleans, and will ser\'e to aid us in ascer-
taining as far as possible the material available
for the preparation of a history of human efforts
towards the proper treatment of the insane in this
city.

The Charity Hospital, of New Orleans, com-
menced its career as a private hospital and con-
tinued so from 1779 to 181 1, when it was given
to the city of New Orleans. In 1830 it became
a State institution, and has remained so ever since.

From 1830 to 1S40 it was supported bj' a tax
derived from licensed gaming-houses, which was
ample for the purpose. In 1846 to 1847, the
legislature levied a tax of $2.50 a head on all
immigrants from foreign countries lauding from
vessels at the port of New Orleans. This income
was large, and continued for several j-ears, but it
gradually diminished from #76,000 collected in
1854 to $14,000 in 1859. It was in consequence
of the diminished revenue derived from foreign
immigrants, that the Charity Hospital became
more and more a burden to the State treasur}-.
It is evident from the preceding facts that the
city records of the Charity Hospital date from
1811 and the State records from 1830.

It is evident that the Charity Hb.spital of New
Orleans was occasionallj- charged with the care of
the indigent insane, for we find that in 1843 the
number of cases, entered upon the hospital
records as due to insanity, was forty-eight with
five deaths, twenty-three discharges and twenty

1889.]

TREATMENT OF INSANITY.

703

remaining. In 1832 mania is credited with
twenty-one cases and seven deaths : melancholia,
two cases ; monomania, three cases. The records
of the hospital are not at this time accessible to
the writer — between the years 1S33 and 1842 —
hut we have reason to believe that the insane of
the city received at different times assistance,
either directly or indirectly, through the admin-
istrators of the Charity Hospital. lu such re-
ports as I have been able to examine, between the
years 1832 and 1849, the destructive effects of al-
coholic stimulants are well marked. Thus in 1832,
thirty-two cases of delirium tremens were entered,
with thirteen deaths, seventy-nine cases of intem-
perance with fifteen deaths. In 1842, mania a
potu, 122 cases and twenty-nine deaths, inebriety,
forty-six cases, three deaths; 1843, mania a potu,
51 cases, five deaths. In 1846, delirium tremens,
159 cases, twentj'-five deaths ; mania a potu, six-
teen cases. In 1848 delirium tremens 177 cases,
fifteen deaths ; inebriety fifty-two cases, five
deaths, mania a potu eight cases, fifty-nine
deaths; intemperance, eighty-four cases: mania
a potu, ten ca.ses.

After careful examination of the archives of
the Charity Hospital of New Orleans, with the
kind assistance of Sister Superior Philomena and
Sister Agnes, the following facts were established:

1. The wooden building on the right of the
main building on Common street was devoted to
the treatment of the indigent insane of New
Orleans up to the time of their removal to Jack-
son in 1848.

2. The lower rooms were used as cells for the
violent patients. The third storj- of this wooden
building (now known as the female department
on Locust street) was occupied as sleeping apart-
ments by the attendants of the insane.

3. The iron bars remained on the windows of
this wooden (Locust street; building of the hos-
pital until 1872, when Sister Agnes had them re-
moved.

4. The insane department of the Charity Hos-
pital was in full operation in 1846, and was
\isited and in.spected in this year by Sister Philo-
mena, on her waj' to Natchez, Mississippi.

5. It is probable that the report of the division
for the in.sane was for a portion of the time, at
least, rendered separately from that of the hos-
pital generally.

I have sought information from all available
sources amongst those who have resided in New
Orleans during a considerable portion of the
present century, and was rewarded by the follow-
ing communication from Judge Charles Gayarre,
the venerable arfti learned historian of Louisiana:

" New Orle.'VNS, May 8, 18S9.
" Prof. Joseph Jones, M.D., 156 Washington Ave.,

" My Dear Sir: — I have understood that before the
existence of the insane asylum at Jackson, demented
persons, who, before 1848, were not numerous, used to
be taken care of at home bv their own families, when

this could be done. Otherwise, these unfortunate beings
were sent to the Charity Hospital, where, if I am not
greatly in error, there was a part of the building ap-
propriated for them. I regret to saj* this is all I know-
on the subject.

" I gladly avail myself of this opportunity to renew to
you the expression of my high esteem and distinguished
consideration. Very truly yours,

Charles G.^v.\rre."

The preceding statement of Judge Gayarre
corresponds to all the facts that I have been able
to collect with reference to the disposition of the
indigent insane in New Orleans prior to the year
1848.

TREAT.MENT OF THE INDIGENT INSANE IN NEW
ORLEANS, L.\.

The Legislature of Louisiana in March, 1847,
passed " An Act to Establish an Insane Asylum
in the State of Louisiana." The asylum was first
thrown open for the reception of patients in De-
cember, 1848. Previous to this time a portion of
the indigent insane were cared for by the Admin-
istrator of the Charity Hospital of New Orleans.
LTpon their arrest the indigent insane were first
incarcerated in a building attached to the Parish
Prison consisting of a series of ill-\-entilated cells,
and this continued to be the custom up to the use
of the United States Marine-Hospital building as
a city insane asylum.

TEMPORARY ASYLUM FOR THE INDIGENT INSANE
OF NEW ORLEANS IN 1 856.

Notes furnished by Dr. C. Delcrc, City Physi-
cian, upon the Temporary Insane Asylum in Ncvj
Orleans.' — "When Dr. Delere entered upon his
duties, December i, 1856, the asylum contained
fifty-six persons ; one of them had been there for
a year, others for several months. The insane
were huddled together in the cells, and the}- often
fought each other at night, and some came forth
in the morning with their heads barbarously
bruised with the blows they had received.

" Dr. Delere has addressed some petitions to the
Common Council to inform them of the abuses
which reigned in the asylum. Upon the entry of
his duties a lunatic was compelled to undergo a
detention of sixty days before he could be con-
veyed to Jackson. Upon Dr. Delere's demand
the Council, some three or four weeks since,
adopted a resolution authorizing the City Physi-
cian to demand, whenever he should judge proper,
the conveyance to the asylum at Jackson of every
lunatic .sent to the temporary asylum, without the
delay which heretofore they have been compelled
to undergo at the said temporary asylum.

"The City Physician complains that lunatics,
beggars and persons afflicted with delirium tre-
mens, are all sent, without distinction, to the
temporary asylum. He deems it a violation of
the laws of humanity thus to confound two class-
es of persons separated by the abyss of insanitj'.

■ New Orleans Med. and .Surg. Journal, January, 1858.

704

THE CLINIC.

[November i6,

' ' He deems it of the highest importance to ex-
pedite as much as possible the conveyance to the
Jackson asylum of the insane sent to the tempo-
rary asylum, for the h^'gienic condition of the
temporary asj'Ium is entireh- unsuitable to the
treatment of insanitj-, whilst the same hygienic j
conditions at Jackson offer the same advantages ;
besides, that this last establishment is perfectly
prepared for the treatment of this sad affliction.

"The Citj' Physician further thinks that there
should be another asylum similar to the one at
Jackson, near the city, and for the following
reasons :

" I. Since most of the insane are furnished by
the cit}', the proxirait}- of the place will enable
the relations to visit them easily and more fre-
quently.

"2. The expense will be much diminished,
since the transportation of the insane from the
cit}- to Jackson is ver\f expensive.

"3. It will be a source of emulation to the
physician at the Jackson asylum, who, instead of i
being isolated as now and abandoned to his own
solitary exertions, will find himself surrounded
by co)ifreres, with whom he would be enabled to
exchange the lights of experience.

"In the present state of things an individual,
upon being sent to the temporary asylum, is sub-
mitted to the examination of the physician of the |
establishment (the Cit\- Physician), who retains i
him until he has obtained accurate information of
his mental condition. He is sent in virtue of an
order of a recorder, which order is issued upon
the affidavit of any one. If the individual is at-
tacked with delirium tremens onl}', the doctor re-
tains him and only restores him to liberty when
he has perfectly recovered his senses. If he finds
that the individual is afflicted with mental alien-
ation, he fills up one of the blanks furnished bj-
the Citj' Attorney-, and sends it to the Judge of
the First District Court. The Judge then fixes a
day for the examination of those designated as
insane. The City Physician is summoned, is put
upon his oath, and swears that his affidavit (con-
tained in the above mentioned blank form) is true.
After this the Judge orders the sheriff to have the
insane (who has thus passed through the form of
the law) sent to the asylum at Jackson."

Dr. Barkdull, phj-sician of the In.sane Asj-lum
at Jackson, wrote in 1857 on this subject:

"The opinion I have formed respecting this
prison has not been derived from an5-bodj', or
friends of patients, but from a more reliable source
than either ofthe.se, namely: from the filthy con-
dition in which we receive tho.se who have been
confined there any length of time."

156 Washington k\e.. New Orleans, La., .■Vug. 19, 1SS9.

THE CLINIC.

The J0URN.A.L will be sent to anj' address from
now until January i, 1891, for $5.00.

GYNECOLOGICAL CLINIC.
BY E. E. MONTGOMERY, A.M., M.D.,

PROFESSOR OF GYNECOLOGY IN THE MEDICO-CHIRL"RGICAL HOS-

PIT.-iL OF PHIL.^DELPHIA. .AND PRESIDENT OF THE SOCIETY

OF .AMERICAN GYNECOLOGISTS .AND OBSTETRICIANS.

[Reported for The Journal.]

Carcinoma Uteri. — Mrs. G. , aet. 35 years, mar-
ried, mother of four children, eldest a^t. 19, young-
est 9 years, no miscarriages. Labors were normal.
She has enjoyed excellent health, until within
the last two j-ears when she first noticed that her
menstruation recurred everj- three weeks, beyond
which she experienced no especial discomfort un-
til last March, when she had a continuous bloodj'
discharge. She then consulted a physician, who
found a laceration of the cervix covered with ex-
uberant granulations which he several times
curetted preparatory- to an operation. She im-
proved for a short time when the condition be-
came more severe than ever, menses were very
free and continued for eight days. Within the
last two months severe pain began to occur, and
was quite severe and lancinating. The character
of the symptoms from which she complains
taken with the physical signs to be described
later, leads us irrevocably to the diagnosis of
malignant disease.

Malignant disease occurs with greater fre-
quency in the uterus than in an3' other organ.
In the uterus, the cer^-ix is most usuallj- the seat
of origin. This greater relative frequency goes
far to confirm the assertion that it originates as
the result of some previous injury. The cervix
is the natural site of injun,- during the processes
of parturition. This is still more evident, when
we consider the infrequenc5' of carcinoma in the
uterus of the unmarried female. The disease is
most likelj' to occur between the fortieth and
fiftieth years of age, but, in my experience, in
the wards of the Philadelphia Hospital, I have
seen a number of cases in women between 20
and 40. In these younger cases, the disease
seems to have an especial virulence, and is much
more rapid in its progress. The period of great-
est frequenc}- is that near the climacteric. A pa-
tient in good health will notice that her menstrual
flow becomes excessive ; that it is followed by a
thin watery discharge, often quite irritating and
having an unplea.sant odor, or the menses may
have ceased for months or years, and there is a
slight return of bloody discharge following coi-
tion or some unusual exercise, or the discharge
may be quite profuse and the woman thinks she
is having a return of the menses. The patient
may suffer from severe lacinatiug pain, or this
sj-raptom may be entirely absent. I cannot too
strongly impress upon you, the importance of ex-
cessive menstruation, or hcemorrhage, at or near
the menopause.

1889.]

THE CLINIC.

705

Permit no patient suffering from this symptom to
be in doubt as to the possible gravitj- of her situ-
ation, and insist upon the importance of physical
examination to determine its cause. Not unfre-
quently the anxiety produced bj' such symptoms
are lulled with the assurance that it is indicative
of change of life and will cease with the meno-
pause. This is a false security and consumes
valuable time. Under such a delusion the oppor-
tunity for medical relief escapes, and patient and
physician awake to find a fatal termination con-
fronting them. Examination of this patient dis-
closes a large spongy mass filling up the vagina ;
passing the finger about it, nodules are felt upon
the vaginal walls and upon all sides. The uterus
is quite large, more or less fixed, and indications
of involvement of the broad ligaments. As we
look at the patient we see a peculiar anemic ap-
pearance, occurs often as combined result of the
haemorrhage discharge, pain and mental distress.

The cachexia is accepted as an indication of
systemic infection. It is doubtless due to the
absorption of material from multiple abscesses in
the degenerated tissues, as the removal of the
latter is often followed by a healthy appearance
of the skin. The extent of the disease in this
woman precludes the pcssibility of a radical cure.
Where the disease is confined to the uterus, how-
ever slight, whether confined to the cer\nx or the
body, the onlj' justifiable operation, in my opin-
ion, is the extirpation of the entire organ. Just
as we would remove a whole mammary gland,
when one of its lobules was diseased, so would I
believe the subsequent immunity against relapse
greater in carcinoma uteri when the whole organ
has been sacrificed.

This operation, however, is only justifiable,
when the disease is confined to the uterus, the
presence of vaginal involvement, infiltration of the
broad ligaments, nodules in the intra-uterine
peritoneum, or tissues, would preclude it for the
reason that it is not justifiable to subject our pa-
tient to a grave operation that affords no hope of
a successful result. But the time for the radical
cure having gone by for this patient, is there
nothing we can do that will afford her an oppor-
tunity for prolonged life, for increased comfort?

The patient is now suffering from htemorrhage,
from the drain of a continuous discharge, and
from the absorption of septic material. The re-
lief of these symptoms for a time will improve
her condition and prolong her life. This we will
endeavor to accomplish by scraping, curetting
and cutting awaj- the diseased tissue until firm
solid ti.ssue is reached. We place the patient in
the semiprone position and insert a Sims' specu-
lum. As I do so, you see this brain-like appear-
ing mass, filling up the vagina. I proceed to
.scrape this away, using my finger as the safest
curette for the reason that I am better able to
judge by it the e.xtent of the disease, the amount

of involvement of surrounding parts, and avoid
the possibility of opening into an adjoining
viscus.

Having completed the removal so far as is pos-
sible with the finger, and ascertained that we can
safely use the curette. I now use this sharp cu-
rette which has, as you see, a hole through its
handle, and from this fountain syringe we will
keep a current of water playing upon the parts as
the curetting is done. By so doing the detritus
is continually washed away, and we have the in-
fluence of heat, or an antiseptic, upon the de-
nuded surface. With the .scissors we now cut
away the ragged edges, and I show you the
uterus with a funnel-shaped cavity excavated
nearly to the fundus. There is considerable ooz-
ing from this surface, to control this, and prepare
the parts for the next step we apply some pledg-
ets of absorbent cotton saturated with liq. ferri
persulph. i to water 3, making a firm tampon in
the vagina. This tampon will be left 24 to 48
hours and removed, the vagina carefully cleansed
and protected by sodii carbonas. 3j, vaseline ,lj,
and pledgets squeezed dry from zinci chlor. and
aq. aa, 3j, applied to the raw surfaces. In the
application of this agent, it is extremel}' im-
portant to protect well the vaginal surfaces. The
.sodii bicarbonas. unguent, is an excellent agent
for this purpose. It should be spread over the
surface of the vagina and about the vulva. The
uterus is exposed by the Sims' speculum and the
pledgets applied so as to come in contact with the
diseased surface ; dry cotton is applied over it
and then a large pledget wet with a' saturated so-
lution sodii bicarbonas. This agent neutralizes
the superfluous caustic and prevents the destruc-
tion of the vaginal and vulvar tissues. These
applications are removed in twenty-four hours
and the vagina syringed several times daily.
The slough begins to separate about the third
day, and is completel}' thrown off in from a week
to ten days. The extent of the slough will de-
pend upon the amount of the organ involved and
the excavation of its cavit5\ The method of
treatment is often followed bj' most excellent re-
sults. The general appearance becomes much
improved, the face bright and healthy, the haem-
orrhage arrested, the discharge ceases, and pain
is lessened. The return of the disease in its
active form maj' be delayed by a suitable regi-
men and the administration of certain remedies.
The diet should promote the nutrition and enrich
the blood, as beef, mutton, eggs and milk, in
other words an albuminous diet. Of remedies,
arsenic, mercury and chian turpentine are most
highly appreciated. While I have not had the
marked results from the use of the turpentine
claimed for it by its special advocate Mr. Claj-yet,
I have seen several cases in which the progress
of the disease seemed much less rapid under its

7o6

MEDICAID PROGRESS.

[November i6,

MEDICAL PROGRESS.

A Comparison of Antipyretics. — From a
comparison of cases, in which he has carefully
tabulated the effects produced, Dr. A. Crombie,
of Calcutta, has reached the following conclusions:

1. As regards efficaC5% antipyrin comes first,
and there is little to choose between antifebrin
and phenacetin.

2. Regarding safety, the advantage lies with
phenacetin.

3. As regards rapidity of action, antipyrin,
probably on account of its solubility , comes first,
antifebrin second, phenacetin third. The fall of
temperature after the use of phenacetin is more
gradual, and the minimum is not reached for
three, four, or even five hours after the adminis-
tration of the drug.

4. As regards duration of effect, the advantage
lies with phenacetin.

5. As regards certainty of action, the order is
the same as that of rapidity, /. c, antipyrin, anti-
febrin, phenacetin.

6. As regards inconveniencies in a hot climate,
like that of India, phenacetin is followed by just
as profuse sweating as that produced by either
antifebrin or antipyrin, and this is the great
drawback in the use of antipyretics.

Dr. Crombie believes that there are often cases
of fever following chill or exposure to the sun
when the exhibition of antipyretics is promptly
followed by a cessation of all further febrile
symptoms. In remittent and continued fevers
antipyretics exert no specific action and are, upon
the whole, inferior to the cold pack, although
there are often practical difiiculties in the way of
using the pack which render the administration
of antipyretics imperative. Hyperpyrexia in it-
self is inimical to life both by reason of the struc-
tural changes which are induced by it, and the
disturbances of digestion which occur when the
temperature exceeds 103°. Phenacetin excels
the other antipyretics in possessing a soothing
soporific effect. In heat, apoplexy, sunstroke
and hyperpyrexia generally, antipyrin is indicat-
ed ; in temperatures of 103° to 105°, antifebrin or
phenacetin : in temperatures below 103°, prefer-
ence should be given to phenacetin. — Indian Med.
Ga~., July, 1889.

A C.\SE of Extraordinary Elevation of
Temperature. — Dr. Lorentzen (^Cent. fur
Klin. Med., Augu.st 17, iSSg) reports the case of
a married woman, 20 years of age, where the
bodily temperature reached the remarkable height
of 112.8°. The patient was under treatment for
hoemoptj-sis, but exhibited no other signs of
phthisis. She had immerous attacks of dyspnoea,
in some of which she became cyanosed and lost
consciousness. The attacks were accompanied

by severe pain in the left side on a line with the
anterior margin of the axilla, in the fourth inter-
costal space. There was also a moderate degree
of hj^peraesthesia in the left ovarian region.
There was no cough and no hsemoptysis during
the attacks. The attacks themselves generally
followed emotional excitement. There were oc-
casional periods of sudden retention of urine, re-
quiring the use of the catheter, but there were no
other manifestations of hj-steria. On the 9th of
January, 1889, when the patient had been under
treatment for several months, the reporter found
his patient in a feeble condition with eyes closed,
face flushed and skin dry, but not verj- warm.
She was slightly delirious and complained of pain
in left side and back and of nausea. Dr. Lorent-
zen measured the temperature in the rectum, al-
lowing the thermometer eight minutes in which
to register, when the mercury was found to meas-
ure 1X2.8°. The rectal temperature was again
measured, this time with a second thermometer,
while the axillarj- temperature was taken with a
third, the results being respectively 112.8° and
112.6°. The pulse at this time was 144, respira-
tions 24. The thermometric measurements were
taken with great care and with corrected ther-
mometers. The temperature remained high for
several days, after which it dropped to normal.
The patient recovered graduall)- and remains well
at date (Jul3% 1889). In default of a more satis-
factorj' explanation the reporter ascribes the ele-
vation of temperature to hysteria.

Compression of Pulmonary Artery in the
Course of Acute Pneumonia. — Dr. E. Tor-
DiEU (Journal dc Mcdccinc, No. 14) records the
case of a child, 5 years of age, admitted into hos-
pital for well-marked acute lobar pneumonia of
the left upper lobe, who presented a loud systolic
murmur in the second left interspace, and trace-
able toward the axilla. The bruit persisted when
the patient was discharged, but so also did the
dulness and bronchial breathing at the left apex.
The notion of congenital narrowing of the pul-
monary artery was unsupported by any collateral
evidence, and it was shown that similar liruits
have been described which were subsequently
proved to have been due to pressure upon the
pulmonary arterj- by enlarged glands or phthisi-
cal consolidation. It was therefore surmised that
a like causation explained the bruit in this case
— a notion which was borne out by the fact that
the limit completely disappeared later, when a
soft hajinic apex murmur alone was audible. —
The Lanect.

Antiseptic Properties in Human Saliva.
— From a series of experiments with the saliva of
human adults. Dr. Floradin has found that the
sulpho cyanide of potash, which is alwaj's pres-
ent, has decided antiseptic properties. — Pragcr
incd. W'oelienseliri/t,, Aug. 21, 18S9.

1889.]

EDITORIAL.

707

Journal of the American Medical Association

PUBLISHED WEEKLY.

SuBSCRiPTio.N Price. iNCLnDiNG Post.ige.

Per AuNUM, IN Advance $5.00

Single Copies 10 cents.

Subscription may begin at any time. The salest mode of remit-
kance is by bank check or postal money order, drawn to the order
of The Journal. When neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
letters.

Address

Journal of the .American Medical Assocl4.tion,

No. 68 Wabash Ave.,

Chicago, Illinois.
All members of the Association should send their Annual Dugs
to the Treasurer, Richard J. Dunglison, M.D., Lock Box 1274, Phila
delphia, Pa.

London Office, 57 and 59 Ludgate Hill.
SATURDAY, NOVEMBER 16, 1889.

STATE EXAMIN.\TIONS AND SCHOOLS OF
MEDICINE.

There can be little diiference of opinion regard-
ing the need for a higher and more uniform cri-
terion of professional attainments than now ex-
ists, and few observant men, outside of medical
college faculties, will denj- the absurdity' of allow-
ing possibly incompetent teachers to examine and
license the pupils whom they may have faultily
or insufficiently instructed. But the search for
a practicable method of reform must encounter
many difficulties, general or' local, inherent in
our system of government. In countries where
imperial control is exercised over medical educa-
tion, the prescription of the subjects and sequence
of the curriculum, the constant super\-ision of
teaching, and the selection of the fittest to con-
duct the final examination, are theoretically
feasible, and ma}- be made to extend throughout
the domain. In America, it is doubtful if national
regulations could be legally established, even if
there were agreement concerning their desira-
bilit}-, and the chance of improvement must de-
pend on the separate action of geographically
continuous, but constitutionally severed States,
of whose legislative bodies it is hardly deroga-
tory- to saj' that thej- are rarely guided by a pro-
found knowledge of the scientific bases of the
ais mcdcndi, but are usually rather actuated by
the hallucination that the sol^ purpose of the en-
tire faculty of a medical school is to impart to
successive classes of unreasoning pupTls certain
traditional and inflexible dogmata touching the

administration of drugs. At the prompting of
this curious misconception, charters have been
granted to "homoeopathic" and "eclectic" med-
ical colleges; in some instances even wilder thera-
peutic vagaries have been incorporated with
collegiate powers ; and as an inevitable result,
several schemes for State examinations in medi-
cine have been defeated by the clamor of these
one-idea ' ' schools ' ' for equal representation in
the examining boards. In New York, which has
been one of the greatest sinners in the matter of
indiscriminate charters — exerting a severe nom-
inal quarantine against physicians from other
States or foreign parts, but leaving it open for
any of its own irregular chartered schools to
countersign the diplomas of Paris, London, Ber-
lin, or Podunk — a recent convention of the
homoeopathic fraternity naively resolved that the
creation of a State board composed chiefly of
"allopathic" examiners would probablj^ lead to
the obliteration of homoeopathic doctrines, and
that a fund should be raised to influence legis-
lators against the passage of any Act tending
toward such a disastrous end. With "practical
politics" as sponsor for the offspring of the
morganatic alliance between ignorance and law-
making, and the ' ' new code ' ' faction officiating
as monthly nurse, the rachitic probability of
short life does not prev-ent the cries of the fretful
twins from disturbing the peace of the neighbor-
hood ; and harassed governors, as well as the
perturbed public, maj- be tempted to administer
some "soothing syrup" for the sake of their
own quiet. And until the public, including law-
makers and governors, shall hav-e learned that
there is as great a difference between a medical
school and a " school of practice " as there is be-
tween a horse-chestnut and a chestnut horse, and
that it is worse than folly to attach the adjective,
"homoeopathic" or "eclectic," to anatotm-,
physiologj', pathologj-, and the other sciences
which constitute a medical education, the one
subsidiary chair of materia medica will continue
to absorb exclusive attention, and to present a
rock whereon all argument will split.

If this mischief making subject, as usually
taught, were abolished from all our schools, the
sacrifice would be small in comparison with the
advantage gained. We say, "as usually taught,"
for when we smile at the gibberish of the Hahne-
mannian " symptomen codex," with its "Aeon. ,

7o8

DREAMS.

[November i6,

Ars., Bell., Brj'.," and so on to the end of the
alphabet, we must remember that in our own
ranks there are routinists from whom students
learn little or nothing of the toxic or ph3-siolog-
ical action of- drugs, but only the empirical state-
ment that quinine is "good" for paroxysmal
fever, or that a combination of rhubarb and soda
is appropriate in childhood, with a series of
arbitrary' prescriptions for the names of different
diseases. The miscalled chair of " Practice of
Medicine ' ' has been modified bj' the advance of
scientific knowledge, until it means to-da}^ the
principles of medicine, and its occupant concerns
himself much more with pathologj- and diagnosis
than with medicinal treatment, dealing, as the
scientific mind must ever deal, with facts rather
than with opinions. If the dr5' bones of " ma-
teria medica" — covered only with the mummi-
fied integument of imaginary and antiquated
"therapeutics" — were laid at rest in a hermet-
icallj- sealed sarcophagus, and its place ceded to
a living pharmacology, teaching the "how" and
' ■ why ' ' of toxic or remedial action, the gradu-
ate would be enabled to intelligently adapt his
treatment to the pathological indications of the
case before him, and the squabbling of sects
would soon cease. None save unblushing charla-
tans would venture to object to an examination
which should test the candidate's knowledge of
general and special pathology and the demonstra-
ble facts of pharmacologj-, leaving to his own
judgment and conscience the practical correlation
of the knowledge so displaj-ed ; and no prophetic
gift is needed to foresee that the requirement of
such knowledge would lead to the extinction of
" schools " founded solely for the maintenance of
visionary theories.

DREAMS.
We have somewhere seen a storj- of a young
mother who, seeing her baby smiling in its sleep,
exclaimed: "The little darling! The cherubs
are talking to it." "Oh, no mum," replied the
nurse, " 'tain' t the cherubs — it's the colic!" It
is to be feared that the progress of science has
tended, for the time, to detract from the poetical
feeling with which dreams were regarded when
they were suppo.sed to be supernatural warnings,
portentous of the fate of individuals and of na-
tions. Still, although we may no longer hope to

learn the waj- to fame and fortune while sleeping
off a Christmas dinner, and even the divination
of one's future partner for life by dreaming over
wedding cake sometimes fails, the mental phe-
nomena of sleep are by no means unworthj' of
stud}', not only for their intrinsic interest, but on
account of their affinity to the various morbid
psychical states.

In the. American Journal of Psychology, Vol. I,
No. 3, Mr. Julius Nelson gives some of the re-
sults of observations made upon himself as a pre-
liminarj' to the stud}- of the general subject of
hallucinations. He says that he possesses the
dreamj' diathesis in an extraordinarj' degree,
which would certainly seem to be borne out by
his statement that he has memoranda of over one
thousand dreams per j-ear for the period of more
than three j'ears covered by his obsen-ations. A
prophylactic measure, which he found efficacious
against bad dreams in childhood, is curious
enough to be quoted : ' ' On composing m3'self
for sleep, the object of a dreaded dream was by
voluntarj- act brought before my mind, and while
held there I said mental!}-, ' Shall I dream of
that ? ' (here visualizing the scene which past
dreams had taught me to fear) and then the sub-
ject was dismissed with a confidence that I should
not be troubled by that dream for that night."

He finds that his dreams may be divided into
three distinct classes : The first, which he calls
"evening dreams," are only experienced on go-
ing to bed in a tired and sleepy condition, with-
out becoming fully awake in the process of un-
dressing. In such circumstances the transition
from a semi-conscious state to one of normal re-
pose is marked by a sudden nervous discharge,
accompanied by a spasmodic start, which often
coincides with the tragic climax of a dream. In
the second class, " night dreams," the mind con-
tinues to be busied with the ideas and emotions
which have engrossed the attention during the
day. The third, and by far the most numerous
class, "morning dreams," occur after the brain
has been refreshed by the night's repose, and
" differ from the foregoing classes in the fact that
they are new or varied combinations of past men-
tal experience, worked up with great fertility of
fancy and multiplicity of transformation."

In compiling his observations he found that
the variations in the amount of dreaming on dif-
ferent nights were not altogether irregular, but

1889.]

EDITORIAL NOTES.

709

presented a certain rhj-thm, the period of which
was twentj'-eight days. He also found that sex-
ual excitemeut, as shown by the frequency of
nocturnal emissions, presented a corresponding,
though not altogether coincident, periodicity.
He is inclined to bring the two facts into relation.
A question like this, however, can hardly be de-
cided bj' observations on a single subject.

Heerwagen, in " Philosophische Studien,"
Vol. v., Xo. 6, undertakes the investigation of
dreaming by the statistical method. He obtained
answers to 406 circulars on the following points :
Sex, occupation, frequencj-, vividness and dis-
tinctness of recollection of dreams, duration and
soundness of sleep, time of day at which intel-
lectual work is most easily performed, nervous
troubles, and temperament. Of the persons fur-
nishing the information 264 were men, of whom
151 were students, and 142 were women. The
following are his principal conclusions : Women
sleep much less soundlj- than men, and dream
much more. Dreams are more frequent in light
than in sound sleep. With advancing age, how-
ever, while sleep becomes less sound, dreams di-
minish in frequency. Dreams are more vivid and
better remembered in persons who dream fre-
quently. With men, dreaming seems to have no
influence on the need of sleep, but women who
dream frequentlj" sleep nearly half an hour longer
than those who dream seldom. As might be an-
ticipated from the foregoing, those who dream
much go to sleep less quickh' and are less likely
to have unbroken rest than those who dream lit-
tle. Of the students, 80 per cent, sleep through
the night without waking ; of the other men, 70
percent.; of the women, only 43 per cent. In-
tellectual labor is easier in the morning to those
who sleep soundl}- and dream little. Nervous-
ness is favorable to dreaming, and is more fre-
quent in women. Persons of phlegmatic tempera-
ment sleep most soundlj' and dream least. The
author supposes that the reason of the inverse
proportion of the frequency of dreams to the
soundness of sleep is due to a greater sensitive-
ness of the brain to internal as to external
stimuli.

It is not probable that the subject is by any
means exhausted, and the material for further
researches is available to almost anyone. It is
to be hoped that scientific researches in this field
will be less rare in the future than they have
been in the past.

EDITORIAL NOTES.

HOME.

Li Po T.\i, a Chinese physician, who has

resided in San Francisco for thirtj^ j-ears, is

said to have a professional income of S6,ooo per

month.

The Transportation of Dead Bodies. —
The Association of Baggagemen, which recently
met in Detroit, passed resolutions insisting that
all bodies of persons dead from contagious dis-
eases, held for transportation, must be properly
prepared for shipment by being wrapped in sheets
saturated with mercuric chloride and placed in
metallic caskets, to prevent the spread of the
disease.

The Country Doctor is the title of a new
journalistic venture to be issued January i, 1890,
under the editorial management of Dr. J. T.
McColgan, of Arcot, Tenn.

To OUR Readers. — Through a mistake in our
mailing department duplicate copies of The
Journal of November 9 were sent to some of the
members and subscribers. We shall esteem it a
favor if those receiving said duplicates will return
them at once, addressed to the Business Depart-
ment, 68 Wabash Ave., Chicago, 111. Write on
the outside wrapper from whom returned, and the
postage (two cents) will be remitted to the sender.

The Medical Mirror. — This is the name of
a new monthly medical journal to be published in
St. Louis, Mo., the first number of which will be
issued in Januarj^ 1890. It is to be edited by Dr.
I. N. Love, who is already so prominently con-
nected with medical journals that he needs no in-
troduction either to the editors or readers of our
prominent periodicals. His name in connection
with the Mirror is an ample guarantee that its re-
flections will be at once clear and truthful, and
that it will shine by inherent rather than by bor-
rowed light. It will not bus\' itself about "that
long felt want," but will create wants for itself.
and in its manner of dealing with these its read-
ers will doubtless find abundant satisfaction. We
bespeak for the Mirror a generous support on the
part of the profession, confident that it will be an
honor to medical journalism.

Dr. John S. Billings, of Washington, D. C,
will deliver the Cartwright Lectures this 3-ear.
The subject will be "Vital and Medical Statistics."

yio

EDITORIAL NOTES.

[November i6,

A New Medical College Building. — Work
has been commenced on a new building for the
Medical College of the New York Infirmary for
Women and Children, at the corner of Livingston
place and Fifteenth street.

Dr, H. Longstreet Taylor succeeds Dr. A.
B. Thrasher as Editor of the Cincinnati Medical
Journal.

North Central Illinois Medical Associa-
tion will hold its sixteenth annual meeting in the
Congregational Church, LaSalle, 111., on Tuesday,
December 3, commencing at 10:30 a.m. The an-
nual public address will be delivered in the even-
ing by Dr. Henry Ziesing, of Peru, on " Heredity
and Adaptability as Factors in Education." This
Association embraces several counties and nearly
one hundred members. Its meetings of one day
and evening only are replete with matters of in-
terest to the general practitioner ; its discussions
practical and free, and the relations of its mem-
bers cordial and unresen-ed. Physicians eligible
to membership are invited to unite therewith and
contribute papers or clinical reports and present
for examination rare and interesting cases of dis-
ease or pathological specimens. The Secretary is
Dr. Wra. O. Ensign, of Rutland, 111.

The Hudson River State Hospital at
Poughkeepsie, N. Y., is to be enlarged.

foreign.

Sanitary Council in Teheran, — The last
number of the Weekly Abstract of Sanitary Re-
ports issued by the Surgeon- General of the U. S.
Marine-Hospital Service, contains the transac-
tions of the Sanitar}- Council held in Teheran on
September 10, and submitted by Dr. W. W. Tor-
rence to E. Spencer Pratt, United States Minister:

It is reported that four Jews, natives of Bagdad,
having avoided quarantine, have arrived at Ker-
mansha. They are closely confined and have
been forbidden to go about.

Various information received from Khanakin
regarding cholera, is reported to have been with-
out foundation and unofficial. Some objection
being raised by the European physicians as to the
reliability of this report, it was suggested that
the Persian consul resident at Khanakin should
lie the proper informant.

The Turkish physician asked as to state of in-
habitants of the country lying between Kerse-ih-

■ Shirun and Khanakin ; that they should be led
to hope that something definite was being done
for their relief ; that it is necessar}- that four phy-
sicians be stationed each at Kerse-ih-Shirun and
Kermanshah, two to be engaged attending pa-
tients with cholera, and the other two to attend
those suffering from other disorders, and perhaps
one other to be engaged in superintending quar-
antine regulations.

A question having been asked by a European
physician as to the measures being taken to re-
move bad odors, his excellency the Nasier el
Malk, president of the council, replied that full

} regulations had been instituted formally for the

' carrying out of all that is necessarA- in that re-

' spect in quarantine.

The physicians said, in reply, that strict regu-
lations were necessarj- and must be carried out
wherever cholera exists ; that most particular

I pains should be taken as regards cleanliness and
removal of bad odors, the thorough cleansing of
houses and thorough fumigation, and that those

j dying of cholera should be wrapped in cloths
dipped in a proper solution of perchloride of mer-
cury. His excellency, the president, replied that
as regards cleanliness and fumigation, such orders
have and will continue to be given, but that as
regards burial and corpses, nothing could be done

' contrarj- to the religion and custom of the coun-
try.

According to latest reports from Khanakin
cholera has increased, and at Bundakauh and on
the other side of the river also ; that it is ven,-

! severe in the tribe of Jof and on the increase,

i many dying daily ; that the people are scattered.
In Khanakin, on the 17th of Moharum, six
persons died of cholera, on the i8th five. Ap-
parently the disease is milder, but it is reported
that the Gaiam-Migom has forbidden any one re-
porting the number of deaths.

A Medic.\l Service for the Chinese army and
navy is to be established.

j A New Ophthalmological Society has re-
cently been establi.shed in Paris under the presi-
dency of M. Chevalereau.

The Riforma Medic.\, the Neapolitan daily
medical journal, has received the first prize in
the Section of Medical Pulilications at the Exhi-

I bition of Hygiene and Medicine, recently held at

> Padua, Italv.

1889.].

TOPICS OF THE WEEK.

711

TOPICS OF THE WEEK.

.A.NCIENT SURGERY IN GERMANY.

Ambroise Pare, who became a master barber-surgeon
in 1536, and died in 1390, has been called the reformer of
surgery, and the French claim in particular that their il-
lustrious countryman was the first to apply the ligature
to arteries. Professor Edmund Rose, in an address de-
livered before the " Freien Vereinigung Berliner Chirur-
gen " May 13 of this year,' laid before the meeting a copj'
of a work dated 1497, byjeronymus Brunschwyg, a Stras-
burg surgeon. On page i9of this work is a colored wood-
cut of an operation room, with a description of various
instruments then in use — the amputating knife and saw,
various probes, needles in handles, small hooks for tak-
ing up arteries ( " damit aufziihehen die Adern " ), small
and large spatulic, bent to assist in drawing out the liga-
ture {" die do Haar uss zieheti"), etc. Further on the
whole armaiiientariinii for the extraction of shots or
pellets is given. It must be remembered that the arque-
buss, the first form of gun fired by a trigger, first came
into use about the middle of the fifteenth centurj-. On
page 5 1 are represented six simple trephining instruments.

Professor Rose is troubled because, even in the latest
edition of a well-read German surgical work, Pare is
still called "the reformer of surgery," whereas his sur-
gery was still " barbaric " when other surgeons had made
advances. His oxen with human heads are exactly the
same as in Licetus. He was not the first to abandon the
old way of treating gunshot wounds (namely, by pouring
boiling oil into them), nor did he discover the ligature of
arteries, or bring it into general use. Petit, himself a
Frenchman, protested against this prevalent idea in the
eighteenth century, and at the close of that centurj^ Mur-
sinna, in Berlin, commended his way of controlling haem-
orrhage after removal of the mammary gland. A plue
-with a complicated dressing was fastened over each sep-
arate artery. Jeronymus Brunschwyg's own words run
thus: " Dass is/, so du siehest cin Ader/ast pliiteii, als
an dt'iii Hals die (,'iessadcr (carotid) oder cin verwiindete
Piilsader, dass du die Adev heiatiziehesl mil der Nadel
mid dadurch stichest, uitd inter Nadeln die ^Ider verk-
nitpfest mil dem Fadeii, der do in der Nadeln ist, nnd\
dann der Xadeln duicliziehest. Und ein Siiicklein Fa- \
dens an der Ader blcibl liengen, itber etlich Tag verfuelet '
das ober Theil des Adern, und geht der Fadcn heraus." I
[That is, when you see an arter\- bleeding fast, such as
the carotid in the neck, or a wounded "pulse-artery,"!
you draw out the artery with the needle, and therebv '
penetrate, and tie the artery behind the needle with
the thread which is in the needle, and then draw out
the needle, and a small piece of thread is left hanging
from the arterj-. -After some days the upper end of the
artery mortifies (decomposes), and the thread is de-
t.iched.] These words are plain enough; the man who
used them had evidently ligatured arteries himself.

.■\s regards gunshot wounds, old Jeronymus Brunsch-
wyg acted on the sound principle of extreme cleanliness.
He spoke of poisoned arrows, etc., just as we, a fewj^ears I
' Berliner Klin. Wochenschrift, July i, 1S89. I

ago, talked of "infected " wounds without any clear idea
of wound diseases. He cleansed the wound with violet
or linseed oil (occasionally camphorated*, and expresslv
says "ein zvenig gewarmt " (a little wannedl. Thus, he
did not advocate the use of boiling oil in such cases.
Long afterwards .\mbroise Pare omitted the use of this
latter means of treating gunshot wounds on one occasion,
and tells us that he could not sleep that night from anxi-
ety for his patient's welfare. As to washing with t^oafs
milk, this had already been recommended by Henrich
von Pfolsprundt in his Bue/t der Biindth-Ertznei, pub-
lished in 1460. The above fluids were evidently found to
be antiseptic, or rather free from nocuous germs of their
own, hence their proved utility on many a battle ground.

The unguentum elemi has been called the balsam of
ArcEeus. We find the same balsam in Brunschwvo's
work. Here it is spoken of as " that best of all balsams
for recent wounds that can be had, and its like can hard-
ly be found." .\nd again, " it almost makes flesh grow."
But, in another place, he inveighs against the indiscrim-
inate use of that " Strassburg balsam, discovered about
the year 1460, and now spread abroad throughout all
Germany."

Refracture after faulty union of fractured ends of bones
has been attributed to a Swabian surgeon of the name of
Bosch, who lived in the middle of the last century. This
also is bosh. Brunschwyg did the same thing; he either
broke the bone across his knee or laid the limb, envel-
oped in a cloth, across two supports, and trod on it with
his naked foot. Extension was effected graduallv by
screws; that is, in recent cases — old ones were let alone,
on the principle, as we are told, that it is " better to be
alive and limp, than to die even with a straight limb."

"Window" bandages were recommended for com-
pound fractures and wounds. A "doltdrank" was given
sometimes to overpower a patient with sleep, so that in-
cisions might be made and a fragment of an arrow, etc.,
removed without pain. The chief ingredient was opium.
."Ancient surgery in Germany, to judge of this work, had
evidently arrived at a high pitch before .'Vmbroise Part-
was born. — Editorial — British Medical Journal.

THE HIGH DEATH-R.\TE IN RUSSIA.

Dr. Leinenberg, of Odessa, publishes in the Inter-
nationale Klinische Rundschau a lengthy article on the
mortality of Russia, which is full of interest for the sta-
tistician. He says that in the number of births alone
Russia ranks first of all European States, as thev annual-
ly amount to no less than 4S.8per 1,000 of the popula-
tion. The latter would consequently grow with abnor-
mal rapidity if an enormous mortality did not make this
impossible. This mortality is, according to Janson, 37.3
per 1,000, while the Statistical Central Committee reports
it at 36.8 per 1,000. As to the causes of such high figures,
Dr. Leinenberg points out that they depend largely on
high infantile mortality. He states that 104.8 boys are
born to every 100 girls, and that amongst the Jews the
proportion of boys born rises to 12S.9 for each 100 o-jris.
The mortality of boys, as of the male sex in general, is
correspondingly greater than that of the female sex, in
the proportion of 36.7 to 35.2. Of 1,000 newly born chil-

712

TOPICS OF THE WEEK.

[November i6,

dren 263.4 die before they are a year old. This mortality
in the first year of infancy is in the province of Novgorod
2S1 per 1,000, and in the Rusk district of the province of
Moscow it reaches the figure of 550.S per 1,000. Even
this enormous number has been surpassed by the town
of Irbit, which shows a mortality during the first year of
life of 560.2 per 1,000. The provinces of Ekaterinoslaw
and Wilno are distinguished by the lowest infantile mor-
tality, the figures mentioned in the report of the Statis-
tical Central Committee being 139.7 per 1,000 for Ekater-
inoslaw and 11S.9 per 1,000 for Wilno. Comparing the
infantile with the general mortality- in Russia, the author
points to the following two important statistical results :
Children up to the fifth year of age form more than one-
half of the deaths from all causes. Infantile mortality
shows a tendency to increase every year. This great in-
fantile mortality in Russia must be largely attributed to
the want of proper diet and of sufficient care, especially
amongst the agricultural population. In summer, which
is the time when nearly all the children die in the coun-
try, the parents are in the fields, leaving their infants at
home with no super\'ision and without sufficient food.
This sometimes leads to strange and sad accidents, as in
a case mentioned by Giljarowskj-, in which pigs devoured
the buttocks of a child which had been left alone at home
for a considerable period. Griasnoff attended a child
which under similar circumstances had been attacked by
goats and had lost every finger on both hands. Dr. Lei-
nenberg also goes on to speak of the health of those who
have passed the crisis of the fifth year. Of 1,568,315 boys
born in the year 1S58, only 750,622 were alive in 1S79,
and when out of this number 272,974 were examined for
the purpose of military conscription, 58,824 men — /. e.
21.5 per cent. — were found to be suffering from various
incurable or chronic diseases, and had consequently to
be returned as unfit for military service; so that of all
bovs born in 1S58, 47. 8 per cent, reached their twenty-
first year, but only 37.6 per cent, preserved good health.
— The Lancet.

FIFTY YEARS OF COUNTRY PRACTICE.

Dr. A1.ONZO GarcELON, ex-Governor of Maine, is 76
years old, and is still in the active practice of his pro-
fession. He this year completes the semi-centennial of
his medical career. The Lewiston Journal gives us some
gossip regarding the doctor's life-work, but particularly
about his travels. He estimates that with his horse and
chaise he has driven about three hundred and sixty-
thousand miles, or fourteen times around the earth.
Such an estimate is based on the supposition that he has
travelled an average of a little less than twenty miles a
day, or seven thousand two hundred miles a year.

This is perhaps, a rather high estimate, but it is quite
within the bounds of possibility.

The reflection which occurs to one in contemplating
these figures is that an enormous amount of purely me-
chanical and unproductive labor has to be expended by
the country doctor in his daily work. While this time is
not by any means all lost, for there is health and mental
rest, or, perhaps, productive ratiocination, in a moderate
amount of ambulation, yet three thousand miles is too

far for the average man to go with horse and carriage,
and expect to do the highest class of work in life.

It is all the more credit to Dr. Garcelon that he has
succeeded in travelling pretty nearly as far as to the
mioon and back, and yet has acquired both political dis-
tinction and medical prominence. But the country
practitioner most needs a means of locomotion swifter
than the horse. Dr. Garcelon in riding his three hun-
dred and sixt)--thousand miles has had to give up nearly
seven solid years, and twenty' jears of working days out
of his total fifty, simpl}- in riding to his patients and
home again. — Medical Record.

responsibility of the drunkard.
M. Motel read a paper on this subject before the In-
ternational Congress of Psychology recently held at
Paris. He said that a man was not responsible for a
crime committed during the delirious period of drunk-
enness, nor when the crime was committed bj' a man
suffering from chronic alcoholism, whose brain has
undergone those changes which compromise the regular
functions of the organ. The responsibility was attenu-
ated in the cases of those persons naturally of a weak
intellect and who take drink badly; it is also extenuated
when it has been proved that the man got drunk unin-
tentionally. On the contrary to those who got drunk
with intention, and where alcohol was taken to give
courage in order to commit a crime, no extenuation
should be allowed. In conclusion, the author proposed
that in presence of the great increase of alcoholism in
France, and the terrible crimes committed under its in-
fluence, the government be invited to take steps to
guarantee society against criminal dipsomaniacs, and for
that purpose to establish special as3'lums for the treat-
ment of habitual drunkards. The assembly adopted this
proposition unanimously. — Medical Press and Circular.

THE FRENCH SURGICAL CONGRESS.

The fourth French Surgical Congress was opened on
October 7, in the grand amphitheatre of the Faculty of
Medicine of Paris, under the presidency of M. Larrey,
who succeeded M. Verneuil. About one hundred sur-
geons, members of the Congress, were present. The
President delivered a short address, after which the
Secretary-general, Dr. Pozzi, read a list of the names of
the officers of the Congress, .\mong the names of the
Honorary Presidents occurs that of Sir Thomas Long-
more, of Netley. Several papers were subsequently
read. On Tuesda}- the time of the Congress was chiefly
occupied by a well-sustained discussion on the immedi-
ate and remote results of operations performed for local
tuberculous affections. During the sitting on this day, a
fire broke out in the great amphitheatre, and the mem-
bers had to make a speedy exit. The pictures, tapes-
tries, and hangings, as well as the seats and tables, were
burned, and the amphitheatre had a narrow escape from
destruction. The fire is said to have been due to the
overheating of the caloriflrc. Some of the paintings
destroyed represented episodes in the history of medical
science, and were very valuable. The damage is esti-
mated at 30,000 francs.

1889.]

PRACTICAL NOTES.

713

PRACTICAL NOTES.

THE EFFECTS OF THE PROLOXGED USE OF
ARSENIC.

The effects of the continued use of arsenic
have been the subject of so much discussion of
late in connection with the Maybrick case, and
so many statements have been made by those
whom we are unable to recognize as able to
speak with authority, that the following expres-
sion of opinion from Mr. Jonathan Hutchinson,
which we take from the second instalment of his
Archives of Surgery, will be read by all with in-
terest. He writes : " My experience in its me-
dicinal use has been very considerable, and m}-
impressions as regards its effects when long con-
tinued are certainly very different from what we
have recently seen so freely expressed. I never
knew a patient become fond of arsenic, or experi-
ence agreeable effects from its long continuance.
On the contrary, nothing but anxiety to be rid of
a loathsome skin disease will induce the majority
of those for whom it is prescribed to continue
taking it. Its general effect if pushed is not to
give vigor, but to diminish it, and make the pa-
tient feel apathetic and uncomfortable." — British
Medical Journal.

SULPHONAL.

M. Raymond has recently tested, at the St.
Antoine Hospital, the value of sulphonal as a
narcotic. Though far from being an ideal nar-
cotic, it proved useful in many cases. It had
scarcel3' an}' action on the respiratory system ; on
the circulator}' sj-stem it had the same influence
as sleep when this was natural ; the temperature
was slightly lowered. The secretion of urine was
increased, that of the sweat glands diminished.
The tongue and mouth were sometimes drj- ; oc-
casionally, though rarely, the patient vomited.
M. Raj-mond found that sulphonal was not an
ansesthetic ; it had sometimes a hypertesthetic
action. Small doses had no influence on muscu-
lar contractility ; doses of 6 grams were followed
by ataxic movements of the limbs. Doses of i
or 2 grams were safe ; women were more easily
affected by sulphonal than men. Progressiveh'
increasing doses were unnecessary. After a cer-
tain time it could be discontinued ; sulphonal
was superior to morphine in this respect. It was
especially useful in insomnia resulting from gen-
eral debility, neurasthenia and cerebral disturb-
ance ; where there was actual cerebral lesion the
action of sulphonal was more intense, and in such
cases it had to be administered with great care.
Sleeplessness from abuse of morphine was relieved
by sulphonal ; it was also useful in phthisical pa-
tients who were rendered sleepless by coughing.
It was inert when sleeplessness resulted from
rheumatic pains, sciatica, cardiac troubles, also

in Bright's disease and intense dyspnoea. Sleep
produced b}- sulphonal was calm, lasted from six
to eight hours, and came on about half an hour
or one hour after administration. The disadvan-
tages attending the use of sulphonal were fatigue,
giddiness, and sometimes positive vertigo. — Paris
Correspondence British Medical Journal.

THE COC.\INE HABIT.

Dr. E. Fletcher Ingals writes us a note re-
garding the cocaine habit as follows :

I have just read the article in the Journal by
Dr. Morgan, on Cocainism, and although much
interested in the report of the case, I feel confi-
dent that the doctor's conclusion, viz.: " In the
treatment, the drug should be immediately and
totally discontinued," and his further conclusion
that the habit is harder to conquer than any
other, are radically wrong.

I have had much experience with cocaine, and
have had two cases in which the habit ruined the
individual, but in either of these cases, I believe,
it would have been an easy matter to withdraw
the drug graduallj' and finally entirelj', if they
could have been properlj' cared for. In both of
them the drug was graduall}- reduced without
their knowledge, until at last 75 per cent, had
been cut off, and this without hardly exciting
the suspicion of the patient. If at that point
they could have been taken in charge bj' some
authorized friend, the habit could have been
easih' stopped without distress to the patient.
These cases came from my earlj- use of the drug,
when I gave the patients a prescription for it,
and cautioned them not to use too much. I have
learned that it is never safe to prescribe cocaine,
for although the habit maj' under proper condi-
tions, I think, be easily broken, it is more easih-
formed than the opium, alcoholic or chloroform
habit. — Indiana Medical Journal.

IS phenacetin

A remedy in WHOOPING

cough ?

Dr. R. Heimann, of Landau, answers the
above question affirmativeh-, having used the
drug experimentally- in a case in which antipyrin
entirely failed. The success was so surprising
that he administered the drug in two other cases.
It reduced the number of paroxysms, which had
been from ten to fifteen per diem, to three, and
on some daj-s the}- entire!}- ceased, only reappear-
ing at night, when no phenacetin was given.
Dr. Heimann gave a boy of 3 j-ears 6 grains in
four doses of I'j grains, a girl of 2 years 5 grains
in three doses, and an infant of 7 months 3 grains
in four doses, without observing the slightest ill
effects. One grain and a half of phenacetin
would, on the average, retain its effect for three
hours. The author recommends further trials of
the drug. — Lancet.

714

SOCIETY PROCEEDINGS.

[November i6,

SOCIETY PROCEEDINGS.

Tri-State Medical Association.

First Annual Meetijig , held at Chattanooga, Tenn.,
October /f and i6, iSSg.

In pursuance to a call issued by several Socie-
ties of Alabama, Tennessee and Georgia, dele-
gates from these States met in Chattanooga and
effected the permanent organization of what prom-
ises to be an excellent Association.

First Day.

The professional part of the proceedings began
with Microscopical Demonstrations by Dr. Jas.- E.
Reeves.

Dr. W. L. Gahagan read a paper on The
Physiology of the Heart atid its l^alves.

The paper contained an accurate description of
the muscular anatomy, the innervation, the action
and the sounds, normal and pathological, of the
heart.

Dr. Drake said that the question "What
makes the heart beat ? ' ' had not yet been satis-
factorily answered, and called attention to the im-
portance of recognizing the differences in the
nervous mechanism of the lower and higher or-
ders of animals.

Dr. James E. Reeves read a paper entitled
The Importance of the Microscope in the Practice of
Medicine.

Remarks on the paper were made by Drs. W.
C. Townes, G. A. Baxter and J. B. Cowan, who
all emphasized the importance of microscopical
investigations at the bedside. The paper was
carefully written and the subject handled in so
masterly a manner as to be above criticism.

Dr. J. E. PuRDON, of Cullman, Ala., reported

A CASE OF FRACTURE OF THE SKULL IN AN OLD
MAN — RECOVERY.

The man was 65 years old, and the interest in
the case lay in the fact of recovery at that age
from such an extensive fracture. The opening,
after the removal of bone, was 3 inches or more.
The fracture was over the third convolution. The
loss of memor>' of names was a marked symptom
from which the patient had only partially recov-
ered.

The discussion, participated in by Drs. G. A.
Baxter, E. T. Camp, W. L. Gahagan, James E.
Reeves, J. F. Lynch, J. B. Cowan, P. B. Green,
W. B. Wells, Jas. Grange and Frank Trester
Smith, was largely on the location of different
centres of the brain and the effect and .symptom-
atology when injured, and the use of the trephine.

Dr. Baxter related a case in which there was
an anomalous distribution of the anterior branch
of the middle meningeal artery, which was wound-
ed while trephining for compression cau.sed by a

blood clot. The haemorrhage was controlled by
pressure, the plug of bone having been inserted
in the opening. Later the blood clot broke down
and was discharged. There was good union of
the plug of bone and full recovery.

Dr. Andrew Boyd, of Scottsboro, Ala., read
a paper on

croupous PNEUMONIA,

in which he briefly reviewed and discussed the
etiology at length, holding the view that the dis-
ease is due to a specific germ, citing cases to prove
his position. He thinks the diagnosis can only
be made from physical signs, and that the rusty
sputum and herpes labialis are pathognomonic.
The disease runs a definite course from seven to
fourteen days. He mentions four varieties of
treatment : depletory, sedative, stimulating and
mercurial ; and reasoning from analogy he con-
cludes that the best plan is to keep down the fever
and stimulate the heart.

The paper was discussed by Drs. G. W. Drake,
Jas. E, Reeves, P. D. Sims, E. T. Camp, J. E.
Purdon, C. N. Cooper and J. B. Cowan.

Dr. DR.A.KE called attention to the importance
of keeping in mind the difference between fibroid
phthisis as sequelae and croupous pneumonia.

Dr. Max Thorner, of Cincinnati, presented a
paper entitled
imaginary foreign bodies in the throat.

These were divided into three classes: i. Cases
where something had been removed from the
throat but the sensation of a foreign body re-
mained ; 2. Cases where the sensation was due to
some pathological lesion of the throat ; 3. Cases
where neither of the above causes exist but where
the sensation is either reflex or produced by some
remote ailment ; as, for instance, indigestion, or
where the trouble is purely neurotic. The treat-
ment varies. Some can be persuaded that there
is no foreign bod}- there, in some it is necessarj^
to resort to innocent deception. The author cited
a case. Pathological conditions, as enlarged ton-
sils or uvula, varicose veins on the back of the
tongue, hj'pertrophied papillae or lymphoid nod-
ules on the tongue, should be removed. Inter-
current affections should be treated. Cases of a
purely neurotic character are rarelj- permanently
relieved.

The paper was discussed by Drs. N. C. Steele,
Frank Trester Smith and N. C, Cooper.

Dr. Smith related a case where deception had
been unsuccessfully tried, and called attention to
the importance of a careful examination for patho-
logical conditions that might account for the sen-
sations, especially local swellings.
Second D.\y.

Dr. J, A. Long, of Long's Mills, Tenfl., read
a paper on

typhoid fever.
The doctor said that the invasion was insidious

I889.J

SOCIETY PROCEEDINGS.

715

during the initial stage ; tongue white, smooth
and glossy, tip and edges red, trembling when
protruded, subsequently many changes, speckled
appearance ; the pulse dicrotous, in the beginning
weak, and this is characteristic of typhoid fever.
Headache comes on during the second week and
lasts ten days. Rose-colored eruption invariably
present; muttering delirium in all forms and cases
of the disease. Both infectious and contagious ;
maj' be a mixed fever, as he saw in Polk Co.,
Tenn., without tympanitis but the pulse had a
reacting beat. The causes of the disease, filth
about old barns and out- houses; diagnosis so easy
that there is no disease likely to be mistaken for
it when symptoms are well marked, yet there are
some cases which do not have well marked ty-
phoid symptoms. There is little doubt that the
first cases in a family arise from the influence of
infection, and in the later ones the infection acts
as a predisposing cause to the contagion of the
first cases. He has no faith in the germ theory.
It is the fever that kills. The report covers 505
cases with a death-rate of less than 2 per cent.
His main reliance in treatment is to combat ulcer-
ation of the glands of the small intestines, which
is one of the earliest symptoms, by giving tur-
pentine in I drop doses every hour. Whether it
acts as a diffusible stimulant to slow ulceration,
or as a disinfectant, he does not pretend to say.

The paper was discussed bj- Drs. G. W. Drake,
J. E. Purdon, L. P. Barber, W. L. Gahagan,
Chas. N. Cooper, R. D. Boyd, Jas. E. Reeves, H.
E. McReynolds, C. Holtzclav, J. F. Lynch, J. B.
Cowan and Frank Trester Smith, who presented
a specimen of ulceration of the intestine.

Dr. Reeve,s said: The paper just read, not-
withstanding the long experience and high pro-
fessional standing of the essayist, is defective in
many particulars. As a clinical picture of ty-
phoid or enteric fever it is so faulty, so unnatural,
that those familiar with the original would scarce-
ly recognize the specific picture, and I can only
account for the warm commendation it has re-
ceived on the ground that it is not ea.sj' to follow
the reading of a paper on any subject with such
correct understanding of its value as to enable
the hearer to discuss it fairly and critically. My
excuse for the criticism I shall offer is that for
forty years I have been a student of enteric or ty-
phoid fever, and by such training I am able, I
think, to compare the picture just presented with
one which I myself long ago gave to the profes-
sion,' and which to-day I could not improve,
notwithstanding the greater clinical experience
gained in the last twenty-five 3'ears.

I do not know a typhoid fever in which the
" headache comes on in the second week, a dicro-
tous pulse during the initial stage without cough

' " A Practical Treatise on Enteric Fever, its Diagnosis and
Treatment; being an analysis of 135 consecutive cases derived from
private practice and embracing a partial Histor\' of the Disease in
Virginia." Philadelphia: J. B. Lippincott & Co. ' Pp. Joo. 1S59.

and bronchial rales ; muttering delirium in all
cases, where cause of the disease is filth about old
barns and out-houses, where " the first cases in a
lai'ge family arise from the influence of infectioii^
and in the later ones the infection acts as a predis-
posing cause to the contagion of the first cases,'" and
where ' ' ulceration of the glands of the small in-
testine is one of the earliest sj'mptoms." This is
wonderful ! He has so far modified the turpen-
tine plan of treatment given by the never to be
forgotten master in the theory and practice of
medicine, the late Prof. Geo. B. Wood, that he
recommends but i drop of turpentine every hour
" to. prevent the ulcers from getting headway."
He relies upon this dose of turpentine as a diffu-
sive stimulant, to slow ulcerations or to disinfect
microbes I He contradicts himself in some of his
statements, e.g., after saying "the diagnosis is
plain and easy when the historj', sj-mptoms, etc.,
are studied," he declares "some cases have no
well marked typhoid symptoms." Finally, he
boasts that his fatal cases have not exceeded 2
per cent.! and this is the answer that he himself
makes to the question that naturally suggests it-
self— Were his cases all genuine cases of typhoid
fever? I am sorry to have felt myself compelled
to make these remarks, but the demands of med-
ical truth are inexorable, and I must beg that my
criticisms go- on record with the paper.

Dr. Dr.\ke said that the paper contains the
most complete pen picture of the disease which
had ever been presented to his mind, and barring
some confusion in regard to infection and etiology,
merited high commendation. Much interest at-
taches to the paper as being the result of the ob-
servation of over 500 cases in a practice of forty-
five 3'ears in the same locality. Dr. L. gave his
own observations of his cases without reference
to text-books or the experience of others. Tur-
pentine, quinine, alcohol, milk and home-made
beef-tea are the medicines and foods Dr. Drake
had used in his practice.

Dr. W. C. Townes, of Chattanooga, read a
paper on

HYPNOTISM AND SUGGESTIBILITY.

Dr. Townes had recently studied the subject of
hypnotism in Paris, and claimed that it was a
means that had too long been relegated to charla-
tans. In support of his claim that it should be
recognized he cited several cases where patients
had been cured b)- this mysterious agenc}'. He
showed that the phenomena of moving tables,
etc., are real, that certain of our actions are made
unconsciously', dependent upon complicated brain
action and also on double personality. Hypno-
tism is a peculiar psychical state which we are
able to create in the subject and which increases
his suggestibility. From a medical standpoint
the aim is to produce this state, so that suggestion
will excite the nervous system to perform acts

7i6

SOCIETY PROCEEDINGS.

[November i6,

that will lead toward a cure. Homoeopatli}', mi-
raculous waters, granules and Brown-Sequard's
elixir of life act by suggestion, often resulting in
a cure. The author closed b}- citing the conclu-
sions adopted by the recent Congress in Paris :
that hypnotism should be taught in medical
schools, but should be under authoritative admin-
istration.

Dr. J. E. PuRDON, of Cullman, Ala., read a
paper entitled

THE SPHYGMOGRAPH AS A NEW REAGENT IN
PSYCHICAL RESEARCH.

Dr. Purdon's paper had for its object the' ad-
vancement of a claim to the discovery of the fact
that psj'chical influence of one nervous system
upon another at a distance, and unconnected by
any of the ordinars' physiological bonds, could be
demonstrated by the aid of the sphygmograph.
He claimed to have identified in many instances
forced relationships of the pulse tracings from the
fact that certain neurotic subjects had departed
from their usual trace forms to conform to those
of individuals with a more dominant nervous sys-
tem. Dr. Purdon further argued that this was a
first step towards the proof of physical connection
between the higher centres of different brains
which the progress of modern ps3-cholog3- obliges
us to acknowledge, in the face of the now well es-
established fact of psychical community, mind
reading, sympathetic sensibility, etc. He argued
against the fundamental principles of materialism
by falling back upon the possibilities of the infra-
conscious intelligence and by regarding mind and
matter as but different aspects of the one underly-
ing reality.

These two papers were discussed by Drs. G. W.
Drake, James E. Reeves, J. B. Cowan and G. A.
Baxter.

Dr. Drake said : We have heretofore been
taught that nerve impulses are confined to the in-
dividual in whose organism are contained the cere-
bro-spinal and ganglionic nervous systems. In
Dr. Purdon's paper the startling thought is pre-
sented that nerve impulses (or nerve fluid) may
escape from the body of one individual and, like
electricity, passing through the inter\-ening me-
dia, atmosphere or even a stone wall, penetrate
the body of another individual. When impulses
from the cardiac centres of one person raaj- pass
to those of another, or to the nerves leading from
them, and so control the pulse as to cause the
sphygmographic tracings of the individuals to be
essentially identical ; when impulses — a current
of fluid — as instanced in the cases of the prison-
ers cited in Dr. Purdon's paper, pa.ssed through
prison walls and affected individuals in separate
cells; this fluid must be more sulitle than electri-
city, since the latter might have shattered the
walls, while there was no trace left in the walls
by the passage of the nerve influence, but the

doctor shows traces of the sphygmograph claimed
by him to have been caused bj- impulses which
passed through the walls. There were peculiar
noises in the room when Dr. Purdon made these
observations on the three prisoners, like rappings
on tables, noises produced by the passage of this
subtle fluid (nerve impulse) through non-con-
ducting media which would be encountered here
and there in the atmosphere of the room ; little
thunders, as it were, analogous to the thunder of
lightning. Dr. Purdon appears to teach that cur-
rents of thought ma}- pass from one brain to an-
other, as in mind reading, and currents of painful
impulses from a parturient woman to a sympa-
thetic spectator, and during pregnancy the hus-
band ma\- suffer, by transference, the nausea
which belongs to the wife. If Dr. Purdon's the-
ories be true, how may we know that our thoughts
are our own and not currents of impulses from the
brains of others? This is a legitimate inference
from his theories.

As to hypnotism and suggestibility presented
by Dr. Townes; the brain centres are kept awake
and active b}- impulses which flow in through the
five senses, and also by thoughts or ideas from
the mind — a separate existence from matter — im-
pulses may be conducted by ner\-es to any or all
of the brain centres, or subconscious impulses
ma}' originate in these centres. Now, then, if
these centres, either by impairment of the centres
so as not to receive impulses or impairment of the
nen-es so as not to conduct them, or the shutting
off of the stimuli so as not to act on the peripheral
terminations of the nerves, the centres thus treat-
ed are in a hypnotic state, while other centres
may be awake and active. There may be thus
localized hypnotism. To become an expert in the
practice of hypnotism it is necessary to study the
, methods of temporarily suspending or retarding
' the action of the brain centres. If you have to
control a normal action in the subject, by the
same means you may be enabled to modify an ab-
' normal action which is producing some functional
' disturbance. The quieting of the fretful babe by
the mother's gentle patting and sweet lullaby is
due to hypnotism, and later the aches and pains
are cured by the mother's kisses — suggestion.
The method by suggestion is a species of faith
cure and depends in a great measure on the cre-
dence of the patient in the promises of the phy-
sician. Suggestibility, as I understand it. is a
susceptibility to certain psychical influences, and
may be increased by the hypnotic state. Hypno-
tism and .suggestibility are old ideas clothed in
the habiliments of science. Let us beware how
we handle the tool of the charlatan lest we give
our endorsement to methods we streiuiously con-
demned in the near past. Psychologv is destined
to work great revolutions in medicine, but let us
take our soundings often as we near shoal waters.
I. To be concluded. 1

1889.]

DOMESTIC CORRESPONDENCE.

717

DOMESTIC CORRESPONDENCE.

LETTER FROM KEW YORK.

(FROM OCR OWX CORRESPONDENT.)

N'ciu York County Medical Association — The
late Professor Alexander B. Mott — A Double Fiv-
tus — Podalic Version in Contracted Pelvis.

At the last meeting of the New York Couuty
Medical Association Dr. John Shrady read a
memoir of the late Professor Alexander B. Mott,
which was listened to with much interest, and at
its conclusion the following minute was adopted :

In the death of Alexander B. Mott the well-maintained
heritage of a name illustrious in the annals of surgery is
transmitted to posterity with added memories of good
work faithfully done.

Self-reliant, ingenious in device, and exceptionally
skilful in execution, his career exemplified the best at-
tainment of his chosen art, and his departure leaves a
vacancy long to be deplored.

Sharing the grief of the whole profession which he
adorned, this Association desires to record its special
regret for the loss of a valued member, and its sympathy
with those who mourn not alone for the distinguished
surgeon, but for the beloved relative or dear friend.

Dr. Augustin M. Fernandez then presented a
specimen of double foetus united at the thorax
and upper part of the abdomen, relating the cir-
cumstances of its birth, which was attended by
himself in September, and giving an admirable
resume of the existing knowledge in regard to
such monsters and their delivery. The mother,
a Cuban lad}- who was stopping temporarily in
New York on her way to the Paris Exposition,
was past the sixth month of pregnancy, and
when Dr. Fernandez made his first examination
he was surprised to find three feet protruding
from the os uteri. A physician from the house-
staff of the New York Hospital, which was near
by, was hastily summoned in constiltation, but
there was no special trouble in the delivery,
though the monster was born dead. One of the
children measured 14 inches in length and the
other \zy2 inches; weight 4^4 pounds. They
were both males and well developed, and their
faces were turned toward each other. The pla-
centa was delivered twenty-five minutes after
their birth, and there was but a single umbilical
cord. The uterus contracted well and the mother
made an excellent recovery-.

This double foetus belonged to- the order of
symmetrical navel-joined monsters (Fisher), in
which the band of union varies from a compara-
tively narrow band, as in the case of the noted
Siamese twins, to complete union of the thorax
and a considerable portion of the abdomen. In
this instance it involved the sternum throughout
and all the upper part of the abdomen, there be-
ing but a single liver, which was of large size.
Dr. Fernandez, in studying the literature of the
subject since he met with this case, has found.

like Playfair, that the authors who have placed
on record the birth of double monsters have gen-
erally occupied themselves more with a descrip-
tion of the structural peculiarities of the foetuses
than with the mechanism of their delivery, so
that, although the cases to be met with in medi-
cal literature are verj^ numerous, comparatively
few of them are of real value from an obstetric
point of view. For obstetric purposes Playfair
confines his attention to four principal varieties
of double monstrosity, which are as follows: i.
Two nearly separate bodies united in front, in a
varying extent, by thorax or abdomen (as in the
present instance). 2. Two nearly separate bodies
united back to back by the sacrum and lower
part or the spinal column (as in the case of the
"double-headed nightingale," Millie Christine),
3. Dicephalous monsters, the bodies being single
below, but the heads separate. 4. The bodies
separate below, but the heads fixed and partially
united.

The principal paper of the evening was by Dr.
George Tucker Harrison, Vice-President of the
Association, on "Podalic Version in Contracted
Pelvis," and embodying, as it did, the results of
careful and accurate observation by an accoucheur
of high reputation and widely extended experi-
ence, it constituted a contributioti of real worth
and great practical interest.

Dr. Harrison commenced with a reference to
the verj' vague and indefinite views of the aver-
age practitioner as to when forceps, version, cra-
niotomy, Caesarian section, or the induction of
premature labor are indicated in cases of narrow
pelvis, and said that this was scarcely to be won-
dered at, considering the divergence of opinion
existing among distinguished authors and teach-
ers regarding the therapeutical doctrines of this
condition. From several passages in the writings
of the ancient Celsus he thought it was evident
that that celebrated author had a knowledge of
podalic version, and a passage from Philumenos
showed that in head presentations, when these
obstacles to the birth occurred, it was practiced
by the Roman physicians. With the destruction
of the Roman empire its literarj' and scientific
knowledge disappeared, and it was therefore, he
said, an inestimable boon that Ambroise Pare
conferred on humanity when he rescued this
method from oblivion and recommended its use
as a conservative measure in dystocia from pelvic
contraction.

Having paid a tribute to the zealous and suc-
cessful labors of de la Motte on behalf of podalic
version, he proceeded to speak of those of Sir
James Y. Simpson, and designated as epoch-
making his writings on this theme. At a meet-
ing of the Obstetrical Society of Edinburgh, held
in Januar>', 1887, this distinguished authority
had the opportunity of showing to the members
a large infant extracted the previous evening by

7i8

DOMESTIC CORRESPONDENCE.

[November i6,

the operation of turning through a pelvis the
brim of which was greatly contracted. Although
the child was born dead, the fact that the head
had passed the contracted brim undiminished
gave him an incitement to further investigations.
In writing of this case afterward he said that it
was, at the time of its occurrence, one of intense
interest to him in two points of view : First, it
was the first case in which he or any other ac-
coucheur had ever tried the effects of ether inha-
lation during labor ; second, the case appeared
to him to be one of great moment as an opposite
illustration of views which he had been jjrevious-
ly led to entertain as to the possibility and pro-
priety of substituting, in some instances, extrac-
tion by the feet for extraction by the crochet ;
the deliverj- of the infant by the hand of the ac-
coucheur, instead of its delivery by instruments ;
the lateral compression of the child's head by the
contracted sides of the pelvis, instead of its more
dangerous oblique or longitudinal compression
by the long forceps ; and, above all, the transient
and not necessarily fatal depression of the flexible
skull of the foetus for the destruction and neces-
sarily fatal perforation of it.

Simpson thus summed up and recapitulated
the advantages obtained by podalic version in
contracted states of the pelvic brim :

1. The fcetal cranium is of a conical form, en-
larging from below upwards, and when the child
passes as a footling presentation the lower and
narrow part of the cone-shaped head is generally
quite small enough to enter and engage in the
contracted pelvic brim.

2. The hold which we have of the protruded
body of the child, after its extremities and trunk
are born, gives us the power of employing so
much extractive force and traction at the engaged
fcetal head as to make the elastic sides of the up-
per and broader portion of the cone (viz: the bi-
parietal diameter of the cranium) become Com-
pressed and, if necessary, indented, between the
opposite parts of the contracted pelvic brim, to
such a degree as to allow the transit of the entire
volume of the head.

3. The head, in being dragged downwards into
the distorted pelvis, generally arranges itself, or
may be artificially adjusted so that its narrow bi-
temporal instead of its bi-parietal diameter be-
comes engaged in the most contracted diameter
of the pelvic brim.

4. The arch of the cranium or head is more
readily compressed to the flattened form and size
required for its passage through a contracted
brim by having the compressing power applied,
as in footling presentations and extraction, di-
rectly to its sides or lateral surfaces, than by hav-
ing it applied, as in cephalic presentations, partly
to the lateral and partly to the upper surfaces of
the arch.

Lastly I may add, as a result of the whole

mechanism, that the duration of the efforts and
sufferings of the mother is greatly abridged hy
turning, when used as an alternative for cranioto-
my and the long forceps, and that thereby her
chances of recovery and safety- are increased.

Simpson's teachings, Dr. Harrison went on to
say, met with a hearty reception in Germany,
and it was especially through the brilliant and
enthusiastic advocacy of these doctrines by Schroe-
der and Gusserow that they received general
recognition on the part of the German obstetri-
cians. In England such high authorities as
Barnes, Braxton Hicks, Leishman and Duncan
had employed version to a greater or less extent,
while others equally well known gave the prefer-
ence to the high forceps operation. In France
version had never been a favorite procedure, and
especially since the introduction of the Tarnier
forceps had it lost ground. In this country ver-
sion has found comparatively few advocates, ex-
cept within restricted limits. For the value of
their contributions the names of Taylor, Goodell
and Lusk were worthy of special mention, and
the latter, in his excellent text-book, had dis-
cussed the subject in a spirit of judicial fairness.
Dr. Harrison criticized with much vigor the
article by Dr. Cameron on "Forceps vs. "\'ersion"
in the American system of obstetrics, from which
he quoted the following passage : ' ' Except in
cases of considerable pelvic contraction the for-
ceps operation may be regarded as comparativelj'
harmless in skilled hands, while internal version
is always a serious undertaking, involving more
or less danger for mother and child, even when
performed with the greatest skill. The unprac-
ticed operator is far less likelj- to do harm with
the forceps than with version. Whenever, then,
it comes to be a question of choosing between for-
ceps and internal version, the forceps should be
selected, unless specially contra-indicated, because
the operation will be easier and at the same time
safer for the mother and child. ' ' More false doc-
trine, Dr. Harrison thought, could hardly be em-
braced within the same number of sentences.
Shrceder had shown in the clearest manner that
this putting in contrast forceps and version is an
error, and ignores true obstetric relations. When
version was still practicable, the forceps was con-
tra-indicated ; and when, on the other hand, the
forceps was indicated, the time for turning had
already passed. The objections to the use of the
forceps in high-.standing head were mainly two-
fold. In the first place the forceps grasps the
head in the fronto-occipital diameter, so that the
' tendency is to enlarge the transverse diameters,
' which have to pass the conjugata, and at the
' same time to prevent the over- riding of one parie-
tal bone upon the other. In the second place it
is not in the power of the forceps to accomplish
the inflection of the bones, which is an important
factor in the moulding of the head.

iSSg.]

DOMESTIC CORRESPONDENCE.

719

The advocates of podalic version in contracted
pelvis, he said, were divided into two parties, ac-
cording as they respectively formulated the thera-
peutical indications. The one side recommend-
ed waiting, so long as the passage of the child's
head appears possible and devoid of danger ;
when further delay is no longer permissible in
the interests of the mother, perforation and ex-
traction with the cranioclast in high-standing
head ; forceps in the case of a living child, after
the narrow part has been surmounted; in unfavor-
able engagement at the brim, fixation not ensu-
ing within a certain period, version and extrac-
tion. The other side sought to avoid the possi-
bility of a perforation by a prophylactic version
before any symptom of danger threatened the
mother. Dr. Harrison said that for years his
own practice had been based upon this view, and
that he could not earnestly advocate the advan-
tages of this method of procedure. Long ago
Simpson had argued that the protraction of labor
was, per se, dangerous both to mother and child,
and that any operation was dangerous and fatal
in proportion to the length of time allowed to
elapse before the artificial delivery was accom-
plished. For these reasons he declared that in
proportion as turning was practiced earlier, so
far would it be attended by greater safety and
greater success.

The conditions most favorable for version were,
of course, intact bag of membranes and complete-
ly dilated os uteri. Often, however, the physician
was not called to the case until the membranes
had alread}' ruptured, and this might have oc-
curred prematurely. This premature rupture was
especialh' to be regretted in a contracted pelvis,
as it rendered the prognosis for mother and child
more unfavorable, the explanation being that
such an accident is more apt to occur at an early
stage of the labor in a narrow pelvis. He fully
agreed, therefore, with Nagel in the opinion that
in a premature rupture of the membranes version
should be undertaken as early as possible, and
that we should not wait for full dilatation. It
was of the utmost importance, as influencing the
result, that the after-coming head should be
brought through the pelvis with as little delay as
possible, and upon the best method of accomplish-
ing this the views of different authors were at
variance. All were agreed, however, that the
head must be guided into the pelvis and drawn
through it with the chin flexed. The finger in
the mouth served mainly to approximate the
chin to the breast. A supremely important mat-
ter was the pressure from without through the
abdominal coverings, traction on the trunk being
made by the hand over the nape, according to
the Veit method. Dr. Harrison's experience has
been entirely in accord with that of Nagel, who
suggests the propriety' of rotating the chin be-
hind, when still in the inlet of the pelvis, so that

the sagittal suture runs in one or the other ob-
lique diameter. In this way, he said, he had re-
peatedly accomplished delivery in exceedingly
contracted pelves.

In the discussion of the paper Dr. Charles A.
Leale described the method he pursued in induc-
ing premature labor and delivering by version in
anus where the pelvis was contracted to such an
extent that it was not deemed expedient to allow
the woman to go to full term ; and Dr. Joseph
Kercher spoke particularly of the difficulty in
correctly estimating the pelvic diameters, stating
that he had known good obstetricians to resort to
the early use of version or the forceps in cases
where the pelvis was in reality of normal size,
under the impression that there was present a
considerable degree of contraction. In his opin-
ion podalic version was not to be recommended,
as a rule, in primaparse, except the os were well
dilated and the membranes unruptured ; breech
labors being much more dangerous to the latter
than to multiparae.

In closing the discussion Dr. Harri,son spoke
in deprecation of the emphasis which most of the
I text-books on obstetrics laid upon the rarity ot
contracted pelvis in this country as compared
with European nations. It was, no doubt, true,
he said, that this condition was somewhat less
common here than in Europe, but at the same
time it was met with with sufficient frequency to
make it necessary that every practitioner of mid-
wifery should be fully prepared to treat such cases
in the most skilful manner. Personally he had
had some terrible experiences with them in this
city, and as every one was liable to come across
them in his practice, he thought it was a great
mistake that the student and young physician
should be allowed to get the idea that they were
so rare that he need regard the chance of his en-
countering one as only a remote contingency.

At this meeting, which was the first the Asso-
ciation has held since the long vacation, twenty-
nine new members were elected, and a committee
was appointed to consider and report upon the
best methods of suppressing illegal practitioners
and mitigating dispensarj- abuses in the city of
New York. p. b. p.

Chloroform Accidents.

To the Editor: — I take the liberty of writing
you in regard to the article on ' ' Chloroform Acci-
dents" in The Journal of October 19th.

I have been for many years following the prac-
tice there described for prevention of death under
anaesthetics, and have over and over again pre-
sented it to the profession of this country . First
in the American Journal of Medical Sciences, April,
1876, on "The Influence of the Injection of Nar-
cotics upon the Anaesthetic Process;" again in
"Transactions of the vState Medical Society of

720

NECROLOGY.

[No\'EMBER 1 6,

Ohio," 1879, in which paper I particularly urged
the influence of atropia in sustaining the heart's
action; further, in American edition "Holmes'
Surgery," and several times in journals.

Now, I do not wish to trouble you, and care
little about the personal honor of priority in this
matter, but think that when a procedure is pub-
lished as a good thing, being so discovered abroad,
those who have worked at it for many years be-
fore in this country deserve mention.

In speaking oi priority of this process, I do not
claim originality, but only that I have been a
persistent and repeated advocate of it. I believe
it to be one of the most important and most valu-
able modifications of the anesthetic process.
Nussbaum first used it. When in Miinich, in
1887, 1 took the trouble to call upon him in refer-
ence to it, but found that he never carried it be-
yond his first essay.

The method was placed upon a scientific basis
by Bernard Q' Lccotis sur t Asphyxic et F Anaes-
thetic'), and the results as to death of dogs there
given is quite as striking as that in the article
3-ou have published.

I am verv respectfully and truly j-ours,

J. C. Reeve, M.D.,

Dayton, O., October 19, 1SS9.

Tenth International Medical Congress.

To the Editor: — I have received the following
letter from Professor Virchow, the President-elect
of the next Medical Congress.

Very truly yours,

John B. Hamilton.

Treasury Department, U. S. Marine-Hospital Bureau,
Washington, D. C, October 50, 1SS9.

Berlin, October i, 1S89.

Dear Sir: — The Organizing Committee of the Tenth
International Medical Congress is now constituted. I
myself am elected President, and Dr. Lassar (Karlstrasse
19, N.W. 1 Secretary-General. We will be very happy to
receive the Transactions of the Ninth International Con-
gress, and we hope to see you and many of your country-
men at the new session.

I am, sir, ver}- sincerely your obedient servant,

' Professor Rud. Virchow.

HoUand Claims the Microscope.

To the Editor: — Allow me to call your atten-
tion to an error in The Journal of September
14th, which mistake I have recently seen in one
or more other journals. On page 385 of The
Journal, under the caption of "The Tercenten-
nial of the Microscope," you ascribe the invention
of that highly useful instrument to a Zacharias
Janssen, of ]\Iagdeburg, the capital of a Prussian
province. Saxony. Zacharias Janssen, to whom
belongs the credit of constructing the first cam-
pound microscope (the simple micro.scope was
known previous to that timej, was not a German
but a //ollander, born and reared in Middclburg,

the capital of the province of Zeeland, one of the

eleven provinces of the United Netherlands.

Germany and the Germans seem particularly
anxious to monopolize the credit of most of the
useful inventions — now they laj' claim to the
invention of the microscope. "Honor to whom
honor is due." J. VanderLaan, M.D.

Muskegon, Mich., September 14, 1SS9.

NECROLOGY.

Dr. Isaac E. Taylor.

This distinguished physician, so well known to
the medical profession and so highly honored,
died at his residence in West Thirty-fifth street,
New York City, on the 30th ult., at the age of
77 years. He was from the time of its organiza-
tion until his death the first and only President
of Bellevue Hospital Medical College, and has
always been esteemed as one of the foremost pro-
moters of medical education.

About ten days previous to his death he was
attacked with acute pericarditis and was confined
to his bed. Up to the moment of death he had
not been considered seriousl}' ill. While lying in
bed and reading from a book his daughter noticed
that he suddenly threw his hand over his head,
sank into his pillow and in three-quarters of an
hour he was dead. Mrs. Taylor died in 1867.
Four children — Mrs., Pierre Lorillard, Col. Stew-
art Taylor, Mrs. Hilliard M. Judge, and an un-
married daughter, are his immediate surviving
relatives. His was a well rounded life, full of
j'ears, of unusual achievement and of signal hon-
ors. To the family bereaved and to the Faculty
of the College, the profound sympathy of the pro-
fession will be most freely accorded.

Dr. Ij. F. Warner.

Dr. Levi F.\rr Warner, of Boston, for many
years an influential member of the American
Medical Association, and in 1874 one of its Vice-
Presidents, was born Oct. 25, 1822, at Nor\vich,
Chenango Co., N. Y. He died Oct. 12, 1889, at
Boston, two weeks before the completion of his
67th year. Educated preliminarily at the Acad-
emy at Mexico, N. Y., he studied for his profes-
sion during 1842-3 at Geneva Medical College,
and subsequently graduated in 1862 at Lind Uni-
versity, Chicago. He commenced practice at
Vienna, at Oneida Co., N.Y., and removed thence
to St. Louis, where during the war he was A.ss't
Medical Examiner for the First District of Mis-
souri. He then came to Boston, and was ad-
mitted a member of the Mas.sachu.setts Medical
Society. He was one of the founders of the
Gynaecological Society of Boston, and .soon be-
came recognized as of especial skill in the diag-

1889.]

BOOK REVIEWS.

721

nosis and treatment of the diseases of women.
He conducted successfulh- a large practice until
his death, which was from cerebral hsemorrhagic
effusion, the result of an accident.

Though always participating with interest in
the discussions at the various scientific societies
with which he was connected, he wrote but little,
save quite a number of obituaries of deceased
members of the American Medical Association.
His paper, however, "On the Connection of the
Hepatic Functions with Uterine Hyperaemias,
Flexions, Congestions and Inflammations" in
the Transactions of the American Medical As-
sociation for 1878, vol. xxix, exerted a distinct
influence towards obtaining in New England a
wider respect by general practitioners for the
specialty of gynecolog}-, then still upon trial, and
at the same time ser\'ed to curb the somewhat
inordinate zeal of a portion of its younger en-
thusiasts.

The writer of this notice was long associated
in practice with Dr. Warner, and the relation was
of the most intimate character. From first to
last he was always faithful to his duties. Not a
shadow of difierence ever arose between the two,
and there was never an unkind word uttered.
Scotch in his parentage, several of the most im-
portant traits in his character were doubtless in-
herited. His father a clergyman, he knew the
Scriptures absolutely, and the}' were ever in his
mind. He was Presbj^terian from childhood, but
towards the end of his life held close relations
with the Congregationalists, with whom his latelj-
deceased wife was in communion. He enjoyed
in a pleasant way religious controversj% but it
was rather as a kind teacher than as an an-
tagonist.

He was one of the most genial of men. Full
of anecdote to overflowing, cheerful and merrj'
by nature, he carried comfort to the despondent
even when his own disappointments and sorrows,
and he had many of them, were weighing most
heavily upon him.

He was almost perfection itself in his chosen
professional work. Always successful in obtain-
ing the full confidence of a patient, he never
proved unworthy. He was untiring, in the most
chronic and discouraging cases, to a marked de-
gree. Persistent in following up the instances of
this kind that were confided to him, he often pro-
duced the most surprising and unexpected cures,
restoring women to their full usefulness who had
for many years apparently been hopeless invalids.
At his funeral there were scores of such, who
dated their restoration to domestic happiness and
to life itself, a long time back, wholly to him,
and so lamented their lo.ss accordingly.

To those who treated him fairly he was de-
voted in his friendship. He was true as steel,
and as gentle as a child. Though naturally
sensitive and quick tempered, he was always

ready to make acknowledgements if it should
prove that he had been in error. He disliked to
have wealthy patients, declaring that in the
middle-class one found the most gratitude. To
the poor, both in private and hospital practice, he
always gave freely of his thought and time, and
had he not, besides, contributed much and con-
stantly in other charit)', he would have amassed
a fortune from his profession.

He has left instead a better legacy, the loving
recollection of a thoroughl}' upright and honest
man, a most delightful companion, an always re-
liable friend, a really good physician. May he
rest in peace. H. R. s.

BOOK REVIEWS.

A System of Obstetrics. By American au-
thors. Edited by Barton Cooke Hirst, M.D.,
Associate Professor of Obstetrics in the Univer-
sity of Pennsylvania, Obstetrician to the Phila-
delphia and Maternity Hospitals, etc. Vol. II,
illustrated with 221 engravings on wood. Pp.
xi, 854. Philadelphia: Lea Bros. & Co. 1889.

The second volume of Hirst's splendid System
of Obstetrics forms a valuable contribution to the
American literature of this subject. In subjects
where recent advance has been made, as in the
study of the bacteriology' of puerperal fever, the
more recent views of the authorities are set forth
with a minuteness of detail which is nowhere else
to be found in obstetrical works. Indeed, were it
not for the work of the bacteriologists of the pres-
ent day, it would be diflicult for obstetrical writers
to find anything new to off'er their readers, and
in point of fact some of the recent publications,
with all their pretensions, will be found to have
made but very little improvement on their edi-
tions of a dozen years ago.

Like all works of the character of the one under
consideration, there is a lack of consecutiveness
and balance in the arrangement and treatment of
the several topics, while on the other hand there
is a certain advantage in becoming familiar with
the views of a number of authoritative ^\Titers.

The present volume contains valuable articles
by Dr. Theophilus Parvin, on the "Diseases and
Accidents of Labor;" articles on "The Forceps"
and "Embryotomy," by Dr. E. G. Davis; arti-
cles by Dr. Jas. C. Cameron on ' ' The Premature
Induction of Labor, ' ' and ' ' Version ' ' (would it
it not have been better to have said the ' ' Induc-
tion of Premature Labor?"); an article on the
"Caesarean Operation, Symphysiotomy, Laparo-
Elytrotomy and Laparo Cystectomy," by Dr.
Robert P. Harris ; " Inflammation of the Breast
and Allied Diseases Connected with Childbirth,"
by Dr. Henrj- J. Garrigues ; "The Etiology of
Puerperal Fever, " ' by Dr. Harold C. Ernst ;

722

MISCELLANY.

[November i6, 1889.

"Some Complications of the Puerperal State In-
dependent of Septic Infection," by Dr. Barton
Cooke Hirst ; " Insanitj' and Diseases of the Ner-
vous Sj'steni in the Child-bearing Woman," by
Dr. Jas. Hendric Lloyd ; " The Management and
the Diseases of the Newborn Infant," by Dr. J.
Lewis Smith ; " The Surgical Diseases of Infan-
cy and Childhood," by Dr. Stephen Smith ;
"Congenital Anomalies of the Eye," by Dr. G.
E. De Schweinitz.

It will be noticed that some of these contribu-
tions are a little outside the strict limits of ob-
.stetrics, but the reader will find that the value of
the work to the practitioner has been greatly en-
hanced b\' the addition of these excellent chapters.

MISCELLANY.

Chas. Chadvvick, Ott:.'! R. Wyeth, Louis A. Schoen,
Geo. J. Schoen, Chas. F. Hermann, Geo. Ej-esell, and
Horace L. Roy, druggists of Kansas City, Mo., were re-
cently fined f 500 each and costs for counterfeiting a prep-
aration known as bromidia.

LETTERS RECEIVED.

111.; Dr. DeLaskie Miller, Chicago; Dr. J. Hillmantel,
Missoula, Mo.; Battle & Co., St. Louis, Mo.; Lutz & Mo-
vius, New York; Dr. Henry O. Marcy, Boston; Dr. Wm.
Creighton Woodward, Philadelphia; Dr. C. -A.. Freeman,
Trenton, Mo.; Dr. Geo. A. Dixon, New York; National
Medical College, Washington, D. C; Dr. J. L. Rollins,

[Auburn, Cal.; Dr. H. C. Dalton, St. Louis, Mo.; Dr.

i James B. BuUett, New York; Columbus Medical College,

, Columbus, O.; Dr. J. D. Scouller, Pontiac, 111.; Dr. J. H.

j Bennett, Wauseou, O. ; Dr. I. S. Stone, Lincoln, Va. ; Dr.

: J. H. Lyon, Roslyn, Wash.; Dr. J. F. Maine, Fort Wayne,
Ind.; Dr. E. M. McDonald, Davlestown, Wis.; Dr. Da%-id
S. Suivelv. Fort Bennett, Dak.; Dauchv & Co., New

, York; Dr.' H. C. Menam, Salem, Mo.; Dr! E. M. Nelson,
St. Louis, Mo.; Dr. C. F. Phillips, Stevens Point, Wis.;
Dr. Henrj- W. Williams, Boston; Dr. Samuel B. Rowe,

i Rolla, Mo.; Dr. G. S. Franklin, Chillicothe, O.; Dr. S.
S. Bishop, Chicago; Dr. Landon B. Edwards, Richmond,
Va. ; Charles H. Phillips Chemical Co., New York; Dr. J.
L. Rollins, Auburn, Cal.; Dr. K. H. Boland, Atlanta, Ga.;
Dr. Joseph Gutz, Florence, Ariz.; Dr. A. J. Sprague,
Cleveland, O.; Dr. M. A. Bogie, Kansas City, Mo.; Dr.
F. E. Bell, Palmvra, 111.; Charles Scribner's Sons. New
York; Dr. R. J. Dunglison, Dr. Thomas Hay, Philadel-
phia; Dr. Beugnies-Corbeau, Givet, France; Dr. J. B.
Mattison, Brooklyn, N. Y.; D. Appleton & Co., New
York ; Philadelphia Academy of Surgen,- ; Dr. H. R.

j Storer, Newport, R. I.; Mariani'& Co., New York ; John
E. Ruebsam, Washington ; Canton Surgical & Dental
Chair Co., Canton, O.; Drs. Knode & Gillette, Omaha,
Neb.; Dr. H. H. Maynard, Los Angeles, Cal.; Dr. B. M.
J. Conlin, Alexandria, Dak.

Dr. H. G. Chritzman, Welsh Run, Pa.; Parke, Davis &
Co., Detroit, Mich.; Dr. Ephraim Cutter, Windsor, Eng.;
Dr. Charles F. Fisher, Clayton, N. J.; Dr. .'Vuna E.
Broomall, Philadelphia; V. R. Donetta, New York; Dr.
J. S. Gerhard, .\rdniore. Pa.; Thos. Leeniing & Co., New-
York; Lea Bros. & Co., Philadelphia; Dr. H. C. Dalton,
St. Louis, Mo.; Dr. H. L. Getz, Marshalltown, la.; Dr.
John Price, Philadelphia; Universitv of Michigan, Ann
Arbor, Mich.; Wm. R. Warner & Co., Philadelphia; Dr.
Henry P. Wolcott, Cambridge, Mass.; Dr. G. R. Wells,
Gold Hill, Col.; Dr. Frederick E. Hyde, Whiteboro, N.
v.; Dr. George G. Sabin, Black River, N. Y.; W. P.
Cleary, New York; Dr. I. S. Stone, Lincoln, Va.; S. R.
Niles, Boston; Henry W. Quin, New York; Dr. Rufus B.
Hall, Cincinnati, O.; Dr. J. N. Martin, Ann Arbor, Mich.;
Gladstone Lamp Co., New York; Dr. A. T. Cabot, Bos-
ton; Dr. S. C. Newman, Pasadena, Cal.; American News
Co., New York; Dr. L. C. Moore, Muscatine, la.; V. Gol-
der, Charleston, Mo.; Dr. P. Brvnberg Porter, New York;
Dr. J. M. Bessey, Toledo, O.; G. Putnam's Sons, I. Hal-
denstein. New York; Peacock Chemical Co., St. Louis,
Mo.; Dr. R. M. Jordan, St. Louis; W. H. Shieffelin &
Co., New York; Western Reserve University, Cleveland,
O.; Dr. N. .\. Olive, Meridian. Tex.; Dr. William Perrin
Nicolson, .•Atlanta, Ga. ; Dr. .\. VanderVeer, Albany, N.
Y. ; Publishers' Commercial Union, Chicago; Drs. Knode
& Gillette, Omaha, Neb.; Dr. J. C. Reeve, Dayton, O.;
Dr. Wm. C. Rives, Newport, R. I.; Dr. C. W.' Nutting,
Etna, Cal.; Dr. A. R. Baker, Cleveland, O.; L. S. Trow-
bridge, Detroit, Mich.; Dr. Thos. F. Riimbold, St. Louis,
Mo.; Dr. R.J. Dunglison, Philadelphia; Dr. W. H. Ged-
dings; Bethlehem, N. H.; K. A. Marks, New York; Dr.
H. H. Roedel, Lebanon, Pa.; J. Walter Thompson, New-
York; Ward Bros., Jacksonville, 111.; Dr. H. J. Smith,
Blackshear, Ga.; W. W. Harncr, DeGraff, O.; Rio Chem-
ical Co., St. Louis, Mo.; Dr. Jo.seph Price, Philadelphia;
Dr. G. W. McCaskey, Fort Wayne, Ind.; Dr. J. A: Hin-
ton. Friendship, Tenn.; Dr. Eugene Grissom, Raleigh,
N. C; Dr. G. C. Fisher, Patoka. Ind.; R. W. Gardner.
New York; Dr. F. D. Moonev, St. Louis, Mo.; Mrs. J.
M. Henrj', Rockport, 111.; Dr' W. W. Landon, Fowler,

Official List of Changes in the Stations and Duties of
Officers Serving in the Medical Department. U. S.
Army, from Xoveiiiber 2, iSSg, to Xovember S, i88g.

By direction of the Secretary of War. Major Robert M.
O'Reilly, Surgeon, will, at the expiration of his pres-
ent leave of absence, proceed to Ft. Logan, Col., and
report in person to the commanding officer of that post
for dutv. Par. 6, S. O. 256, A. G. O., November 2,
I 18S9.

i Capt. James C. Merrill, Asst. Surgeon, is relieved from
dutv at Frankford .\rsenal. Pa., and ordered to dutv at
Ft. 'Reno, Ind. Ter. Par. 6, S. O. 256, A. G. O., No-
vember 2, 18S9.

Capt. Charles S. Black, .\sst. Surgeon, is relieved from
duty at Ft. Sidney, Neb., to take effect upon the expi-
ration of his present leave of absence, and will report
in Dersou to the commanding officer. Ft. DuChesne,
Utah. Par. 6, S. O. 256, A. G. O., Washington, No-
vember 2. iSSg.

Capt. R. W. Johnson, .\sst. Surgeon, granted leave of ab-
sence for one month, to take effect on or about Novem-
ber 10 prox. Par. 4, S. O. 1 10, Dept. of Ariz., Los .-Vn-
geles, Cal., October 29, 1SS9.

Bj- direction of the Secretary of War, leave of absence
for two months on account of sickness, with permis-
sion to leave the Div. of the Missouri, is granted
Capt. Junius L. Powell. Asst. Surgeon. Par. 2, S. O.
258. A. G. O., Washington, November 5, 1SS9.

Lieut. F. J. Ives, Asst. Surgeon U. S. .\.. granted two
months' leave of absence. Par. 3, S. O. 256, A. G. C,
November 2, 1SS9.

Official List of Changes in the Medical Corps of the U. S.
Navy for the Week Ending Xovember 9, iSSg.

Surgeon B. F. Mackie and .\sst. Surgeon Geo. McC. Pick-
rell, detached from the U. S. S. " Ossipee " and placed
on waiting orders.

CORRIGENDUM.

On page 677, last line but one, in The Journal o! November 9,
for " gr. T," read gr. j.

THE

Journal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.

PUBLISHED WEEKLY.

Vol. XIII.

CHICAGO, NOVEMBER 23, 1889.

No. 21.

ORIGINAL ARTICLES.

THE SO-CALLED THIRD TONSIL. ITS
IMPORTANT RELATIONS TO NASO-
PHARYNGEAL AND NASO-
AURAL CATARRH.

/iead be/ore the Section of Laryyigologv and Otology, at the Fortieth
Annual Meeting of the American Medical Association, at New-
port, June, iSSg.

BY JOSEPH

SURGEON OF

A.

WHITE, A.M., M.D.,

EVE, EAR,

THE RICHMOND (VA.)
AND NOSE INFIRMARY.

tonsils, I must either remove or destroy this
hypertrophied tissue as a means to that end. I
have often been astonished at the rapid improve-
1 ment, after this was done, of cases that had
previously resisted all methods of treatment.

Even when there is no perceptible enlargement
of the tonsils, I frequentlj' find it necessary, as a
means to the same end, to destroj' what might be
called the normal glandular tissue between the
pillars of the fauces, especially when there is a
constant, or, even occasional exudation of whitish
secretion from the follicles, a condition generally
known as "chronic follicular tonsillitis." In
such cases it is my habit to introduce a fine
galvano-cauterj' point, or chromic acid into the

It would seem to be an unnecessary and super-
fluous task to present a paper on this subject be-
fore an assembly of specialists in nasal, aural and ; succulated follicle aud set up adhesive inflam-
throat diseases, but as all our knowledge in medi- mation.

cine is the result of the aggregate experience of \ The role played by the tonsils in the human
different observers, I would crave your in- economy is a question in considerable doubt, and
dulgence whilst I add my mite to- the general \ the attempt of some writers to show that they
fund. are ' ' leucocyte manufactories ' ' has not had the

Much has been written of late years on support of demonstrative facts. There is no
Luschka's tonsil, adenoid tissue, lymphoid vege- , question of their having soiic function to perform.

tations, etc., and whilst the fact that deafness
sometimes results, especially in children, from

but we don't know its value or importance. We
do know that the decided presence of this glandu-
any excessive accumulation of this formation, no j lar tissue, whether faucial, pharyngeal or lingual
particular stress has been laid on the active in- ' is nearly always accompanied by some patholog-
fluence it exerts in the production and aggrava- ical manifestations, and that their absolute de-
tion of naso-aural and naso-pharj-ngeal troubles, struction is followed by no disaster to the indi-
even when present in a slight degree only. \ vidual, but in a very large proportion of the

Whilst it may be true, as stated by so many ■ cases, by decided benefit,
observers, that the presence of glandular hyper- 1 Possibly, the so-called third tonsil plays a more
trophy in the post-nasal space is the frequent re- \ important role in the production of aural and
suit of a previously existing catarrhal condition : naso-phan,-ngeal troubles, with secondary lar\'n-
of its mucous lining, my experience would lead geal changes and reflex manifestations, than the
me equally to the opposite conclusion, that the ' faucial or lingual tonsils combined
presence of this glandular hypertrophy', however
produced, and however little, is an active agent

in keeping up a more or less so-called catarrhal
condition of the mucous lining of the post-nasal
space, and its extensions into neighboring cavi-
ties, especially the ear. That this is true of nasal
polypi, we all admit. Thej- may be produced by
a nasal catarrh, but once there the catarrh can-
not be cured without their removal. This holds
equally good of hypertrophied faucial
even when only moderately enlarged

It is easy to understand how deafness may re-
sult from any excessive glandular hypertrophy,
or, any great development of adenoid tissue at
the pharyngeal vault, because it then acts practic-
ally as a direct impediment to the proper ventila-
tion of the Eustachian tubes. This is sometimes
the case, even where nasal breathing along the
lower meatus is comparatively easy ; but more
frequently so, when the hypertrophy or tissue
tonsils blocks the post-nasal openings as well. I have
I have seen cases, as all of my hearers have also, where

found, if I wish to get rid of a naso-pharyngeal the post-nasal space was completely obliterated by
or aural catarrh in the presence of enlarged , masses of soft fungous tissue growing from vault,

724

THE SO-CALLED THIRD TONSIL.

[NOVKMBER 23,

back and sides, and projecting below the arches
of the soft palate. One would suppose that such
a condition of affairs would eventuallj' lead to
great and irremediable deafness, if these masses
were not soon removed, and it is probable that it
might do so, but it is not in accord with my
experience.

I have seen quite a large number of cases of
excessive development of this soft lymphoid tis-
sue in the last ten j-ears, but have never seen but
one case where it caused marked permanent deaf-
ness, and that was in a man 48 years old, from
whose histor)- 1 should conclude that he had been
in that condition all his life. The removal of the
tissue, and the treatment of the resulting middle
ear catarrh very much improved his hearing
power, but his deafness was still quite noticeable.
The cartilaginous mouths of the Eustachian
tubes had been permanently deformed, and the
palato-tubal muscles paralyzed bj' the long con-
tinued pressure, and their long inaction.

Paresis of the palate and palato-tubal muscles
is one of the results of this condition, and may
bring on, independent of any changes in the
drum cavity or tube, what Weber- Liel long ago
described under the heading of ' ' paretic deaf-
ness ;" and, the removal of the tissue should be
followed bj' a course of electricity, to restore as
far as practicable proper tone to these muscles.

Marked depreciation of hearing is nearly
always present in these cases of great develop-
ment of soft lymphoid tissue, but it is easily
remedied by the ordinarj' treatment of Eustachian
and tympanal catarrh, although I doubt if abso-
lutely perfect hearing is ever restored. I have
just finished the treatment of a j'oung man 20
years of age, who has been very deaf all his life,
from such a blocking up of the post-nasal space,
and a three months treatment with removal of
the tissue from vault, sides and back of the space
has entirely restored hearing, although the result-
ing naso-pharyngeal catarrh is not yet cured.

We have, however, other forms of hypertrophy
of the glandular tissue at the v-ault and sides of
the post-nasal space. Instead of a mulberr}'
looking mass, there may be only a small rounded
projection from the vault, or a cone-shaped bodj'
with its apex downward, or two rounded lobules
at either side with a marked sulcus between them,
or several small knob-like outgrowths, or a flat
cushion-like ma.ss padding up the vaulted roof
into a plane low pitched ceiling, and extending
from side to side, and from front to back without
obstructing the post-nasal openings. Sometimes
these are composed of soft tissue easilj- removed,
and sometimes they are dense and hard.

I have found that the Eustachian tubes are
more especially injured by such a ti.ssue when
thej' are of a firm dense consistence than when
.soft. The resiliency or elasticity of the cartilagin-
ous openings is seriously damaged by the pressure

of these masses, particularly when thej' extend
or grow above ami behind the tubes, and the in-
variable accompanying catarrh of the naso-
pharynx b}' extension to the middle ear adds to
the impairment of hearing. Such cases I find
more difficult of a restitutio ad integrum.

It is probable that the percentage of impaired
hearing accompanying hypertrophy of the third
tonsil is greater than we would suppose, because
slight defects of hearing would most likel5' be
overlooked b)- both patient and physician, and
our statistics therefore only include cases where .
this defect has become clearlj- noticeable. If
aurists would invariably look for such hyper-
trophy in all cases of middle ear disease, suppura-
tive or non-suppurative ; if rhinologists would
alwaj's test the hearing power carefully, when-
ever the}- find such hypertrophy present, we
would soon get accurate statistics on this subject.

Since I have made my ' ' self- retaining palate
retractor," I invariably use it in examining the
post-nasal space of all cases that present them-
selves for throat, or middle ear troubles, and
whenever I find any hj'pertrophy of the third
tonsil I test the hearing with the result of hav-
ing, at times, found commencing deafness not
previously suspected. During the last eighteen
months 565 patients have applied at my private
office for treatment of naso-phar\'ngeal and mid-
dle ear affections, of whom 197 had disease of the
middle ear.

Out of the whole number 134 had hypertrophy
of the third tonsil, of whom 62 cases suffered
with var}ang degrees of deafness, i.e., 20^0 per
cent, of the total number shovv'ed such hj^per-
trophy, and a fraction over 30 per cent, of these
had middle ear complications.

Of these 134 cases, 29 had verj^ large faucial
tonsils, 54 turbinated hj-pertrophy, 18 deflected
septum, 22 secondarj' larj-ngitis, 46 voice troubles,
I had atrophic rhinitis. Nearlj- one-half were un-
der 21 years of age, and 25 per cent, were over 30.

Cases seen at my clinic at the Richmond Eye,
Ear, and Throat Infirmarj', are not included in
these statistics.

It seems to me that this proportion of 20 per
cent, in the whole number of cases is a very large
one, as compared with the reports of other ob-
servers. Possibly climatic influences may have
something to do with the development of this
form of hypertrophy.

The 30 per cent, of impaired hearing were all
decidedly deaf to the watch and low voice, al-
though in some cases the deafness was not notice-
able in ordinary conversation.

A point of special interest, in these cases, is
the large number of voice troubles and larj-ngitis
resulting from the presence of this form of hyper-
trophy by lowering the roof of the phar>-ngeal
vault, thus seriously interfering with its function
as the resonance space for the voice.

1889.]

THE SO-CALLED THIRD TONSIL.

725

This, of course, is no news to any of my hear-
ers, but I doubt, if we all giv^e this matter the
attention it deserves. As far as my experience
goes, I find that all persons who use the voice
habituall}', such as singers, actors, clergymen,
lawj'ers, teachers, etc., have invariably some
difficulty in a prolonged use of the voice if there
is any thickening of the tissues at the pharyn-
geal vault, even when of very slight degree.
The vaulted shape of this space should be per-
fectly' preserved, and everything removed that
alters it in any way if the resonance and timbre
of the voice are to be retained.

Fifty- four cases had marked turbinated hyper-
troph}', and onl}' one atrophy of the turbinated
tissues, the only case I ever saw in connection
with adenoid tissue.

Among my cases of naso-pharyngeal troubles
with or without aural complications, I have found
that the presence of glandular hj'pertroph3' ag-
gravated the symptoms and caused more exces-
sive and annoying secretion, and that many of
them suifered from almost constant headaches,
especiallj' if engaged in an}- occupation requiring
close mental application. The excessive secre-
tion and the irritation resulting therefrom to the
surrounding mucous surfaces, prevents any bene-
fit from local applications, or other treatment,
unless the hj-pertrophy itself is removed or de-
stroyed. In this way the third tonsil has a direct
and deleterious influence on any previously exist-
ing catarrh of the naso-pbarynx, and produces it
where it did not previously exist. |

It also in the same way indirectly produces or
aggravates a catarrh of the Eustachian tubes,
when its location is such as not to have a direct
influence on the ear. When the adenoid tissue
is present in such quantity as to cause nasal
stenosis, so manj- ill efiects result from the ob-
struction, that all writers are of accord as to the
advisability of its removal, merelj- difiering upon
the method of operation. It is useless to here
rehearse the consequences of neglecting to destroy
it, but allow me to mention two results from this
stenosis, as affected by the operation for removal
of the tissue. One is anterior turbinated hyper-
trophy, which I find ver\- frequently accompanies
it, and which in a larger proportion of cases dis-
appears spontaneously after the post-nasal space
has been cleared.

The other is the occasional paralysis of the alae
of the nose, the dilatorcs nasi and the compressor
naris becoming paretic, probably from non-use ;
and this result is a serious one, for, if of long
continuance, I doubt if it is ever radically cured;
at least whenever present, I have found it a seri-
ous impediment to the restoration of nasal breath-
ing, even after the nose and post- nasal space were
perfectly clear.

But whilst writers are in accord about the re-
moval of the third tonsil, when its hypertrophy

causes nasal stenosis, there seems to be a differ-
ence of opinion when this is only of slight de-
gree ; some advocating its entire removal ; and
others, regarding it as a normal appendage with
some unknown function to perform, being of the
opinion that it is best let alone.

Now, is the third tonsil so called an essential
normal appendage of the post-nasal space, or is
its prese?ice a congenital anomaly or the result of
changes iji the muciparous and follicular glands'?
I am sure the former question may be answered
in the negative and the latter in the affirmative.
I regard any tissue of any shape, whether
pendent, rounded or flattened, that interferes with
the vaulted aspect of the pharyngeal roof, as a
congenital anomaly or a pathological formation,
that ought to be removed or destroyed, because,
even if it has not alreadj- brought about some
naso-pharyngeal trouble, it will do so, sooner or
later.

I so regard it, as, in at least 80 per cent, of the
cases that have come under my observation for
treatment of such troubles, there was not the
slightest sign of any such formation as glandular
tissue, the mucous lining of the vault being
seemingly intimately adherent to the periosteum
of the base of the skull. This mucous membrane
has the same minute follicular and muciparous
glands as the rest of the mucous lining of the
throat, with a special aggregation of them in the
location of Luschka's tonsil, so-called.

Any pathological process in these glands may
result, as suggested by Dr. Bosworth, in sufficient
thickening or hypertrophy, to change a micro-
scopic into a macroscopic condition. The former
is the physiological, the latter a pathological
state. This process ma}- be arrested with the
slightest perceptible enlargement, or, go on to
the development of soft fungous masses, adeno-
matous tumors, or even dense connective tissue
growths.

With my self-retaining palate retractor in posi-
tion, I have made numerous examinations of dis-
eased and healthy post-nasal spaces, to look for
some evidence of the normal third to7isil as also
for the opening or mouth of the so-called ///arrw-
geal bursa ; as yet I have nev^er found the former
except in the pathological conditions referred to,
and I have never been satisfied that I have found
the latter at all, although I have occasionally
seen and treated what might be the inflamed bursa,
but which always .seemed to me a dependency of
the third tonsil and its pathological changes.
Hence, I am still a skeptic about these parts be-
ing essential, normal constituents of the post-
nasal space. I know I am a heretic in this re-
spect, but crave that indulgent consideration
which all true believers give to heretics on the
ground oi invincible ignorance.

Some twelve years ago in a transient visit to Dr.
J. Solis-Cohen, he picked up a pair of post-nasal

726

THE SO-CALLED THIRD TONSIL.

[November 23.

forceps that he used for the removal of adenoid
growths, and said in answer to some remark of
mine about the danger of seizing the wrong tis-
sues, that he considered anything they would
grasp as legitimate prey. This statement fully
represents my views at the present date, that any
tissue at the vault which can be grasped by the
cutting forceps should be removed.

I have found beneficial results follow the treat-
ment of cases of post- nasal catarrh, after the
ablation of all tissue at the vault, that had previ-
ously resisted every application.

In some cases the secretion is small in quantity,
but is difficult to dislodge, and forms a small
mass immediately at the vault, that soon emits
an excessively disagreeable odor, as pronounced
as that of ozcena.

Such cases I thoroughly cauterize with the
galvano-cauterj^ electrodes so as to destroy the
glands that secrete the unpleasant exudation — as
I find this the only method of doing away with
this feature of the case. As to the methods of
removal I think it matters very little how it is
done, provided it is done thoroughlj-. Large
masses of adenoid tissue are best removed with
the galvano-cautery snare or the cutting forceps.
So also of the dense hypertrophies spoken of
above, but the use of the forceps is quite painful,
even with a free application of cocaine.

Smaller hypertrophies, and that smooth mass
of tissue so often seen lying in between the
Eustachian tubes, and coming down just to the
level of the superior arches of the post-nasal
spaces, making a low pitched /r'a/ ;w/'out of the
arching vault, are best gotten rid of, by burning
with the galvano-cauten,- points, or moxa-
electrode, although it can also be partially re-
moved by the forceps.

I have found my palate retractor an enormous
help in such work, because the muscular move-
ment of the palate never interferes with a perfect
view of the parts whilst operating, and I have
never seen a case I could not operate on with its
aid, whilst without it I have often been baffled
in obtaining a satisfactory' view of the parts. In
fact all post- nasal operations can be done better
and more readily with it than without it, for it is
easier to perform any surgical work by sight than
to depend merely on the " tactus eruditus." I
have latterly been enabled with its help to remove
adenoid tissue in children 5 or 6 years of age,
under the influence of cocaine instead of giving
chloroform as I was formerly in the habit
of doing.

CANCER OF TONSIL. REPORT OF CASE AND
EXHIBITION OF SPECIMEN.

As malignant affections of the tonsils are com-
paratively rare, I thought the history of the fol-
fowing ca.se would be of sufficient interest to
report.

August 2, 1887, a gentleman, 58 years of age,
applied to me for treatment of a throat trouble,
which had been annoying him some months.
The history he gave showed a gradual enlarge-
ment of the left tonsil with occasional pain until
he had gotten into the following condition ;

He could no longer eat .solid food, and could
swallow liquids only with difficulty. The pain
occasionally was quite severe. His breathing
was labored, and when lying down, especially if
on his right side, he suffered from attacks of
suffiacation, that at times were verj- alarming.
His articulation was so imperfect that it was
difficult to understand him.

The examination revealed a large tumor spring-
ing from the site of the left tonsil, growing down-
wards so as to press on the epiglottis and almost
fill the throat.

A larj'ngeal inspection showed paralysis of the
rigid vocal cord, it being in the cadaveric
position.

I removed the tumor by encircling it with a
steel wire, and constricted it until its base was
squeezed into a small dense pedicle. I then re-
moved the steel wire and completed the operation
with the galvano-cautery snare. The relief was
immediate, both respiration and deglutition be-
coming almost normal. When the eschar came
awa}', I destroyed the remains of the base with
the galvano cautery, and repeated this operation
several times at intervals of some weeks until the
parts had assumed, a perfectly normal appearance.

Neither faucial pillar, nor any part except the
glandular tissue between the pillars was involved,
nor were the Ij^mphatics implicated. The para-
lyzed vocal cord never entirely recovered.

Six months later I saw him again and there
had been no return of the trouble. More than
a j'ear afterwards I heard from him, and he wrote
that his throat was entirely well.

Part of the growth was sent to Dr. Jno. S.
Billings, Curator of the Array Medical Museum
in Washington, for examination, and the follow-
ing report was received from Dr. Wm. M. Gray,
the Microscopist : " The specimen of tumor re-
ceived proves to be an epithelioma of squamous
type : it probably started as a papilloma and de-
generated into an epitlielioma, as the cells are ar-
ranged like tho.se in a papilloma, and are just
beginning to infiltrate."

In March, 1889, my patient called on me again,
.suffering from dyspnoea aiid dysphagia. I found
on examination that there had been a recurrence
of the growth below and in front of the original
site, involving the anterior faucial pillar, the base
of the tongue on the left side, the glosso
epiglottic fold and extending down to the lower
third of the pharynx. The tumor pres.sed down
upon the larynx, pushing the epiglottis far over
to the right side, and almost occluding the open-
ing. He said the trouble had re-appeared alwut

1889.]

THE SO-CALLED THIRD TONSIL.

727

two or three months previously and had developed
with great rapidity.

With mj- galvano-cautery snare I removed as
much of the tumor as possible, especially the por-
tion pressing on ^he upper part of the larynx.
There was great difficulty in encircling it, and I
was obliged to resort to transfixion with large
needles to enable me to do so. I passed a needle
threaded with coarse silk as far back in the base
of the growth as possible, bringing it out just in
front of the epiglottis.

Mj' cauterj- wire was attached to the thread
and drawn through this opening. I then trans-
fixed the anterior portion with a large needle,
leaving it in position. The wire was hooked
under each end of this needle passed through the
cauula, the current turned on and quite a large
mass removed. This enabled him to breath
easier and to take nourishment, and in a few days
he returned home.

I told him that nothing but palliative measures
could be made use of, and that possibly a
tracheotomy rt'ould become necessary. In the lat-
ter part of April he returned in great distress,
because of the violent pain, and much emaciated
and weakened by the recurring and alarming
haemorrhages, and inability to take much nourish-
ment. The growth had not perceptibly increased
and the epiglottis was as you see it now. Strange
to say up to this time the lymphatics were not
involved, the left sub-maxillary gland alone be-
ing noticeable to touch. Two days after his
entry into the hospital, he died verj^ suddenly of
heart failure.

A portion of the growth was sent again to Dr.
Billings, and on June the 8th the following report
was received from him :

"Dr. Wm M. Gray reports the specimen of
tumor sent as a typical hard cancer (scirrhus).
He also states that he has re-examined the first
specimen sent from the same case, and adheres to
his original report of squamous epithelioma."

The points of special interest about the case
apart from the rarity of this form of malignant
disease of the tonsil, are the development of a
typical hard cancer of epitheliomatous structure
out of a simple papillomatous tissue, and the fact
that there was no implication of the glands of the
of the lower jaw and neck even to the last
although all the other signs of malignant dis
ease were present.

Dr. D. Brvson Delav.\n, of New York, said
that he believed that the large percentage of cases
of adenoid disease found by Dr. White was due
to the unusual care exercised by that gentleman
in the examination of his cases, and that man)-
cases of slight hypertrophy not usually considered
of pathological importance were actually produc-
tive of .serious results, and therefore to be in-
cluded. He preferred a solid uvula retractor to

the skeleton instrument presented by the writer
of the paper.

Dr. Jonathan Wright said : I have used
Dr. White's retractor in perhaps a dozen cases,
and, at least in mj- experience, it has provoked
violent constriction of the pharj'ngeal muscles
and made post-nasal examination b}' mirror very
difficult and disagreeable to the patient. Under
ether I should think it might well be used, as the
pharj'ugeal muscles are more or less paralyzed.
My inexperience with the instrument may have
been the cause of m}' failures.

Dr. Mackenzie never uses the palate retractor,
although it is easilj' conceivable that in certain-
cases its use may be of very great advantage. He-
has used Wales' method, but finds even by thfs'
process there is often gagging and salivation,
which interferes with the operation. He asked
how the retractor exhibited differed, except in
weight, from that invented by Dr. Porcher ?

Dr. Thrasher : In my operations on chil-
dren for the removal of the third tonsil I invaria-
bly operate under chloroform and without a pal-
ate retractor, depending simply on touch. By
this means the operation can be safely, easily and
rapidly performed.

Dr. White, in reply, said that in the remarks
made, except in those by Dr. Delavan, no refer-
ence had been made to the subject matter of his
paper, the other gentlemen having confined them-
selves to an attack on his palate retractor. As
far as he was concerned he preferred to use one,
because he thought it easier for him and better
j for the patient that he should perform his opera-
tion with a perfect view of the parts, and not trust
to his dexterity or his sense 0/ touch to avoid an
error. It was simply a question of taste, as there
j was no question of the fact that one could see
better with the retractor than without it. In an-
swer to Dr. Mackenzie's question about the dif-
ference between his retractor and Dr. Porcher's,
he would say that in general principle all were
alike, but that his own was lighter and worked
in an entirely different way from all others, being
adjustable or alterable for each patient, and the
projecting bar in front turning out of the waj- of
the operator b}^ a hinge-joint. Moreover, its
proper use required some experience in applj'ing
it, and with such experience the objection urged
against it would probably fall to the ground.

Dilatation of the Stomach in Syphilis. —
; Dr. Jullien, of Paris, has observed a number of
instances in which dilatation of the stomach de-
veloped in tertiary syphilis, and believes that it
was in many instances the cau.se of nervous symp-
toms which were usually attributed directh^ ta
syphilis. Large doses of the iodide of potassium
are, he thinks, not infrequently the cause of the
dilatation.

728

TREATMENT OF SYPHILIS.

[November 23,

DISCUSSION ON "THE INDICATIONS

FOR, AND DURATION OF, THE

TREATMENT OF SYPHILIS."

Read in the Section of Dermatology and Syphilograpky, at the Fortieth
Annual Meeting of the American Medical Association,
June, iS8g,

THE INDICATIONS FOR AND THE DURATION OF
THE TREATMENT OF SYPHILIS.

to the person affected, we have also to consider
the serious risks which are continually run from
the infective nature of the disease, both in the
more commonly thought of venereal contact, and
also in the innocent relations^ of family, social,
and industrial life ; as well as in the matter of he-
, reditarj- transmission, which is almost sure to
The chairman, Dr. Bulkley, opened the dis- ; occur during a certain period or stage of the dis-
cussion with a brief paper on \ ease. Unfortunately, the exact duration of this

infective period is unknown, for although in
many cases it seems to terminate in two or three
years, in other instances the disease has been
The subject selected for our discussion this af- : communicated from one to another even after the
ternoon is one of verj* great practical interest, and ' lapse of many years. Syphilis can be transmitted
one upon the decision of which, in individual cases, ' hereditaril}' long after its contagiousness appears
the very gravest consequences may rest. It is one to have ceased in other directions, and, as far as
which the physician cannot shirk if he would, I know, no limit has been set, after the occurrence
and one upon which it often becomes his serious of infection, at which offspring maj' not exhibit,
duty to decide and insist, even against the will of | to a greater or less degree, some evidences of the
the patient. No one can tell what results may , poison having been acquired with their life. All
follow to the patient or others from an imperfect this refers, of course, to untreated syphilis, or that
treatment of syphilis, and no one can measure the ; which has been very imperfectlj' treated,
amount of harm which may be escaped by.the in- j The other side of the picture is, however, most
telligent and faithful performance of duty toward , encouraging. Seen from the beginning and treat-
one who has become infected with syphilis. ed properlj^ and faithfully for a sufficient length
The subject, together with the side issues to of time, and under the most favorable conditions,
■which it might lead, such as the innocent acquir- syphilis is easily manageable, need give but little
ing of syphilis, marital syphilis, hereditary syphi- trouble, further infection can be prevented, and,
lis, etc., is such a great one that it cannot by any in the opinion of manj', the disease is entirely
means be compassed in a single discussion, much curable. The evidence of its curability, as is
less can I attempt anj' considerable consideration well known, has been inferred or deduced from
even of its salient points. The most that I can the fact that it can be acquired the second time,
hope for, in the brief time which should be taken whereas the individual who is still syphilitic is
by one opening the discussion, is to suggest cer- not capable of reinfection.

tain points and lines of thought along which we Such, then, being the disease which we have to
may proceed, leaving the background to be filled ' do with, it remains for us to discuss the subject
by others. before us, namel}' : "the indications for, and the

Syphilitic infection takes place from the mo- ' duration of the treatment of syphilis." I do not
ment when the syphilitic virus is implanted upon suppose that it is necessar}- for us to enter at all
a surface bereft of its epidermis or epithelium : ' upon the symptoms of syphilis or its manifesta-
or, in other words, as soon as the poison can be ! tions, which are familiar to all, except so far as it
reached by absorbing tissue. It is not necessarj^ ; may be necessarj- to allude to them in reference
for our discussion to consider, or even to know 1 to the treatment necessary at the various periods
exactlj', in what manner the infective material is ! of the disease : and we should rather confine our
taken up, although it probably enters the lym- ' attention to the form of treatment best at differ-
phatics at once ; it is sufficient for our purpose to ! ent stages, and the duration of the same, and to
know that when once the virus has entered the the total duration of treatment requisite,
system, the person is syphilitic, and if the course \ i. The first question for us to consider is, How
of the disease is not influenced by extraneous ' early should the treatment of syphilis begin: when
forces it will, in the large proportion of cases, i in the existence of the disease should we com-
develop in a certain manner, and run a more or
less definite course, the natural history of which
is now pretty well known and described. This
course, beginning with the chancre or primary
lesion, and followed bj- the various later manifes-
tations, known as secondary and tertiary lesions,
may extend over many years, and may result in
greater or less permanent damage to the indivi-
dual, and in addition "may and does in certain
cases destroy life.

In addition to the personal distress and danger

mence active treatment calculated to overcome
and nullify the poison-?

If the di.sease were produced artificiallj-, as we
vaccinate and so communicate the infectious dis-
ease vaccinia, or if the entrance of the syphilitic
poison were absolutely known, it would seem
proper to administer the antidote at once. But,
of course, the syphilitic infection is seldom sus-
pected and never known positively until the
chancre or primary sore forms at the seat of entr>-,
from ten days to several weeks after the date of

i889.]

TREATMENT OF SYPHILIS.

729

its entry into the- system, and the question arises,
when should treatment begin ?

If there were surel}' only one class or variety of
sores or abrasions known, on the genitals or else-
where, and that were always the first manifesta-
tion of syphilis, there would be little or no ques-
tion about the matter. But the difficulty of di-
agnosing these sores is proverbially so great that,
unless I am greatlj- mistaken, every one has at
times found it hard to decide just when to give
constitutional treatment. Shall we wait, as has
been advi-sed, until other manifestations of the
disease occur, upon the skin or elsewhere, in or-
der to be absolutely certain of the diagnosis, or
shall we begin at once when we have reasonable
cause to suspect that the sore is due to syphilis?
I leave this and other questions for your deliber-
ation.

2. The second question which must ari.se to the
practitioner's mind is. How long should the treat-
ment be continued? Under active internal medi-
cation, and perhaps with the aid of some local
measures the sore heals, and all hardness may
disappear in a greater or less length of time.
Possibly if all circumstances have been favorable,
and the treatment has been energetic, there are
none of the so-called early secondary manifesta-
tions of the disease : no lesions appear on the
skin, the throat keeps well, and the hair does not
fall. How long should the treatment be contin-
ued, and when can we be justified in pronouncing
the patient quite fit to cea.se medical treatment?
We are here supposing that the patient fully rec-
ognizes his condition and the dangers of the dis-
ease, is perfectly faithful to treatment, and is quite
willing to abide bj' the decision of the phj'sician.
How soon can his medical adviser permit him to
leave off treatment, with the assurance or expec-
tation that he will have no further manifestations
of the disease, cannot communicate it to others,
and will not transmit it hereditaril}' ?

3. If the patient be unmarried, the question is
often asked, how soon he or she can marry after
acquiring syphilis? As the answer to this de-
pends largely upon the character and duration of
the treatment carried out, it is one which may
also well be considered by us in our present dis- j
cussion.

4. When patients come to us after syphilis has
become thoroughly established, and after it has
exhibited one or many of its manifestations on
the skin or elsewhere, what shall be the dura-
tion of our treatment? Shall we give remedies
only until the lesions have disappeared or ceased
to give annoyance, or shall a regular course of^
treatment be instituted, and if so, for how long a
time?

5. It often happens that some years after the
primary infection, possibly after there has been
more or less of treatment, late lesions, generally
gummy in nature, appear in one or another part

of the body. What shall be our course in regard
to them? Shall we simply give remedies until
the obnoxious manifestation of the disease has
disappeared, or shall we attempt to follow out a
definite and continued course of treatment aiming
at a more radical and permanent cure of the dis-
ease itself?

It would be possible, perhaps, to present many-
more questions for our consideration, but these, I
think, cover much of the ground which often has
to be mentally gone over by the physician facing
a case of syphilis, and in regard to which he might
not find practical aid in reference and text-books.
These, therefore, are presented for discussion, in
the earnest hope that the result of our delibera-
tions may be both profitable to ourselves in set-
tling our views in regard to the matters alluded
to, and beneficial to our patients, in affording
them, and consequentlj' others related to them,
more satisfactory and permanent relief from one
of the worst diseases, when neglected or badly
treated, to which the human race is subject,
namely, sj'philis.

THE POSITIVE DIAGNOSIS OF SYPHILIS, WITH SOME
INTERESTING MEDICO-I,EGAL TESTIMONY,

by Ephraim Cutter, M.D., LL.D.,of New York,
was read by his son. Dr. J. A. Cutter.

For twenty years, a method of diagnosis of
syphilis has proved so satisfactory that it is
deemed positive and also a positive loss to those
who do not use it. The mode of physical explora-
tion is simple but delicate. A drop of blood just
large enough to fill the space between an ordinary
cover glass and an ordinar}' slide is obtained by
puncture on the radial edge of the wrist, which
is generally free from hair. Codman & Shurtlefi",
of Boston, make a scarificator (for the writers)
which extracts the blood in a satisfactory way.
The drop is transferred to the stage of the micro-
scope, which must be good, to wit, for bacterio-
scopy. Fortunately good microscopes are more
common than they were. If the light is properly
adjusted and the observer is sincere and compe-
tent, as the syphilitic blood goes through its bio-
logical movements in dying, there will be seen
here and there more or less numerous, active,
automobile, sometimes saltatory, extremely mi-
nute globar bodies, called spores or microspores,
micrococcus spores or bacteria, of the Crypta
Syphilitica, which, when dancing or are put out of
focus slightly, are copper- colored. The higher
the power, the more distinct this color. With the
--V inch objective of Tolles, the copper color has
been found more marked than with any other
power. Sometimes these spores will travel across
the whole field. They are found in the serum
spaces, over the red corpuscles and in the white
corpuscles. In old cases, they are found in the
urine and specially in the pus of chancres. These
spores are the baby stage of the Crypta Syphilitica

730

TREATMENT OF SYPHILIS.

[November 23,

(Salisbury). The fulh- developed form or parent
plant is a cylindrical filament, slightly tapering,
and is found in the blood in the form of short
curved segments, sometimes slightl}^ clavate at
one end and in long strings or filaments, in coils,
skeins, or comparatively straight. In the walls
of chancres they are verj- curling and spirall}-
twisted like the vegetative filaments of the plant
in carbuncle. These crj-pta syphilitica filaments
are also copper- colored when put a little out of
focus. The mature plant is not so common as
the infantile, which has the power of reproduc-
tion in its immature stage and of producing the
physical and chemical influences of the mature
plant.

The spores are to be distinguished from rainute
globules of fat whose motion can be seen bj- put-
ting milk or, fat emulsion under the microscope.
The3^ sometimes join in pairs like other bacteria,
but not often. Their movements sometimes last
twenty-four hours after withdrawal, if the cover
is protected b}- the thorough drj-ing of the blood
around its edge. Fat globules do not travel across
the field save when borne by currents of capillar-
ity, in which everj'thing moves with them. Fat
globules will not travel in opposite directions as
syphilitic spores do. Thej- are also to be distin-
guished from the spores of vinegar j'east, /. t'., the
second stage of development of tubercle bacillus,
in the blood, by their want of aggregation and by
their mobilitj'.

Vinegar yeast spores occur singly, in pairs, trip-
lets, and so on to massive aggregations which form
emboli and, when detained in the lungs, tubercle.
In the present stage of knowledge the spores of
syphilis are unique in their active, saltatory mo-
tions and copper color. These few words are
enough to suggest the line of research. The sub-
ject is more fit for the pathological or morpholog-
ical laboratory- than a lecture room. Should the
sun be available and a proper dark room be found,
the writer will project syphilitic blood on a screen
and demonstrate the spores thereon with the
morphologies of other blood for comparison.

In a late trial for murder, the suspect's clothes
were submitted to the writer, apparentl}^ stained
with blood which had been more or less washed
by water. In the stud}- of the morphology' of
this clothing, a list was made of the objects found
under the microscope along with the blood as a
matter of detail — not intending to use the foreign
bodies as testimony. But the coun.sel for the de-
fense in his cross-examination told the Judge that
he would show that I was not an expert and that
I knew nothing about the subject. He then :
asked, "What did you find in your examina-
tion?" Thus challenged the list was partiallj-
read, embracing a variety of objects which are
not known to many. In the list was included
syphilitic spores in active motion and enlarged
white blood corpuscles which enclosed syphilitic

spores. These attracted attention in and out of
the court- room. Subsequently the physician of
the murdered man testified that he was treating
him for syphilis at the time of the murder. The
jury hung, ten for conviction and two for acquit-
tal. Just before the second trial a physician
brought me a slide with blood which he said was
taken from a patient whom he thought had syph-

I ilis. I found the spores in active motion. At
the trial, this same phj-sician was called to the
stand, but was noncommital and got away as

I soon as he could. I was then shown the slide
that he had brought to me, and on being ques-
tioned testified that I had found the evidence of
syphilitic blood in it. It then transpired that a
trap had been laid for me, for the blood in the
slide was obtained from the prisoner. Still mj-
evidence was positive, for a phj-sician testified
that he had treated him for sj-philis. This time
the suspect was convicted and sentenced for life.

BIBLIOGRAPHY.

James Henr\- Salisbury. A.M., B.N.S., M.D., LL.D.,
Discoverer of Crypta Syphilitica.

Description of Two New Algoid Vegetations, one of
which appears to be the Specific Cause of S}-philis, and
the other of Gonorrhcea. ( with plate of Sixteen Illustra-
tions.) Amer. Jour. Med. Sciences, Januar}- i86S; also
in Zeitschriftfiir Parisitenkunde, 1S73.

Ephraim Cutter, A.M., M.D., LL.D. Corroborator.

The Morpholog}- of Syphilitic Blood. Amer. Jour, of
the Dental Sciences, November, 1S79.

Throat Syphilis and Tubercle According to Salisbury.
Read before the American Lar\-ngological Association,
1880. Archives of Laryngology, December, 1880.

A New Sign of Svphilis. Gaillard's Med. Jour., April,
1882.

Blood Changes in Syphilis when Treated with Fluid
Extract Stillingia Comp. Gaillard's Med. Jour., Febru-
ary, 18S4.

Crj'pta Syphilitica. Monographia Syphilitica. Sep-
tember, 1S85.

Morphology of Syphilitic Blood, pp. 19, 20, Partial Sj'l-
labic Lists of the Clinical Morphologies of the Blood,
Sputum, Faeces, Skin, Urine, Vomitus, Foods, Clothing,
Vaginal Discharges and Soils. Published by the .\uthor,
1 888.

Dr. C.\rl Seiler, of Philadelphia, inquired
of Dr. Cutter the shape and size of the spores in
question.

Dr. Cutter replied that he could not tell their
size; he had not measured them. With 500 di-
ameters the size was very small and varied from
one to two, the same as blood corpuscles. Their
movement was of greatest importance. Their
shape was spherical.

Dr. Seiler said he did not wish to intnide
himself upon the Section as he was not a member
of it, but the subject of Dr. Cutter's paper was
one with which he had had a little experience.
Ten years ago, at a meeting of the American
Laryngological Association, Dr. Cutter had been
asked by him the same question which he had
just put to his son, and he had got identically the
same answer. During that time the measurement
and study of spores bad vastly improved under

1889.]

TREATMENT OF SYPHILIS.

731

instruments of precision, and it seemed very
strange Dr. Cutter had not taken the trouble to
measure the bodies spoken of. Besides, it was a
well-known property of broken up corpuscles in
the blood to take on the movement and brown ap-
pearance described in the paper. He had no doubt
the so-called spores of syphilis were nothing more
than broken up blood corpuscles which danced up
and down in the serum and gave a copper color.
A strange fact in the presentation of the case was
that the higher the power the smaller the cocci
appeared. Generally the reverse was true.

Dr. Fleischner. of New Haven, feared that
even if the observations made by Dr. Cutter were
correct, they would prove of little practical diag-
nostic value to the general practitioner. Yet the
thanks of the Section were due the doctor for his
researches.

Dr. W. B. Mathewson, of New Jersey, re-
marked that if it could be definitely shown that
this spore did indicate syphilis the fact would
be of great value as placing the diagnosis on
positive ground. But thus far, the connection
between syphilis and the spore had not been
traced. The discovery of the spore of syphilis
had been repeatedly asserted. If he remembered
correctly, Cornil had found this spore in only
about one-third of the cases of actual sj-philis.
He had seen the spore himself frequently in blood
examined, both in syphilitic and health}- persons.
The trial to which the author had alluded showed,
he thought, a recklessness in testimon}- of which
the medical profession should never be guiltj'.

Dr. Root, of Hartford, thought the paper well
worth consideration. He remembered that once
the blood of some patients in a hospital in New
York City had been sent to Dr. Cutter for exam-
ination, also some from the house physicians, and
while the house physicians did not admit the truth
to Dr. Cutter, yet to outside parties it was admit-
ted that his diagnosis was correct in ever}- instance.

Dr. E. N. Brush, of Philadelphia, said that
about 1878 he heard Dr. Ephraim Cutter make
similar statements when in Buffalo, and he at-
tempted to confirm them by observations of his
own. Perhaps his objectives were not of suffi-
cient power ; at anj^ rate, he was unable to make
out anything of diagnostic value. He found the
so-called spores of syphilis in persons who sureh-
did not have syphilis, and he failed to find them
in persons known to be syphilitic. He did not
wish, however, to throw any discredit on Dr. Cut-
ter's work. Certainly if there were a bacillus or
spore of syphilis it would be very desirable to find
it, but it should be remembered that it had been
looked for many years, that spores of various
shapes and colors had presumably been discov-
ered, yet his own work, and the better work of
some of his friends in the profession, had failed
to confirm the discover}-.

Dr. Cutter said, in closing the discussion, i

j that his father had simply desired to bring before
the profession an easy and certain way of diag-
nosticating syphilis. If the sun were not ob-
scured later he would demonstrate the .spores
with the solar microscope.

Dr. Carl Seiler, in discussing some of the
points raised in Dr. Bulkle\''s paper, said that his
experience with syphilis had been mostly limited
to the treatment of its manifestations in the throat,
consequently he knew ver}' little about the chan-
cre. He wished the opinion of the members
whether it was good treatment to remove b}^ sur-
gery gummata when found in the mouth and nose.
He had himself found that when the gummata
were situated on the nasal septum, predisposing
to stenosis, better results were obtained after
scraping them with the curette and then going on
with the usual treatment. In that waj' he obvi-
ated many of the difficulties consequent upon
nasal stenosis, and obtained quicker results than
without. Referring to a point raised by the chair-
man, he said that in his opinion, when local le-
sions of this kind existed they demanded both
local measures and internal remedies. Quick
measures should be used, such as the hypodermic
injection of solution of bichloride of mercury-.
This he constantly employed until the lesions dis-
appeared, and then placed the patient on mixed
treatment for a considerable length of time after-
ward. He thought it bad practice to stop treat-
ment as soon as the lesions disappeared. When
asked what he considered sufficient time, Dr. Sel-
ler replied about two years.

Dr. Corlett had been in the habit of giving
the patient a placebo until it could be decided
whether his chancre were a hard or soft one, not
wishing to modif}- the disease by any remedj-
until a positive diagnosis could be made. Dur-
ing the past year, however, after reading Jona-
than Hutchinson's report, he had somewhat
changed his way of handling his patients, put-
ting them upon mercurial treatment as soon as
he thought syphilis was present. It was his
opinion that the better rule was to wait untH in-
duration took place in the chancre and the h-m-
phatic glands became involved before resorting to
mercurial treatment. He would then place the
patient on mercurial treatment and continue it
for at least a year after all s^-mptoms had disap-
peared. As to removal of the chancre, he thought
it good practice when situated where its removal
would not involve important parts. In the few
cases in which he had seen it removed the disease
ran a mild course afterward, which may have
been due to the removal of the chancre. If a
case presented itself before induration of the l3an-
phatic glands he would most assuredlj' remove
the chancre, if po.ssible b}- the knife, if not, then
bj' a strong cautery. On the glans penis the cau-
tery would be preferable.

As to the medicine to be used during the second

732

COW'S MILK FOR INFANT FOOD.

[November 23,

stage, he believed the only drug which had the
power of eliminating the syphilitic poison was
mercury. It not only had the power of removing
existing lesions, but of shortening the disease.
Potassium salts would cause the lesions to disap-
pear, but not were more prone to return. He
quite agreed with Dr. Seller, that it was necessarj'
to continue the treatment two or three years, and
at least one year after the symptoms had disap-
peared.

Dr. Garlock remarked that iodide of potas-
sium should be avoided in soft chancre; its effects
were decidedly bad. He had found inunctions
with mercurial salts very important in the treat-
ment of syphilis, especially before the second
stage, the symptoms of which it sometimes pre-
vented from appearing.

Dr. Flei^Chner said the fact of the chancre
being soft did not necessarily preclude syphilis.
It was not uncommon to find a simple abrasion
result in an ulcer and finally systemic syphi-
lis become manifest, without there having been
at any time local induration. The question of
time of commencing syphilitic treatment might
often be decided by the time which had elapsed
between illicit intercourse and the appearance of
the sore. A man who came to the doctor for
treatment and acknowledged illicit intercourse
would not be likely to mislead him with regard
to date. If the sore appeared late, say twenty-
one days after intercourse, he would not consider
it necessary to wait for induration before com-
mencing syphilitic treatment. Whether mercurj^
were used by inunction or by injection, he thought
made little difference. The latter mode probably
gave quicker results, but that it was more effec-
tual he could not see. As bearing on the dura-
tion of treatment it might be observed that some
cases of syphilis terminated without treatment ;
they aborted. If, then, he subjected a patient to
treatment and he responded very readily, why
not, after a month's absence of symptoms, wait
and keep watch ? Was it necessary- that an extra
mild case be subjected to two years' treatment?
He thought the treatment should be adapted to
the individual case.

The Chairman agreed in the statement that
absolutely no hard and fast rules could be made
for everj' case of syphilis. He also agreed in the
remark that if a sore appeared at a given date,
say a month, after a single illicit intercourse,
syphilitic treatment might safely be begun, wheth-
er the sore was soft or hard : but in his experience
patients u.sually had had intercourse at different
times within a month or more, and they were
likely to attribute a chancre to an intercourse of
the previous week, whereas it dated from one of
several weeks before. He called attention to a
remark of Mr. Hutchinson which he had found
of infinite value in diagno.sis, namely : that the
first chancre in the young man was almost always

syphilitic. He had called the attention of stu-
dents to that fact many times. A man entering
his clinic and stating that it was his first chancre,
he could usually assure them, although it had all
the appearances of a soft chancre, that within a
month or two the patient would show distinct evi-
dence of syphilis. Dr. Bulkley did not believe,
however, in a chancroidal poison which could be
isolated as the syphilitic poison could be. He
believed the patient lost in strength when treat-
ment was postponed, and he therefore began it as
soon as he felt prettj- sure of his diagnosis. As
to how long to continue it, he could not agree
with Dr. Fleischner. It would be safer, he
thought, to keep all patients under treatment
two years, and there were many who should be
treated much longer. He would, however, allow
them to marry after six or eight months' freedom
from lesions. He has never known one who acted
on that advice cause infection or transmit the dis-
ease to the offspring. He believed that during
late lesions of syphilis there was no contagious
element in the blood.

COW'S MILK FOR INFANT FOOD.

Read in the Seclion of Diseases o/ Children at the Fortieth Annual
Meeting 0/ the American Medical Association, June iSSg.

BY E. F. BRUSH, M.D.,

OF MOUNT VERNON. N. Y.

In India, several years ago, one of the Hindoo
kings, " in order to atone for his cruelties, caused
a colossal golden cow to be made, through the
body of which he passed with profound reverence
and made it the era from which all his edicts
were dated." ' This historical fact is significant.
We have practiced all manner of cruelties with
the luckless infant deprived of its mother's breast;
we have presented all manner of unfit substances
to this small animal, whose only language is a
cry, whose only desire is food. In fact, whenever
a commercial enterprise finds itself burdened with
some waste product that cannot be put to other
use, it has been deemed a good substitute for
mother's milk, and straightway the market is
stocked with another "baby's food," and plenty
of phj-sicians to recommend it and plenty of ba-
bies ready for martyrdom. Now how can the
physicians of the nineteenth century better atone
for all their cruelties toward the human young
than by causing a better cow to be reared, and
from henceforth base all their edicts on the arti-
ficial feeding of infants on this better cow with a
better milk product? I think that, with few ex-
ceptions, we are all agreed now that nothing ex-
cels good pure milk from good healthy cows for
the artificial nourishment of infants, and if the
great body of physicians put themselves about it
with anything like the same energy they have

' •• India and the Hindoos." F. DeW. Ward, 1850, p. 34.

1889.]

COW'S MILK FOR INFANT FOOD.

733

displayed in suggesting substitutes, thej^ can so
reform the breeding of dairy cattle and the handling
of their milk that the suffering of the human
young will be ameliorated to a far greater degree
than was ever hoped for by the astute chemist
who started out, j^ears ago, to make not only a
substitute for cow's milk, but also for that of the
human mother.^ It is this idea of a substitute
that has led us away from the more important
consideration of improving what nature has al-
ready presented to us, Just look at the improve-
ment in the commercial line that the middlemen
have made in their milk transactions. These
men have reduced the purchasing of milk to a
•nicetj' hardl}' surpassed by the purchasers of gold
and diamonds ; they haVe worked down the price
of milk from the producer to the lowest possible
point ; they have dropped fluid measurement and
adopted weight as being more accurate ; in butter
factories the}^ have invented an oil test that will
indicate, in a very short space of time, the exact
amount of butter a given quantity of milk will
yield, and on this test the price of the milk is
regulated ; likewise the cheese factories have
established a standard of solids in milk which
also regulates the price. But all the improve-
ments these men have made do not help us, not-
withstanding the fact that our chemists, sanitari-
ans and health authorities have followed in the
wake of these men and endeavored to make us
believe that the healthfulness of milk is depen-
dent upon the total solids, fats, etc., that relate
solely to its commercial value. A larger percent-
age of fat that is easily removed from milk does
not improve it for our purpose ; it matters very
little to us whether a given quantity of milk con-
tains 12 or 14 per cent, of solids.

In milk for infant feeding we should consider,
first, the variety of fats, the manner in which
they are emulsified and combined ; second, the
amount of albuminoids and their condition; third,
the amount and variety of salts; fourth, the health
of the animals from which it is derived and the
food that has been consumed to produce the milk,
and, fifth, the changes which the milk has gone
through before it reaches the infant's stomach.
When we come to understand all these conditions
we shall readily perceive just what kind of milk
we want, and exactly the kind of cow which,
with a given variety of food, will produce the
very best substitute for the infant in lieu of its
own maternal breast.

Let us then first consider the fats. Taking
the human milk, which should always be our
standard, we find that these solids, according to
the best authoritative analysis, occur in propor-

- ■■ Now I have come to the most important matter of the lec-
ture, and that is the consideration of the proposition at one time
sincerely made of substituting some other food for human milk as
being a better food for infants." Abstract of a lecture before the
New York Academy of Sciences by Prof. Albert R. Leeds, Ph. D.,
of the Stevens Institute of Technology-. "Sanitarium," May 24,
1883. p. .^25.

tions of 2. 1 1 to 6.89.' Now this makes an aver-
age of 4. 131 for human milk. From several hun-
dred analyses of cow's milk in diS"erent parts of
France, England and America the average of the
chemist is 3.91. Thus you will see the differ-
ence, according to the chemist, between the two
varieties of milk is very slight. I know, how-
ever, from the actual experience of practical dairy-
men, that cow's milk contains more fat than is
indicated by the above figures. The lowest
amount of butter obtained from mixed milks is
'i pound of butter from 25 pounds of milk. This
would make the fat percentage 4. In drawing
this deduction I am well aware that a pound of
butter is not a pound of fat, but a pound of butter
obtained from a given quantity of milk represents
I a pound of fat in that milk, because the quantity
of fat in a pound of butter is exactly 84 per cent. ,
and according to the latest experiments at agri-
cultural stations only 84 per cent, of the fat can
be obtained from the milk bj- the process of but-
ter making. Now this percentage of 4 is a low
practical estimate of the quantity of fat, for among
dairy^men, with special breeding and feeding, they
get as high as i pound of butter from 14 pounds
of milk, that is, 7.13 per cent. This is a higher
percentage than has been found by any chemist
in human milk. This is a practical fact, not
chemical inference. It is very easy to understand
where the fault in chemistry' has been. The fat
I in milk is dependent upon the food the animal
receives more than are the albuminoids, and we
all know that ver\' many of the varieties of fat
contained in cows' feed are volatile, and the
chemical methods of using heat dissipate these
i varieties of fat; hence the low percentage obtained
by chemists. We must all admit that the fats
contained in human milk, the product of an om-
nivorous, largely carnivorous animal, containing
fixed and more stable fats, differ from those con-
tained in the cow, an herbivorous animal, whose
food holds more vegetable, volatile and unstable
■ fats. Practically one is a yellow, unctuous,
pleasantly odorous fat, as we see in butter ; the
[ other is colorless, waxy, decidedly different in
odor, and, therefore, it can be easily understood
that the chemist, who is obliged to use heat, will
recover more fat from the human than the cow's
milk. Thus we see that the fat is largely' depen-
dent on the nature of the food, and from the
dairyman we learn that we can regulate the food
of the cow so as materially to affect the propor-
tion of fat secreted. We know very little about
the chemistry of fats ; so far as I have been able
to ascertain, there has been but one analysis of
cow butter fat made up to the year 1875. Wher-
ever we turn, the analysis of Bromeis confronts
us, and later English analysts, while finding this

3 "Composition and Methods of Analj'sis of Human Milk," by
Prof. Albert R. Leeds. Transactions of the College of Physicians of
Philadelphia, third series, Vol. viii, p. J48.

734

COWS MILK FOR INFANT FOOD.

[November 23,

analj'sis to be all wrong, are unable to give us a !
correct one. These later analysts,' without ascer- 1
taining the proportions, have found in butter, |
palmitin, palmitic acid, stearin, stearic acid,
olein, oleic acid, butyrin, butj-ric acid, caproic
acid, caprylic acid, and capric acid. The fat of
human milk has also been analyzed by Robin,

casein is developed from egg albumen. This
illustrates the ripening of albumen. Further-
more, take an egg just laid by the hen and boil
it, and you will. find immature albumen in it:
that is, after boiling, instead of being thick and
firm, like an older egg, much of it is milky. If
boiled a few hours later all the albumen will

several years ago, and also copiousl}' quoted. I j coagulate perfecth-, because it has had time to
think that it is due to us from the chemists that , ripen. There is no doubt that the albuminoids
we have some authoritative analysis of these milk in milk from healthy animals are all cell trans-
fats, that we may know which, if anj', of the [ formations, not an exudate, as are undoubtedly
fattj- acids are the mischief-makers in milk, for I ! the fats and salts, because these latter we can in-
have no doubt that the glycerides and fatt}' acids i fluence by the food verj' plainly ; but in health
from the decomposition of milk have more to do the albuminoids are constant without regard to
with the development of the poisons than the . the food, while during menstruation, pregnancy
albuminoids have. The present popular method and other conditions, nbtably febrile disturb-
of analyzing milk by heat undoubtedly decom- ances, we find the fats and salts not materially
poses the fats, as is evidenced by the skin that affected, but the albuminoids are decreased, in-
forms on the surface of boiling or evaporating creased or totally changed, as we find in colos-
milk. This skin is undoubtedl}' the oxide ofitrum. The casein, besides being riper in cow's
lipyl ; it was at one time considered that it was I milk, b\' reason of its stronger growth, is intended
coagulated albumen, but it does not form /;/ vacuo \ b}- nature to coagulate into a hard mass, because
and will continually form on the surface of boil- j it is the product of a cud-chewer for the nourish-
ing or evaporating milk as often as you remove \ ment of a cud-chewer, and the reason why it does

it, and resembles verj' much the skin which forms
on old paint pots that have contained vegetable
oil. Furthermore, the condensation of milk for
commercial purposes does not preserve the fats ;
hence, condensed milks are more or less skimmed,
the better varieties having onlj^ the more volatile
fats removed, otherwise they would become ran-
cid. I am coming more and more to consider
that the fats in milk are the bodies most likely to
cause the digestive derangements of infancy, and
when we know more of the composition and com-
binations of these bodies occurring in milk, manj'
of the poisons, notably tyrotoxicon, will be less
of a mystery than they are now.

Our second consideration will be directed to
the albuminoids. Some time ago there arose a
mild dispute between two chemists as to the
amount of the albuminoids occurring in human
milk, Prof Meiggs asserting that there was only
I per cent. , while Prof Leeds makes the variation
from 0.85 to 4.86, an average of 1.195. Koenig,

not always coagulate in the infant's stomach, as-
it does in that of the calf is that the latter ani-
mal's stomach secretes a principle called chj-m-
osin ; this is the principle that curdles cow's milk,
and it operates either in an acid or an alkaline
medium. Pepsin will not coagulate milk, and
hence the hard coagulum of cow's milk that
sometimes forms in the infant's stomach is due to
aciditj- of that organ, and this acidity is not al-
ways the fault of the stomach, but of the milk
itself. The variations in the chemistry of the
albuminoids found in cow's milk would not be
surprising to any one if he could examine into
the condition of some of its mammarj- sources,
for often it will be found, on dissecting a cow's
udder, which I always do when making an au-
topsy on a cow, that there are old cicatrices, one
or more quarters of the udder intensely inflamed,
sometimes a mammiferous duct clogged with a
calculus or a clot of fibrin, and besides these
pathological conditions the mammary gland

an earlier analyst, makes the variation from 0.57 subject to benign and malign infiltrations, bacil-
to 4.25. Some of these results give as high a 1 lar>^ tubercular deposits, and eruptive diseases of
percentage of albuminoids in woman's milk as the skin involving the gland and ducts: therefore,
we find in cow's milk, and I have no doubt in I that fibrin, serum and albumen in various forms
my own mind that the time and habit of extract- 1 are found in the cow's milk is not surprising, and
ing the milk has a deal to do with the amount 1 it can safely be assumed that any variation in the
of occurring albuminoids. In other words, when | albuminoids from the normal casein can be

milk is extracted every two hours or less it can
not contain as much of the cell material as milk
from the same source extracted at intervals of
twelve hours. This latter is riper, and it is the
non-uniformity of the ti.ssue which causes all the
difference in the different occurring albuminoids.
We know that during the incubation of eggs

-• Hahner and Angell,
London, 1877.

' Butter, its Analysis and Adulterations."

ascribed to sickness on the part of the animal
producing the milk.

We next come to the salts contained in milk,
and it is remarkable how few analy.ses have been
made to determine the salts or minerals that are
contained in this fluid. Heidlin's analysis, copied
everywhere, seems to be the only exhaustive one
of the salines in cow's milk made during the pres-
ent century. It .seems to me in this case too that

1889.]

cows MILK FOR INFANT FOOD.

735

it is time for the chemist to teach us something
more. There probably never was a time, in our
era at least, when milk was attracting so much
attention as now, and still all our chemists are
content with the total solids, fats, albuminoids
and sugar — just what the butter and cheese mak-
ers want to know. From this much-quoted analy-
sis of cow's milk salts we learn that milk con-
tains, in varj'ing proportions, the phosphates of
lime, magnesia and iron, the chlorides of potas-
sium, sodium and iron, and free soda. Robin
gets from human milk, in addition to the fore-
going, carbonate of lime and soda, phosphate of
soda and the sulphate of soda, and potash. We
have no means of knowing how constant is the
occurrence of any of these salts in milk, or under
what conditions thej- are modified ; we do know,
however, from the experiments of Fehling, that
many of the drugs administered to the milking
female are excreted in the milk. Therefore, we
can safel)^ assume that the saline constituents
occurring in milk are influenced both by the health
and food of the animal. That the phosphates are
craved for by the milking cow is evidenced by
her habit of chewing old bones and the like, and
that there is a lack of this element of food is not
to be wondered at, when we see herds of milking
cows pastured on old, worn-out lands. The prac-
tical farmer knows that exhausted pasture lands
need, more than anything else for their rejuvenes-
cence, the phosphates, and we know that in our
nutrition we need them also. The land on which
a cow is pastured will indicate pretty fairly what
we may expect to find in her milk as salts. We
have all noticed the excessive growth of sorrel
on exhausted land, and can it then be a subject
of wonder that some kind of a vegetable acid
should be found in the milk of animals that are
obliged to include this variety of food in their
summer rations, and sour ensilage or spoiled
brewer>^ g^rains in their winter feed ? Theodore
Hankel's discovery of citric acid in cow's milk,
to the amount of 0.9 and i.i grams per litre, is
just what might be expected.

Sugar, I think, in milk has always been over-
estimated as to its nutritive value, because we
know that carnivorous animals do not secrete
sugar to any appreciable extent, at least so the
chemists tell us ; and when we see a small slut
nursing seven or eight puppies and keeping them
all fat and in a thriving condition, we can easily
imagine that sugar is not one of the necessary
elements of food ; while, on the other hand, we
know that the gross result of condensed milk
feeding, where the sugar is in excess, is not good.
In regard to using the commercial sugar of milk
as an addition to cow's milk for infant feeding, I
think it is a mistake, as there are undoubtedly
all the other crystallizable salts with the milk
sugar, and, consequently, we can know very im-
perfectly what we are feeding an infant with

when we are giving it milk sugar. If the milk
from which the sugar was crystalized contained
improper vegetable salts, these would undoubted-
ly become crj'stalized with the sugar, and many
of the proper salts would have become changed
to the lactates. Therefore, I think, if sugar is
to be used at all, although I deem it of doubtful
necessity, the pure cane sugar is undoubtedly the
best, because you know just what it is. When
we consider the chemistry of milk as we find it
in the books, what does it all amount to? The
chemist has given us to understand that the needs
for bodily nourishment are a certain amount of
the albuminoids, carbo-hydrates, fats and salts.
We can, therefore, from some of the cheap cere-
als, make this ideal food, and for one cent have
as much in nutritive value as we get in milk at a
cost twenty or thirty times greater. Then why
do we give milk ? Because we have tried the
chemist's ideal food with the infants at least, and
however admirable the theory may be, in prac-
tice it is a failure. Nature does not make so
close an allowance that there is nothing to spare
and no margin. She does not measure food by
the rule of three, always exactly in the same pro-
portions. Let us examine the work of the chem-
ists themselves, and we find in human milk a
standard that we cannot ignore, the albuminoids
varying from 0.85 t6 4.86. Therefore, let us not
deceive ourselves with the popular error of the
day, namely, that milk must contain just such a
proportion of .solids, and solids not fat, and .so
forth, to a chemical nicety ; but let us look into
the cow-house and see what goes through the
cow to produce the food for infants, and what
kind of an animal she herself is. Prof L. B.
Arnold, as good an authority as we have in this
country on dairy matters, says, "Milk is the
scavenger of the cow's body." What would be
the sense of taking a sample of water from a
sewer and asking a chemist to examine it for
sewage ; and so, when we go into a dairj' stable
and see dirt and filth, disease and improper food,
need we ask the chemist to ascertain the total
solids, fats, etc., to find if the milk is fit for in-
fant food? When this fluid will not properly
nourish an infant, it is not the cow's milk per se
that is at fault, but it is either a pathological con-
dition of the cow, or improper food or care, or
the conditions through which the milk has passed
on its way from the cow to the infant. It is safe
to say that if we had devoted the .same attention
to the cow, and if the same amount of money that
has been spent on the various substitutes had
been devoted to the improving of her condition,,
the infant, at least, would be better off".

Now we can assert that cow's milk is the best
food for the artificial feeding of infants, and when
this fails the fault lies in one or the other of the
following conditions, or several of them com-
bined: First, a faulty condition of the cow her-

736

COWS MILK FOR INFANT FOOD.

[November 21

self, and this will be indicated by the condition
of the albuminoids ; second, improper food or an
improper manner of feeding and caring for the
animal, and this will be indicated by the fats and
salts ; third, improper handling of the milk after
it is taken from the cow, and this will be indicat-
ed by the ptomaines and extractives. A proper
understanding of these three sources of danger
•will make the feeding of infants a simpler matter
than that offered by any of the substitutes, and
be, at the same time, a more rational method.
We shall consider the conditions of the animal
that render her milk unfit for food. The cow is
a unique beast, differing in man)- respects from
any of our other domestic animals. One of her
peculiarities, that has caused a deal of confusion
among veterinarj' writers, is her normal tempera-
ture. Several years ago I searched diligentlj' in
books devoted to bovine pathology to find the
normal bodily heat of the cow, and the confusion
was puzzling. It is variously stated at from 98°
to 101° F. I myself made several hundred ther-
mometrical examinations under varying condi-
tions, and found that the temperature is not con-
stant in apparent health, as it is, within very
narrow limits, in the human subject. Of course
we cannot tell to a certainty how near to health
a dumb creature is. The standard we have to
adopt with these animals i§ that the^- are in
health when they perform their functions with
profit to their owners. Certainly there are many
slight ailments that do not carr}' the animal be-
5'ond this limit. Therefore, the varj-ing tempera-
ture in the cow may be due to slight ailments
that do not demand the attention of the veteri-
narian. The average temperature of the cow in
apparent health I have found to be i02_5'2° F.,
ranging from ioi>2°to 103°. This, j-ou will per-
ceive, is a peculiarity of the cow, and none of the
other large domesticated animals maintain .so
high a bodily temperature. Another peculiarity
of the cow is the constant employment of her gen-
erative functions. She is always milking or preg-
nant, and both the uterus and the mammar}-
glands are employed almost constantly at the
same time ; hence her ner\'ous functions are ex-
aggerated. Therefore, with an abnormally high
temperature- — for I have found that bulls and
steers have not so high a temperature as the milking
cow — and with an unnatural functional activitj- of
the organs of generation, she is used also as a ma-
chine to transform food into milk, and it is aston-
ishing to what capacity she has been trained in
this direction. With four stomachs, the first
alone with a capacity of 60 gallons, she simply
eats, and she will eat anything. In health .she
is always either eating or chewing her cud, and
her pedigree sometimes shows the closest con-
sangfuinity in her breeding. Now, when we con-
sider all these unusual conditions, is it at all to
be wondered at that the ordinarj- dairj- cow is,

as a rule, an unhealthy animal, more prone to
bacillary phthisis and scrofulous affections than
other animals ? Her nervous sj-stem is more sub-
ject to severe shocks, and, in fact, she is a deli-
cate creature. Her attendants are not usuall}-
either mild or cleanly, nor is her housing always
the best.

Our next consideration is the feeding and care
of this nervous and delicate animal. The ordi-
nary dairyman receives for his milk i}4 to 2^4
cents per quart. At this low price received b}-
the producer he cannot usuall}- give his cattle
just the best food. I noticed in a dair}- journal
this summer an estimate from the New York
Dairj' Commissioner. Taking the milk received
at the creameries as a basis, the average income
from each cow is about $25 a j'ear to the pro-
ducer. This is almost 7 cents a day, from which
the dairyman has to buy food and pay for labor.
This sum alone would not begin to pay for proper
food for the animal ; hence the farmer is driven
to every known expedient to keep his cows in
milk, and the profit being so small, if there is
any profit at all, he must utilize everj- drop of
milk, whether the animal giving it be sick or
well. In this state of affairs, is it not natural
that all the cheap foods, such as brewer}- grains,
distiller}' slops, the refuse from starch factories,
enter so largel)- into the food from which our
daily supply of milk is produced. Of course this
condition of low price and improper feeding does
not appl}' to every dairy, but after years of expe-
rience I have no hesitation in saying that it ap-
plies to the great majority of dairy farms sur-
rounding New York City, at least. I have per-
sonallj' inspected small dairies where the sole ar-
ticle of diet was swill gathered in the city. Good
food is to the cows, of course, the prime absolute
essential for the production of good milk, and
unless the public are willing to pay more for their
milk than they do at present, a reform in this
direction cannot be expected.

The handling of milk after it leaves the cow is
the next important consideration. Owing to the
cow's natural high temperature, 102° to 103° F.,
the milk, when drawn, must cool rapidly, and
this first cooling taking place in the cow-house,
the milk is, of course, more or less affected bj"
the conditions generating odors. If these odors
are not verj- bad thej- can be removed, more or
less perfectly, from the milk by a process of aera-
tion. This can be accomplished either by pour-
ing the milk from one vessel to another in a thin
stream in the presence of a pure atmosphere, or
on a larger scale b}- pumping pure air into it bj'
a suitable machine. One of the most dangerous
methods that I know of for killing the odors that
milk absorbs from dirty stables or improper food,
is that recommended b}- many practical and other-
wise sensible men, namelj-, the addition of nitrate
of potash, that is. common saltpetre. It is very

1889.]

COW'S MIIvK FOR INFANT FOOD.

737

easy, from this addition of uitre, combined with
the glj-cerides and sulphates already contained in
milk that is decomposing, to figure out chemically
bodies approximating to nitroglycerine. It is
suggestiveh' strange that the toxic effects of
nitroglj'cerine are similar to those of tyrotoxicon.
The often reported detonation of this latter ex-
tractive, while undergoing examination in the
laboratory, is also suggestive of the properties of
nitroglycerine. The addition of chloride of lime,
which is also recommended for the same purpose,
although apparently a less dangerous; chemical
compound, should, nevertheless, be prohibited.
Soda is also added to milk sometimes to delay
the souring process. The prohibition of this
chemical maj^ be viewed in the light of a stultifi-
cation, when we consider the large amount of
bicarbonate of soda that is used at the present
day in one of the popular methods of feeding in-
fants. I think it is no less reprehensible on the
part of the physician than it is on the part of the
dairj'man. No chemical substance whatever
should be added to cow's milk by the dairj-man.
Milk that is procurable too far away to reach the
child within a few hours should not be used for
infant feeding. The diSerent degrees of tempera-
ture through which it must pass in its transit by
countr>' wagon, railroad train and city express
are productive of changes that cannot but deteri-
orate the quality of the milk. It is well known
that light, as well as heat, is one of the elements
that hasten decomposition in milk ; hence, the
now popular method of ser\-ing milk in clear
glass bottles is also a popular error.

No milk should be ser\'ed by the milkman for
infant feeding after it is twelve hours old, nor
should it be ser\-ed to the infant while it is warm,
immediately after leaving the cow, for I have
found by actual experiment that cow's milk,
while still retaining the animal heat, if taken into
the stomach, would coagulate into a solid mass;
but this coagulum is not so hard and rubbery as |
the curd we see sometimes formed when milk is
too old. In regard to sterilized milk, I am of!
the opinion that it is far better for us to make an '
effort to improve the quality of milk to such an
extent that it will be needless to sterilize it, be- ,
cause, of course, sterilized milk must take its j
place with condensed milk and other varieties of
preser\'ed food. If we cannot improve our milk,
then, of course, sterilization ought always to be
practiced. Notwithstanding that it is a preser\'ed ,
food, like condensed milk, it is not necessarily
skimmed or sweetened, as the latter is.

Having thus outlined the condition of the milk
we get and the reasons why it is not always good,
let me in the next place suggest remedies for the
existing evils. First, in regard to the cow her-
self No cow that is bred for a butter-maker
should ever be used to furnish milk for infant
feeding. The ideal butter-cow is too closely in-

bred and, consequently, too nervous ; there is too
much free fat in her milk. The ideal cow to fur-
nish milk for our purpose should not be too finely
bred and with little, if any, consanguinity in her
breeding. She should not have had her-first calf
till she was in her third year ; her milk should
not be used after she is six years old, unless she
has been spayed : she should be of a quiet dispo-
sition, her surroundings clean and quiet ; she
should be stall-fed always while giving milk for
infants ; her food should be hay without weeds,
ground oats bran, flaxseed meal, roots (beets and
carrots) bone-meal and salt — in the winter, corn-
meal in addition, and in summer, in lieu of drj'
hay, green cut clover or grasses free from weeds.
She should be curried daily and well bedded, and
in winter the water she drinks should be slightly
warmed. The milk should be aerated and cooled
as quickly as possible. It should then be put
into opaque bottles and securely closed.

Now, why do we not have this kind of cow
and obtain this quality of milk from our milk-
man ? The ver>' first and prime reason is that
milk is sold altogether too cheap. The producer,
as I have before mentioned, gets about 2 cents a
quart ; the railroad or the carrier gets i cent a
quart for all handled, and the distributor gets 5
cents a quart for peddling to the customers; there-
fore, the consumer pays 8 cents. This variety of
milk does not usually agree with the child, and,
therefore, the consumer is advised to buy some of
the baby foods as an addition to the milk, and
this increases the price of the food to something
like 15 to 20 cents a quart. Now, if the producer
got this extra amount of money he could buy
better food and better cows, exclude the milk of
sick animals, and altogether improve the quality
of his produce. But would he do it? That is
the question. vStill, it would be more humane to
make him do it when he is making a living, than
under circumstances as they exist now. So the
question of a purer supply rests verj- largely with
the medical adviser. Instead of recommending
commercial baby foods in addition to doubtful
milk he should advise the parents to purchase
milk at 12 or 15 cents a quart, and when the in-
fant gets sick from digestive troubles then lay the
blame where it is justly due, to the milkman,
and he will lose his customer. The supply of
baby milk in cities should be kept entirelj' dis-
tinct, and should be procured from those farms
that are situated near enough to the consumer to
get the morning's milk of the day of deliverj\
The dairies supplying this variety of milk should
be under strict sanitar\' surs'eillance, for no mat-
ter how good a condition a cow maj' be in, if she
is in heat, has sustained an injur}', or is sick in
any manner whatever, her milk should not be
used for infant feeding until she has completely
recovered. The ideal dairy for supplying infant
food should be composed entirely of spayed cows.

738

THE CLINIC.

[NoVEMBpR 2 J

and thus one constant source of nervous func-
tional disturbance would be eliminated. In my
own herd I have several spayed cows whose milk
I supply for infant feeding. These animals are
much more quiet in disposition, they give a more
constant and uniform supply of milk, and seem
to enjoy a more even degree of health than the
cow who is occasionallj' bulling and becoming
pregnant when giving milk.

Dr. John A. Jeffries said that he was much
interested in Dr. Brush's paper, as he held the
study of cow's milk to be very important. So
long as our present customs remain, man}- chil-
dren must be artificially fed, and cow's milk
properly prepared is the best available .substitute
for the breast milk. B\f means of some mixture,
such as Meig's, the milk can be made to more
closely resemble human milk. It still remains
that the albuminoids differ, and the same is prob-
ably true of the fats. The nature of the fats re-
quires more attention, since some recent physio-
logical work shows that the nature of the fat
fed to animals affects the fat deposited in the S5-s-
tem. He could not agree with the reader that
cane sugar was better than milk sugar. The lat-
ter was now carefully prepared, was the natural
food and was less easilj' fermented in the stomach
and intestines.

As to sterilization, he thought it was very im-
portant. When milk only a few hours old was
used he never had it sterilized, but if the milk
must stand for some time before use it should be
sterilized shortly after milking, before altered, in
the country. The large number of children now
fed on sterilized milk with the most happy results
proved the value of the method beyond question.
The three points in the artificial foods were a
healthy cow, properly preser\'ed milk, so modified
as to resemble human milk.

Dr. E.\RI,y, of Ridgeway, said that while in
the Pennsylvania Legislature during the pending
of the pleuro-pneumonia bill he made an investi-
gation of the dairies in the neighborhood of Phil-
adelphia. He found many diseased cows among
them, and in a stable at Camden, where six out
of thirteen cows died, he found the owner selling
the milk.

Dr. Christopher, of Ohio, was ver\^ much
pleased with Dr. Brush's paper. He had recently
made an investigation of the dairies of Cincinnati.
In one dairy of great excellence he noted that the
cows were thin. In distillery dairies the cows
were fat. Thin cows taken there quickly fatten.
Moreover, the urine of the .swill-fed cattle was
passed with great frequency and in large quan-
tity, while that of properly fed cows was small
in quantity and pa.ssed infrequently. Distillery
cows give milk rich in cream and accumulate fat.
This was without doubt a pathological condition
resulting from deficient oxidation. This milk

further undergoes decomposition with great readi-
ness and is acid in reaction.

Dr. Gates considered Dr. Brush's paper one
of great value. In his experience lean cows are
the best milkers.

Dr. Brush considered Bordin's condensed milk
as good as it is possible to make it, but no con-
densed milk can be made to contain all the con-
stituents of fresh milk. It is preserved food and,
as such, is open to the same objections as all pre-
served foods. Experience has shown that they
do not properly nourish the tissues. What the
diiference is cannot yet be demonstrated, .but
there is something necessary for proper nutrition.
Distillery-fed cows are not fat ; tlie appearance of
fat which they show is due to an cedematous con-
dition. He has often made post-mortem exami-
nations of such cows, and finds the tissues blub-
bery instead of composed of firm adipose tissue.

THE CLINIC.

A STUDY OF THE LOCATIONS OF 7881
PRIMARY CARCINOMATA AS ILLUS-
TRATING THE PROBABILITY OF
A CANCEROUS MICROBE.
BY EDMUND ANDREWS, M.D., LL.D.,

PROFESSOR OF CLINICAL SURGERY I.V CHICAGO MEDICAL COLLEGE
AND IX MERCY HOSPITAL, CHICAGO.

[Reported for The Journal.]

Gentlemen: — It is not yet histologicallj- proved
that there is a cancer microbe. Prof. H. A. John-
son of this citj', obser\-ed objects some }'ears ago
which he thought might be of this nature, and
more recentl}- Thomas, of Dorpat, and Scheur-
lein, of Berlin, have each discovered organisms
which made a similar impression on their minds,
but the final proof of their surmises is not yet
forthcoming. To-day I wish to call your atten-
tion to some important clinical facts bearing on
this subject which render a cancerous microbe a
probability and, therefore, a proper object for
search. True, these facts do not positively prove
the conclusion, but they point so strongly toward
it that the}' may be said almost to settle the ques-
tion.

You are aware that many pathogenic bacilli
and micrococci have their original existence out-
side of the human body; that their spores float in
the atmosphere like inanimate dust, in a dormant
condition, but when they light upon exposed tis-
sues wet with animal secretions they spring to
activity, show a swimming power, and traverse
considerable distances, multiplying as they go
and generating disease. If the cancer germ ex-
ists at all, its actions prove that it has these
qualities.

You are also aware that all primary carcino-

1889.]

THE CLINIC.

739

mata begin in the deeper epithelial cells, close to
the basement membrane. We sometimes speak
of epithelial cancer, meaning a slightly modified
form of the disease ; but in a certain sense all pri-
marj- carcinomata are epithelial ; that is to say,
they all originate in epithelium. A few eminent
authors claim to have found true primary carci-
noma in tissues deeper than the epithelial sur-
faces, but the cases are excessively rare, and I
very much doubt the accuracy of the observa-
tions. Now, bearing these things in mind, allow
me to lay before j'ou certain clinical laws, and to
follow them with statistics.

1. Other things being equal, primary' carcino-
ma is most frequent on those surfaces which by
their position would be most accessible to free
swimming microbes or spores derived from with-
out the body.

2. The liability to cancer is increased if the
epithelial surface is so situated that the spores
can remain upon it for at least some hours with-
out being swept away, as on the lower lip ; but
the liability is greatly diminished if the parts are
frequently swept off, as the globe of the eye by
winking, or the oesophagus by swallowing food
and drink.

3. The liability to cancer is great if the mem-
brane has vast numbers of deep glandular follicles
into which the spores can penetrate and lie free
from disturbance and have direct access to the
more delicate epithelial cells, as at the pyloric
•end of the stomach and the follicles of the mam-
mary glands.

4. Those portions of the skin which are usually
iincovered are oftener attacked than those covered
with clothing and constantly brushed by its fric-
tion. The skin of the face, for instance, produces
more cancer than all the covered portions of the
integument combined.

5. As might be expected, there are a few seem-
ing exceptions to these rules, but so few that
they do not break their general force.

To make good these clinical laws I have, with
considerable labor, made a collection of 7881
cases of primary' carcinoma, gathering them from
my own records and from extensive reports pre-
pared on both continents, and I have tabulated
them for your instruction. The first table shows
the sources of my information and the number of
cancers in each part of the body.

I omit all cancers of the lungs, liver and lym-
phatics, because these are almost all secondary.
It is the primary cancer alone which is derived
from without. The secondary ones are all mere
infections from the primary.

First let us consider primary cancers of the ali-
mentary canal, as given in the table.

The prolabium of the lower lip, though so
small a surface, gives us the surprising number
of about 481 carcinomata. In proportion to the
surface exposed it develops more cancers than

any other part of the body. The reason is not
obscure. The lower lip is in such a position that
vast numbers of germs from the air, from food
and from drink may light upon it and lie there
hours together without being dislodged. Finally
the cracks and abrasions on it are very frequent
from exposure to sun, wind and accidents, and
from the pressure of the pestiferous stems of clay
pipes, and these cracks, etc. , furnish spots of ac-
cess where the spores can reach the deeper epi-
thelial calls. It is natural, therefore, to expect
the disease at such a spot.

Locations.

2;.«i

•o S n tJ U S'l" ■'-" ff'fe.i i«

Alimentary Canal and Appendages

Lips (nearly all lower lip). . .

Tongue

Other parts of mouth

Salivary glands

CEsophagus

Stomach

Intestines

Pancreas

Rectum and anus

Gcnito-Vrinary Tract.

Penis

Urethra

Prostate gland

Testes

Bladder

Ureters

Kidneys

Vulva

Vagina

Uterus

Ovaries

Eyes, Ears and A ir-Passages.

Eye-lids and conjunctiva . . .

Ear

Nasal passages

Larynx

Epidermic Surfaces and Appended
Glands.

Face

Hands

Surfaces of the body covered by
clothing

Mammary Glands

ig6

244

30

59

1,945

127
22

280

62
4
8
62
46

Grand total . . 7,88i

43
30
'5
2,308
54

41
6
3

16

327
39

191
1,232

_•-■ S L, - L- "^

94
17

252

37
170

80

82

lOlS
7

150
39

'1

6
172
55

33
4

16

403

3

70
9

45
332

Now passing inward we find the tongue, though
presenting a larger surface, has less than half as
many cancers as the lower lip ; still it gives us
196 cases. Vast numbers of spores, after passing
by the lips, may light on the tongue and lodge in
the forest of papillae or on ulcers made by ragged
broken teeth. If they could remain there undis:
turbed they might find as safe a nidus as on the
lip, but the constant friction of the organ in the
mouth and the frequent baths of saliva may wipe
and wash away most of the germs, so that attacks
are less numerous upon it than upon the lower
lip.

The salivary glands give us only 30 cases of
cancer. The orifices of their ducts in the mouth
are very small and few spores would find them.
Then these ducts are swept out many times a day
by swift currents of saliva, so that only rarely
could a swimming microbe be expected to make
its way successfully to the gland.

74°

THE CLINIC.

[NoVEiMBER 2j

The other parts of the mouth present us with
244 cases, mostly beginning at the edges of the
gums, where germs might lodge in the crevices
between the gums and the teeth.

The whole mouth thus gives us 95 1 cases of
cancer, a large number, but just what we would
expect from an organ so situated as to be con-
stantly receiving external microbes every minute
of both day and night.

The oesophagus gives us only 59 cases. This
is precisely what we should expect of an organ
which is swept clean throughout its entire length
by ever}' mouthful of food or swallow of water.
Of the few attacks that do occur the major por-
tion are at the lower part, where the sphincter of
the cardiac orifice often detains small portions of
food for some time, and where the follicles of the
mucous glands are deeper and far more numerous
than in the upper portion, so that a lodgment of
swimming germs is more likely to occur.

susceptibility of the two ends of the organ. Most
of the stomach cancers originate near the pj'loric
extremitj', and correspondingly the follicles are
deeper, more numerous and more complicated at
that end. The stomach, therefore, is remarkablj^
well adapted to give lodgment to microbes, and
perhaps few men would escape the disease but for
the fact that its secretions in a state of health are
powerfull}- germicide, destroj-ing not only the
yeast plant and most other ordinary ferments, but
also many pathogenic bacilli, including probablj'
the cancer spores. It seems probable that carci-
noma can attack the stomach only at such times
as the secretions are below par in germicide power,
just as in such circumstances the food may under-
go acid fermentation, making a sour stomach, or
eveu putrefy from the action of putrefacient ba-
cilli.

Figure i.— Peptic gastric gland. (Gray.)

The stomach gives origin to 1945 cases, a start-
ling array, equal to one-quarter of all the primary
cancers of the entire body. I suppose this is
mainly due to two causes. In the first place,
whatever is swallowed remains there for hours ;
and, secondly, the mucous membrane of the stom-
ach is honeycombed with many thousands of
deep follicles, into which the germs have plenty
of time to enter and obtain a permanent lodgment
where they will be secure from being swept away.
For a similar reason there is a difference in the

Figure 2.— Clauds at pyloric extremity of stomach. Gray.i

It follows that probably verj' few cancer spores
reach the intestines in a living condition, and we
should expect primary carcinomata to be few in
these viscera. Accordingly our table gives us
only 127 cases. This small number is the more
striking because the walls of the intestines present
nearly ten times the area that the stomach does,
and they are specially subject to irritations and
inflammations of many kinds. However, as we
approach the rectum and anus, where germs can
enter from without, primarj- carcinoma becomes
more abundant. The anus and lower half of the
rectum, though constituting only a very small

1889.]

THE CI.INIC.

741

fraction of the intestinal surface, give us 280
cases, or more than twice as many as all the rest
of the intestines put together. This is one of the
many facts which constantly tend to make the
clinical surgeon feel that the carcinomatous infec-
tion comes from without the body. Another fact
pointing the same way is this : Cancer of the
upper half of the alimentary canal occurs far
downward along its course, because the germs
are carried along with the food and drink ; but at
the lower outlet primary cancer rarely originates
more than three inches above the anus, because
the downward motion of faeces prevents cancerous
spores from ascending except in a few cases ;
hence the verj' striking fact that probably nine-
tenths of all the primarj' carcinomata of this loca-
tion are within three inches of the verge of the
anus.

Wgure 3.

-Peptic glands of stomach after treatment T\-ith
alkalies. (Frey.)

the list, but after reflection I decided to retain it.
Perhaps, also, I ought to have rejected the kid-
neys, for in most hospital reports a large number
of cases both of tubercle and of sarcoma of these
organs have been erroneously tabulated as cancer
by careless pathologists.

In the female genitals the cancers of the vulva
and vagina are few. These organs are not termi-
nal stations and not specially subject to irrita-
tion ; but the cervix uteri, presenting abraded
spots in millions of otherwise healthy women,
is a natural prey to any such swimming germs
as we have supposed to be the cause of can-
cer. Hence carcinoma of the uterus is ex-
ceedingly abundant, giving us 2,308 cases,
which is almost one-third of all the primary
carcinomata of the body. It is noticeable also-
that almost all cancers of the uterus begin
not high up, but at the cervix. Fig. 4 is a por-
tion of the uterine canal twice the natural size,
showing how completely it is honeycombed with
follicles adapted to furnish lodgment to swimming
spores. Fig. 5 shows the follicles more highly
magnified, and displays impressivelj' their adap-
tation to retain pathogenic microbes in their re-
cesses.

If we consider the male genito-urinary tract we
find a similar condition. The penis furnishes us
62 cases, nearly all on the glans and prepuce,
where germs can lodge and remain undisturbed,
while the urethra, which is swept out by a swift
current several times a day, only presents 4 cases.
The prostate and the testes are, so to speak, ter-
minal stations, and though many spores must fail
to arrive there, yet .those that do are safely lodged
and can germinate undisturbed ; hence we have
more or less cancer of the testes, prostate, blad-
der and even kidneys reported. The figures for :
the testes are utterly worthless in most hospital
reports because of an error in diagnosis by which !
a great part of the tubercles of the testes have ',
formerly been reported as cancer ; and as I have {
been unable to collect a sufiicient number of cases ■
which were proved by microscopic examination, ,
I might have done well to omit that organ .from

Figure 4. — Uterine follicles enlarged two diameters, d d d, fol-
licles ; a a a, orifices. (.'Vm. Syst. Gynecol.)

The mammary gland presents remarkable sta-
tistics. The number of cancers of the organ in
our table is 1,232, the greatest number of any or-
gan except the stomach and the cer\ax uteri. At
first glance this seems contrary to the rule, for
external spores can only enter through the nip-
ple, and that is a small organ, covered and
brushed with the clothing and often supposed to
be dry, except during lactation. However, lac-

742

THE CLINIC.

[November 23,

tation covers a good deal of a woman's life during
child-bearing age. Furthermore, the orifices of
the milk ducts, even when not lactating, are fre-
quentlj' moistened with a very slight exudation
of mucus, and at other times with perspiration.
For these reasons there is abundant opportunity
for swimming spores to light on the parts and
enter the interior. In active lactation thej^ would
be mostly swept out again by the rush of milk,
but in the non-lactating periods they would make
their way undisturbed to the follicles and find
themselves eminently in a terminal station, from
which nothing could dislodge them. The almost
total absence of carcinoma from the male breast
falls in well with this theory, as the smallness of
the nipples and the tightness and dryness of the
orifices of the milk ducts are almost an absolute
protection from the admission of germs of any
kind.

Figure 5.— lutra-uterine glands, e, epithelium ; g g. glands ;
c t. connective tissue ; v v, blood vessels ; m m, sub-raucous layer.
(.\m. Syst. Gynecol.)

There is a striking difference in the liability to
primary cancer between those portions of the skin
which are habitually uncovered, as the face and
hands, and those which are covered with clothing
and habitually brushed off" by its friction. The
face and hands alone give us 366 cases, while the
whole of the covered portions of the skin together
furnish only iqi cases, as if the clothing .served
in some way to prevent the lodgment and devel-
opment of germs by its protective and by its
bru.shing action.

This liability of different surfaces to cancer in
proportion to their exposure to germs, and their
ability to afford them an undisturbed lodgment,
is still more strikingly shown if we compare equal
areas of the different surfaces. I have calculated
the areas of the different organs and the proportion

of cancer to the same area in all. Suppose the
intestines to present one cancer on a given area
of surface, then the number of cancers on the
same area of other organs will be as follows :

Table showing the liability of equal areas of dif-
ferent stirfaces to cancerous infection, the liability of
intestine being assjoned as i :

Lower lip 8,448

Tougiie 1,232

Rest of mouth aud fauces 264

(Esophagus 242

Stomach 572

Intestines i

Rectum and auus 396

Skin of the face 264

Hands 22

Surfaces covered with clothing 4

Vulva 264

Vagina 61

Cervix uteri 5,776

This shows that, in proportion to its area, the
liability of the prolabium of the lower lip to can-
cer is 8,448 times greater than a similar area of
intestine, while that of the tongue is 1,232, of
the stomach 572, and of the anus and rectum 396,
the rest of the intestine being only i. The lia-
bility of the face is 264, while that of the covered
portions of the bod}* \i only 4.

It has been conjectured b}^ very eminent scien-
tific men that cancer is a mere product of ordinar}'
irritation acting upon epithelial tissue or upon
certain masses of embryonic tissue enveloped in
the body and accidentally left over undeveloped
from the foetal state, and that primary cancer at-
tacks organs in proportion to the irritations to
which they are subjected. There is a certain
plausibility to this theory, but in fact it has never
been proved that cancer has ever thus originated
in a single instance ; and, furthermore, the fre-
quency of cancer is far from being proportioned
to the amount of irritation in each organ.

There is one organ which is rebellious to everj'
theory 3'et devised, my own included, and that is
the Schneiderian membrane of the nose. It is
extremely' exposed to irritation and inflammation,
and also to the reception of external germs of
every kind, and yet it is rarel)' attacked with
cancer. It is an organ standing by itself so to
speak, and possessing an exemption from attack
which at present is unexplained.

Now, gentlemen, thotigh the facts I have col-
lected and laid before you point strongly to a
probable cancer microbe, I \vish you to under-
stand that they onlj- prove a probability, and not
a certainty. Science is exacting. Before we can
say that carcinoma is certainly caused by a germ,
the following conditions must be fulfilled :

1. A microscopist must see the microbe.

2. He must obtain a pure culture of it.

3. He must reproduce the disease by inoculat-
ing the pure culture successfully into some ani-
mal. This has not yet been accomplished, but
you ^nd I may, nevertheless, observe the bearing

1889.]

MEDICAL PROGRESS.

743

of clinical facts and note the probability where
demonstration is not j'et possible.

This probability brings with it important prac-
tical suggestions. If cancer is imported from
without the bod3f its invasion may often be pre-
vented. In the breast, for instance, which fur-
nished us with 1,232 cases, everj- germ must en-
ter by the nipple, and it would not be difficult to
prevent that. Bacteriologists find that a simple
plug of cotton in their test tubes shuts out every
foreign microbe. It would be easy to construct
small concave cotton compresses, which could be
worn as protectives on the breast. If desired, the
cotton could be slightly dampened with glycerine
to cause spores to adhere securely to the fibres,
so that movements of the clothing could not cause
them to sift through to the nipple. Additional
security might be had by a thin rubber cap out-
side the cotton.

The stomach cannot be guarded from the en-
trance of microbes, but by attention to a healthy,
moderate diet it may be kept in a condition to
digest perfectly and to destroy most of the spores
reaching it.

The cervix uteri can be cured of its dangerous
abrasions, which probably furnish a nidus to the
.spores, and thus prevent it from becoming the
seat of cancer. So in all parts of the body, such
as the lips, the tongue, the gums, the anus,
etc. If there are cancer spores in existence,
cleanliness and careful preservation of the health
and integrity of the surfaces will shut out the
germs from the tissues which they are liable to
attack.

You see, therefore, that I have a practical rea-
son for wishing you to consider this subject, and
that, acting wisely on the probability discovered,
you may hope to prevent, in many cases, the on-
set of this disease.

No. 6 Sixteenth street, Chicago.

MEDICAL PROGRESS.

Fibrinous Membranes Within the Spinal
Canal. — Dr. Joseph Wigglesworth reports
three cases of general paralysis in which he
ionnd., post morion, fibrinous membranes in con-
nection with the spinal cord. In the first case
the membrane was from one to two lines in thick-
ness and was found lying upon the external sur-
face of the dura mater on its posterior aspect. It
extended from the third to the seventh dorsal
vertebra and was attached both to the dura ma-
ter and to the walls of the spinal canal.

In the second case the membrane was similar
to the foregoing one. In the third case it ex-
tended from the lower cervical to the lower dorsal
region and involved the roots of some of the spi-
nal ner\-es. It was everywhere coherent and

could be detached as a separate membrane. Th<
three membranes were all external to the durs
mater, in which respect they differ from the sim
ilar formations which are frequentlj' discoverec
in the cranium, especially in post mortems of thi
insane. Dr. Wigglesworth believes that thi
membranes described are the result of a hsem
orrhagic effusion within the spinal canal; that ai
inflammatory process is not concerned in thei
formation, and that thej^ would be discoverec
much more frequently if sought. In the thin
case he suspected the presence of the membrane
before the death of the patient, on account of th^
symptoms of irritation of the spinal ner\'es whicl
existed, to wit: retraction of the head and rigid it;
of the extremities. — British Medieal Journal , Sep
tember 21, 1889.

Morphology and Pathology of Nervi
Terminations in Muscle. — Before the Pari
Academy of Sciences, October 7th, Messrs. B.\bE!
and Marinesco reported their studies and experi
ments in the direction above indicated. The fol
lowing is a brief resume:

A modification of histological technique ha;
enabled them to enter into an extensive consid
eration of nerve terminations in muscle. In ex
amining a terminal plaque of the lizard with ;
strong apochromatic homogeneous immersioi
lens they obser\-ed two substances in the last seg
ment of the axis cylinder. One is darkly am
strongly colored by gold and stretches out in ;
network; the other, paler, of a fundamental chai
acter, seems associated with the pale substance 0
the plaque. The sheath of Schwann, spreadinj
out, covers the plaque and becomes continuou
with the sarcolemma. In the plaque the darl
substance forms many sinuous ramifications con;
municating in arcades and possessing laters
branches terminating in crosses. In this sut
stance exist many small rounded nuclei. It ap
pears that the dark substance is continue
throughout the plaque by the paler materij
which surrounds it. In the normal state fin
lateral branches of the dark substance are rarel
seen entering distant nuclei of the sarcolemms
while certain fine prolongations of the peripher
of the fundamental material enter the intimat
structure of the muscle. In man the structure c
the plaque is comparatively simpler.

By cutting the sciatic nerve of the lizard w
have determined an excessive atrophy of th
muscle nerves and of the plaques, a breaking u;
of the network of dark substance, and a disap
pearance of the nuclei. We have repeated thes
experiments upon the rabbit on a very wide scak
Thirty-six hours after section of the sciatic nen-
the lesion is more pronounced in the termina
tions than in the small peripheral muscle ner\'es
It consists of a nearly total disappearance of th
dark network. In place of the ramifications dar!

'44

MEDICAI, PROGRESS.

[November 23,

riform cellules are seen. The fundamental
e substance and the fundamental nuclei are
ite visible. These nuclei are swollen, increased
number, usually rounded, and have a fine
inular zone about them.

Most of the lesions found in maladies of the
■vous and muscular systems correspond in gen-
1 with the lesions experimentally produced,
us, in simple muscular atrophy an atrophy of
: plaques is found, sometimes with proliferation
the nuclei. In hypertrophy of certain muscles
i in Thomsen's disease there is uniform hyper-
sia of the dark substance. In typhoid fever
■re is found a simplification of the terminal
que, and often the peripheral portion of the
minal fibre is replaced by a very fine filament,
the pseudo-hypertrophy of adults we have no-
id a disappearance of the dark portion not
:y of the plaque, but often also of the terminal
erannular segments. At the same time there
en exists a proliferation of the fundamental
clei. In a case of lateral amj'otrophic sclerosis
I terminal fibres and the plaques were exten-
ely atrophied. In the multiple neuritis of lycy-
ti we have in general determined the existence
the same conditions, but at the same time the
;ns of a new formation are seen, and sometimes
in a proliferation of the nuclei of the plaque. —
maine Medicale, October 9, 1889.

Methyl Chloride as a Local An.esthetic.
Dr. Ernst Feibes, in a recent number of the
rliner klitiische Wochensc/in/t, draws attention
the extensive and successful use in the Paris
spitals of methyl chloride as a local anaesthetic.
;thyl chloride (CH^ CD is a colorless, easily
uefied gas, with an odor resembling that of
ler and chloroform. The readiness with which
? gas liquefies adapts it for convenient use, as
:an be stored in a siphon, or in a bottle of any
e specially constructed to conduct heat badly.
mz.y be applied to any surface directly from the
hon, or as a spray, but this method is objec-
nable, owing to the anaesthetized area not being
most cases sufficiently circumscribed. Bailly
IS the following method, which he calls " styp-
f." Tampons composed of cotton wool, sur-
juded by a layer of flock-silk and then covered
th thin silk, are saturated with methyl chloride,
d applied to the part by means of wooden or
Icanite holders. After contact for some seconds
s part gets pale and anaemic, and diminishes in
Lsitiveness. If the tampon be then removed
jre is marked reaction, shown by congestion
d slight itching ; but if the application be con-
lued for a short time longer (a few seconds) the
in assumes a white, dried, parchment-like ap-
arance. This is the time to operate. If you
3ceed further superficial necrosis may result,
le application is sometimes succeeded by itching
d an urticaria-like eruption. It is emploj-ed in

all kinds of small operations — circumcision, open-
ing abscesses, and in neuralgia, lumbago, muscu-
lar pains, gout, etc. In scraping lupus it is best
applied by means of a camel-hair brush, as spe-
cial parts can then be anaesthetized with perfect
precision . — -British Medical Journal.

Treatment of Pertussis with Resorcin.
— Dr. Justus Andeer reports quite remarkable
results in the treatment of whooping-cough with
resorcin. In a child of 7 years, on the second day
after resorcin was prescribed, there was great im-
provement in the symptoms, and sleep at night
was much less disturbed. In ten days, the cough
had disappeared. With five other children the
effects were even more pronounced, all being cured
within a week. An infant of 6 months with vom-
iting after each paroxysm of coughing, was re-
lieved by the second dose, and in five days the
cough ceased. In the latter case, Dr. Andeer
used a '- per cent, solution in sweetened water
given from the nursing bottle. In the former
cases, he gave a 2 per cent, solution in water, of
which half a wineglassful was administered four
times daily, with directions that part should be
used as a gargle, the remainder swallowed. He
does not think that inhalations, or painting of the
pharynx, with this solution, possess any advan-
tages over this simple method, — Centralblatt fiir
mcdidtiisc/icn Wissenschaften. — Medical News.

Treatment of Chronic Catarrh of the
Bladder. — Dr. L. Frey, in the Centralblatt fhr
Chirurg. of August 17, claims that iodoform is
especially suited for the treatment of chronic co-
tarrh of the bladder, on account of its antiseptic,
analgesic, and deodorizing properties.

The bladder should first be cleansed by a douche
of warm water, and then a tablespoonful of the fol-
lowing, in a pint of warm water, injected into it :

R. Iodoform 50 parts.

Glycerine 40 "

Distilled water 10 "

Tragacanth '4 part.

n..

These injections should be repeated everj- third
day. Three or four will usually effect a complete
cure.

Dr. Mosetig-Moorhof has treated twenty-three
cases in this way, all of which were cured. No"
symptoms of intoxication from the drug were ob-
served.— Medical Age.

Quinine in Pregnancy.— Dr. E. A. G. Doyle,
Trinidad, W. I., finds that in the West Indies,
where malarial fevers are common, abortion often
results from the administration of quinine, writers
entertaining an opposite opinion to the contrary-
notwithstanding. He has studied the question in
all its bearings and is convinced that it is the qui-
nine and not the fever that occasions the abortion.
— Brit. /T/6'</. /<?//r., September 31, 1889.

3889.]

EDITORIAL.

745

THE

Journal of the American Medical Association

PUBLISHED WEEKLY.

Subscription Price. Including Postage.

Per annum, in advance $5.00

Single Copies 10 cents.

Subscription may begin at any time. The safest mode of remit-
tence is by bank check or postal money order, drawn to the order
of The Journal. When neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
letters.
Address
JOUTRNAI, OF THE AMERICAN MEDICAL ASSOCIATION,
No. 68 Wabash Ave.,

Chicago, Illinois.
All members of the Association should send their Annual Dues
to the Treasurfr, Richard J. Dunglison, M.D., Lock Box 1274, Phila
delphia, Pa.

London Office, 57 and 59 Lddgate Hill.

SATURDAY, NOVEMBER 23, 1889.

PHTHISIS AND TUBERCULOSIS.

It seems that many of the enthusiasts of the
microbic origin of disease, accepting the demon-
strations of Koch on the origin of tuberculosis,
would explain all the symptoms of pulmonary
phthisis by the action of the same fungus. In
tubercular disease in other parts of the body,
such, for instance, as the large joints, the mani-
festations are quite diiferent from tubercular dis-
ease of the lungs. There is no hectic, however
great the emaciation, until the joint or large peri-
articular tubercular abscesses are opened and in-
fected with pyogenic bacteria. This ought to
draw attention to the fact that phthisis is not a
simple disease.

In the examination of sputa from tubercular
patients, every one has noticed the abundance of
micrococci and non-tubercular bacilli. These ob-
servations have lately been attested by culture
experiments. The tubercular nodules are for a
long time free from pyogenic infection, and the
inoculation of gelatine in these early cases from
i.solated tubercular nodules, whether degenerated
or not, is without result, as the bacillus of tuber-
culosis does not grow on gelatine. When, how-
ever, the disease has advanced farther, the infec-
tion of the avascular tubercular nodule follows as
the result of a capillary bronchitis or accidental
infection, and night sweats and other symptoms
of sepsis begin. Then the cultures show numer-
ous colonies of pyogenic bacteria in the region of

the tubercular nodules. Thus is established a
condition resembling multiple abscess of the lung
accompanied as a natural consequence with sup-
purative bronchitis. With the initiation of the
pyogenic infection, the symptoms take on a graver
character. Before there has been loss of strength
from imperfect aeration of the blood and loaded
action of the heart, now there is prostration from
hyperexia, loss of appetite, night sweats and
other results of sepsis. The dangers from pyogenic
infection of the tubercular lung is scarcely less than
that of the tubercular joint. This latter dan-
ger surgeons have long recognized. To be sure,
the drainage of the lung is more complete and
regular than that of any joint, so that there is
less pronounced toxaemia.

The indications for treatment must be based
upon a careful stud)' of the conditions of parasi-
tism. Until there is some form of medication
which affects materially tubercular disease in joints
or superficial lymph glands, there can scarcely be
a satisfactor}- medication for tubercular disease of
the lung. The administration of gases, hot or
cold, seems like the application of a mad stone —
irrational and irrelevant. When septic infection
of the tubercular lung has taken place, the treat-
ment cannot differ from that of septic infection
elsewhere. The utter hopelessness of internal
medication in such cases has been long recog-
nized. There is nothing to be thought of which
will benefit the patient except drainage, rest and
food.

The proper indications for treatment point to
the prevention first of tubercular infection, and
when that is recognized, to the prevention of py-
ogenic infection of the tubercular lung. It seems
a priori probable, as experience has shown it is
possible, for tuberculosis of the lung, like tuber-
culosis of the joint, to remain in a dormant con-
dition for half a lifetime, or even to disappear
entirely under favorable conditions.

Here, then, is the climatic treatment of the tu-
bercular lung disease. Put the patient in a dust-
less, and therefore aseptic atmosphere, and j-ou
have provided the most rational treatment. It is
an antiseptic dressing to the open tubercular lung.
The outdoor treatment of phthisis, or septic tu-
berculosis of the lung, long ago brought to popu-
lar notice by Felix Oswald, is also the rational
treatment in this last and least hopeful stage of
the disease.

746

CHILDREN AND THEIR TREATMENT.

[November 25

CHILDREN AND THEIR TREATMENT,
Although the subject of the Treatment of the
Diseases of Children is rapidly becoming one
deemed worthy of careful consideration, yet there
remains much room for more rapid improvement
in regard to their discipline and the proper under-
standing of their needs, etc. Unfortunately,
those who are entrusted with the training of the
fathers and mothers of the future are rarely se-
lected for their amiability, or capability of treat-
ing their little charges in a proper way.

This remark applies equally to parents and to
teachers. Even among those who may be re-
garded as fitted by education and mental refine-
ment for the, care of children, it is constantly ob-
served that there is an utter want of information
upon many points in relation to the young, which
frequently gives rise to ver)' injudicious, even
injurious treatment. Popular lectures can not
deal with several of these points, and hence it
becomes the duty of the phj'sician to so instruct
parents and teachers that they may do no wrong
to the innocents in their care. Perhaps the one
point upon which the most ignorance is dis-
played is the needed attention to the urinary
apparatus. Incontinence of urine, a very com-
mon affliction of the young, almost invariably is
regarded and treated as the result of laziness or
even filthiness, and the unhappy sufferer is in
many cases treated most barbarously to break
him or her of the habit. It has happened that
medical men who have no excuse save ignorance
to err in this matter, have assured the parents
that it was solely due to carelessness, etc., and
have been the means of the infliction of disci-
pline at which the soul shudders. Every physi-
cian who reads this should carefully think over
the matter, and see whether he or she has erred
in such a case. Were parents instructed that
this is a misfortune not a fault, children who are
thus troubled would at once be placed under
medical treatment, and cured rather than be dis-
graced or heart-broken by shame and unmerited
punishment.

This affection assumes another phase when the
child so afflicted suffers the peculiar agony of
strangury when denied the privilege of retiring
when the call is imperative. Unfortunately, ow-
ing to the trickery of a few, all have to suffer.
It should suffice if the parents inform the teacher
of this condition of the child, and a request to

retire should at once be honored. In some cases
on the contrar)', in place of strangury, the child
when refused, at once loses control of the sphinc-
ter, and the contents of the bladder are emptied
into the clothing. Either is extremely annoying
to the child and liable to result in permanent
injury.

Another affection incident to childhood is
' ' night terrors. ' ' In many instances, these two
are associated. Equallj' with the bladder trouble,
has this affection been neglected or misunder-
stood. The child is regarded as wilfully perverse,
or as having fallen into a bad habit, and is pun-
ished in a varietj- of ways according to the in-
genuity of its " care takers!" We had better sa\'
"persecutors." Now if every physician would
impress upon the mothers in his practice what is
meant by ' ' night terrors, ' ' no doubt many such
cases would be recognized and placed under the
proper treatment. There is reason to believe that
in some cases, this affliction is liable to end in
some form of dementia. For this reason also it
is imperative that it should be attended to as
early as possible and thus prevent so disastrous
a termination.

In conclusion, while the profession are seeking
all kinds of specialties at which to devote them-
selves, let all seek to inform themselves upon
these verj' important subjects, with the assurance
that thus they will truly be doing the work of
' ' phj'sicians. ' '

THE AMERICAN ACADEMY OF MEDICINE.

The recent meeting of the American Academy
of Medicine, held in Chicago on the 13th and
14th of November, was the first one ever held in
the West. Established at Philadelphia during
the session of the Centennial International Medi-
cal Congress in 1876, this Association has since
that date been earnestly at work to promote some
of the most important interests of the medical
profession. Its immediate objects, as, stated in
its Constitution, are to encourage young men to
pursue regular courses of study in classical and
-scientific institutions before entering upon the
study of medicine ; to extend the bounds of medi-
cal .science ; to elevate the profession ; to relieve
human suffering, and to prevent di.sease. As was
well said by a former president of the Academy,
Dk. Frank H. Hamilton, the Society seeks "to

1889.]

EDITORIAL NOTES.

747

remedy a great and universally admitted evil,
namely, imperfect preparation for the study of
medicine and its almost inevitable sequence, im-
perfect qualification on the part of those who are
admitted to practice." In pointing out the avail-
able means for accomplishing this purpose. Dr. j
Hamilton said that the Societ}^ should labor to
create a healthy public sentiment which shall, in
a measure, influence medical colleges and medical
men ; and that, most of all, it should strive to
create a sound .sentiment among the j'oung men
who contemplate the study of medicine, and who
should have clearly pointed out to them the most
valuable means of enlarging their future fields of:
usefulness as practitioners. The Academj^ is not
intended as a substitute for any other association
of medical men, but as supplemental to all or-
ganizations which have for their object the uplift-
ing of the profession and the enlargement of its
field of useful endeavor.

The present meeting was an occasion of much
interest. The addresses were of a very high or-
der of merit, and some of them, especially that of
the President, Dr. Leartus Connor, abounded
in statistical facts that cannot fail to be of the
greatest interest to medical men throughout the
country.

EDITORIAL NOTES.

HOME.

The John Crerar Library. — The will of the
late John Crerar was admitted to probate in the
City of Chicago on the 14th inst. After the be-
quest of over a million of dollars to various re-
ligious, literary and charitable institutions, and
to many personal friends, he also provides for the
creation and maintenance of a free public librarj'
to be located in the South Division of the city.
The sum appropriated for this purpose is esti-
mated at over two millions of dollars. The exe-
cution of this trust is committed to a Board con-
sisting of men singularly fitted for the work —
and the wishes of the donor, under such manage-
ment, will sureh' be realized. It is to be hoped 1
that with -such ample means at its command, the
board of management will not only develop a
model library for the public, but that ample pro-
vision will also be made for the several profes-
sions as well. If this shall be done, in addition to \
the magnificant reference library which was the 1

noble benefaction of the late Walter Newberr}%
Chicago, maj' soon become a literary centre,
the advantages of which literarj' men will be
quick to appreciate.

Public Health Matters in Detroit. — Dr.
Samuel P. Dufiield, Secretarj^ of the Detroit
Board of Health, informs us that the State Board
recently included typhoid fever as a disease dan-
gerous to the public health and stated that ac-
cording to the law it should be reported to the
Health Officer. As there were certain points as
to whether houses should be placarded or not,
etc., the Detroit Board of Health held a session
pursuant to a call from the President, Wm. Bro-
die, M.D., and the Board directed the following
circular to be issued :

Office of the Board of Health.

Detroit, October 15, 18S9.

Dear Doctor: — Vnder the law requiring contagious and
infectious diseases to be reported to the Board of Health,
it is desirable that this Board be advised as follows:

1. Is typhoid fever in your opinion contagious?

2. Is typhoid fever in your opinion infectious?

3. Is typhoid fever in your opinion both contagious
and infectious?

4. If typhoid fever is either infectious or both conta-
gious and infectious, do you advise that although the law
requires such diseases to be reported to the Health Office,
that it should also be placarded as iu small-pox. scarlet
fever and diphtheria?

By promptly answering, and confining your replies to-
the above questions, and if possible attending the ad-
journed meeting of this Board in the Maj'or's office at
7:30 P.M., Saturday, October 19, you will confer a favor
upon the Board of Health.

By order of the Board.

Wm. Brodie, M.D., President,
Samuel P. Duffield, M.D., Secretary.

There were 89 answers to 450 circulars sent out,
and answers were as follows : Contagious : No,
60; j^es, 26; in doubt, 5. Infectious: No, 14;
yes, 74. Both contagious and infectious : Xo,
54; j'es, 19; in doubt, 5. Placard: No, 69; yes, 20.

On the basis of these figures the Board directed
the Secretary- to notify the profession that the cases
must according to law be reported, but that it was
not necessary to have the house placarded, etc.

The form recommended by the , United States
Baggage Masters' Protective Association was en-
dorsed by the Board. This form compels the un-
dertaker to faithfully do his duty and .swear to
the same having been performed.

Medical Society of the State of Wash-
ington.— In response to a call by the President

748

EDITORIAL NOTES.

[ November 23,

of the Territorial Medical Society, there was a
largely attended meeting of the profession at Ta-
■coma, October 21st and 22d. The Territorial
Society, as such, adjourned sine die. The forma-
tion of a State Society was then proceeded with,
and the following officers were elected : Presi-
dent, Edward L. Smith, Seattle; First Vice-Presi-
dent, J. S. Wintermute, Tacoma ; Second Vice-
President, M. Pietrzycki, Dayton ; Treasurer, H.
S. Willison, Port Townsend ; Secretary, C. L.
Flannigan, Olympia ; Board of Censors: Drs,
Shaver, Heg, Crump, Boswell and Essig ; Board
of Trustees : Drs. Van Zandt, Van Buren, Mer-
rick, Libby and Marion. The regular standing
committees were also appointed. There are about
sixty-five charter members of the Society. The
next meeting will be held at Spokane Falls on
the second Wednesday in May, 1890.

District Medical Society of Central
Illinois. — The fourteenth semi-annual meeting
of this Society was held at Decatur on the 12th
inst., with a large attendance, over 100 physicians
being present. Dr. Ranch, of the State Board of
Health addressed the society briefly in the even-
ing, on "City and Country Sanitation and its Re-
lation to Contagious Diseases. ' '

FOREIGN.

Berliners Eating Horse Meat, — A dispatch
from London says that the consumption of horse
meat in lieu of beef is daily increasing in Berlin,
and it has become almost impossible for the
butchers to procure sufficient genuine beef to
supply the demand of those who are able to pay
the almost fabulous price which that commodity
■commands.

French Physicians, it seems, feel the pulse
of the people of France in more ways than one.
Of the 557 members returned at the recent gen-
eral elections to ser\'e in the French Chamber of
Deputies, 48 are doctors of medicine, 4 are drug-
gists, I is a dentist and i a veterinarian.

The late Father Damien, who died in the leper
settlement at Molokai, Sandwich Islands, will be
succeeded by his brother.

The Scientific Grants ok the British
Medic.'VL Association. — The following addi-
tional grants have been made by the Council in
accordance with the recommendation of the Scien-
tific Grants Committee ; Mr. Hankin ^^50 to con- 1

tinue his investigations into the nature of an al-
buminose that has been obtained from anthrax cul-
tures under certain conditions ; Dr. R. Kirk ^^10
for a research on alcaptonuria and on the distinc-
tion between albumen and mucin in the urine,
and some other points in connection with proteids
in that fluid; Dr. J. R. Bradford ^15 for some
experiments on the action of the cortex cerebri
on the vaso-motor system ; Dr. H. A. Ashdown
^10 for a continued research upon absorption
from the bladder,

The Medical Profession and Temperance.
— The British ]\fedical Journal says : An unusu-
ally large number of important temperance con-
ferences have been held recently, including a Na-
tional Temperance Congress at Birmingham. It
is significant of the lively interest taken by mem-
bers of the profession of medicine in the temper-
ance movement that at Birmingham two metro-
politan physicians and at Norwich a metropolitan
physician and a distinguished provincial surgeon
took a prominent part, while at Glasgow a lead-
ing place in the proceedings was assigned to the
assistant of one of the university medical profes-
sors. A public meeting at Birmingham was ad-
dressed by several provincial members of our As-
sociation. The British. Medical Temperance As-
sociation numbers over 400 members, all ab-
stainers.

Is Man Left-Legged? — Dr. W. K. Sibley
read a paper before the British Association in
which he argued that man was naturally left-
legged. Standing working with the right hand,
there was a tendency to balance on the left leg.
: Race paths were nearlj- always made for running
! in circles to the right, and the majority of move-
ments (such as dancing, running, etc.) were more
readily perlormed to the right. In walking, it
was more natural to bear to the right ; crowds as
well as individuals did so. Troops started oflf
with the left foot ; the left foot was placed in the
stirrup or step of the bicycle in mounting ; the
left foot was the one from which a man took off
in jumping. From measurements made by Dr.
Garson of the skeletons of the two legs, in 54.3
per cent, the left leg was the longer, and in 35. S
the right. From measurements of 200 pairs of
feet, it was found that in 44 per cent, the left, and
in 21.5 the right, was longer, while in 34.5 they
were equal. — Medical Record.

1889.]

TOPICS OF THE WEEK.

749

TOPICS OF THE WEEK.

THE ITALIAN PREMIER ON STATE MEDICINE.

Ill his great speech at Palermo on the 14th of October,
Signer Crispi gave special prominence to what his admin-
istration had effected for the sanitary rehabilitation of
Italj'. " For four years," he said, "there had weighed
on Italians the incubus of an epidemic " — cholera,
to wit — "which, besides phj^sical suffering and material
loss had induced a moral disturbance, inevitable, per-
haps, in a countrj- where hygienic education was still so
primitive and so sporadic. It was a prime necessity,
therefore, to proceed at once to the sanitary rehabilita-
tion of the State, and we made provision accordingly.
We addressed ourselves first to the minds of men, and
we prevailed on them to look the enemy in the face as
the principal means of overcoming it. With anxious
and systematic care we took the sting from present evils,
and then we reconstructed laws to obviate their recur-
rence. Sanitary provisions should impose on the free-
dom of the individual no restrictions but such as are re-
quired for the safeguard of the lives of others. Personal
hygiene is on that account one of those salutary measures
which we are entitled to exact." In cognate spirit the
municipal services were unified and at the same time re-
formed throughout the Peninsula ; "while," continued
Signor Crispi, " we modified the constitution of the Sani-
tary Councils, so as to insure an earnest and an unremit-
ting surveillance over the public health. We restored to
its proper centre — the Home Office — the direction of the
seaboard lazarettos, and by furnishing the chief ports of
the kingdom with the means of precaution and defence,
we established an outpost system to make head against
the importation of disease. By degree and by law of
favor {legge di favore], we assisted the minor commimes
in carrying out their sanitary rehabilitation — an oppor-
tunity of which already more than three hundred have
taken advantage. B\' a modification and extension of
the Bill, enacted for the benefit of Naples, the applica-
tion of which to themselves was craved by some sixty
communes, by considerately evoking and approving
plans of house-reconstruction (piani regolatori) we have
brought to the great cities the blessings of effective re-
sanitation." Nor have more strictly medical reforms
been neglected. " We have reconstituted," said Signor
Crispi, " the whole vaccination service ; we have revised
the Pharmacoptfiia ; and on the frontier towns, as a safe-
guard against epizootic invasion, we have brought up the
the veterinary stations to military efficiency. We have
wrought, in a word, the practical consummation of that
sanitary code whose fundamental idea will prove not the
least title to the love and veneration long earned from
all Italians — whether surviving comrades, or of future
generations — by that soldier of science, of fatherland,
and of freedom, Agostino Bertani. Thus we may pro-
nounce ourselves as on the true path of that sanitary re-
demption for which, not less than the political, Italy was
yearning — a redemption of equal necessity, and certainly
not less of a blessing. An Italy sound in a physical
sense will yield us those vigorous arms which will ferti-

lize her the best — those hardy constitutions which as liv-
ing ramparts will prove her strongest safeguard." The
" youngest of the Great Powers " is to be congratulated
on the enlightened legislation set forth in these eloquent
periods. It will henceforth be her duty to develop, as
well as maintain, the sanitary reforms she has effected,
and to justify in this respect the position she has earned
in the European State-system. — Lancet.

WORK KILLS NO MAN.

From the Harveian Oration delivered at the Royal Col-
lege of Physicians, October 18, 1SS9, by J. E. Pollack,
M.D., F.R.C.P., we quote the following concluding sen-
tences:

I need not say to such an audience as this that work —
the due exercise of every function given to us — kills no
man and shortens no life. The causes are to be found in
what is called our extended civilization. We are no
longer traders to one country, nor for one or two com-
modities; but the telegraph has introduced us into a
widened sphere, and our merchants have investments in
every climate, and enter on risks of a kind so varied that
the knowledge of no one man is sufficient to grasp it.
Hence there are the anxieties of extended speculation,
and a necessary want of the perfect understanding of
each. The knowledge of one kind of trade was formerly
"power," and led to prosperity; now we are playing
games with all the world. Those who are present know
well what part of the organism it is which generally fails
under such pressure. The public sa}- it is brain, but we
know that it is heart — the motor power which Harvey
studied, although, perhaps, he did not foresee to what
pressure a modern civilization and struggle would sub-
ject it.

I have spoken but of the trading class and the specu-
lative class, but all classes of society should learn to
counteract in themselves the depressing agents of excess-
ive worry, and to beware of the race which, once entered
on, may exceed the best of our powers and ruin the ma-
chine.

RESULTS OF VACCINATION.

The opponents of vaccination in England, says Science,
have of late been more active than ever; and as a result
of their activity, a Royal Commissioner has been ap-
pointed, whose duty it shall be to make a full investiga-
tion of the whole subject and submit a report thereon.
Friends of vaccination should welcome such an inquiry,
as the method stands upon such a firm foundation of
facts as to be able to stand the most searching examina-
tion. If it has not accomplished all that is claimed for
it, the failure is due to insufficient or inefficient perform-
ance of the operation, and the sooner such abuse of it is
made public the better. It is a rather remarkable coin-
cidence that just at this time events should transpire at
Sheffield, Eng., which show the value of vaccination.
Small-pox has recently been very prevalent in that city.
In a population of about 320,000 there have been 6,088
cases of the disease, of which number 590 proved fatal.
Dr. Barry, who has made a report to the local Go\ern-
ment Board, finds that the attack rate of the vaccinated

750

TOPICS OF THE WEEK.

[November 23,

childreu under lo was five in i,ooo; of the unvaccinated
of the same age, loi in i,ooo. The death-rates for the
same classes were respectively .oq and 44. In every
1,000,000 of those twice vaccinated there were eight
deaths; once vaccinated, 100 deaths; and unvaccinated,
5,100 deaths. — The Druggists' Gazelle.

THE DE.\TH OF IS.'VAC E. TAYLOR, M.D.

We have received from the New York State Medical
Association the following transcript from its minutes :

The Council of the New York State Medical Associa-
tion sadl\- records its unfeigned sorrow for the loss of a
valued founder, fellow and late president, endeared by
his personal qualities as he was admired for his scientific
attainments.

An illustrious name is transferred from the active list
to the roll of honor of those who have bravely borne
themselves in, the foremost rank and fallen triumphant.

Untiring in industry, wise in counsel, affectionate in
friendship, steadfast in religious faith, beloved bj- his
associates and revered by the profession which acknowl-
edged him as one of its leaders, Isaac E. Taylor lived an
example for emulation by his survivors and successors,
and rests from his labor, leaving a reputation unassailed
by enmity and beyond the reach of jealousy.

By the Council,

John G. Orton, M.D., President.
E. D. Ferguson, M.D., Secretary.

■AXGLO-.A.MERICAN VIENNA MEDICAL ASSOCIATION."

A meeting of British and American physicians was
held recentl3' at Vienna to consider the question of estab-
lishing an association for the purpose of furnishing all
needed information to English-speaking medical men
coming to study in Vienna. A large proportion of those
now in the city were present, and it was resolved to start
such an association, under the title of the "Anglo-Ameri-
can Vienna Medical Association." A committee of man-
agement was appointed, whose chief duty will be to sup-
ply- information to newcomers on their arrival as to ma-
triculation, medical courses, lodgings, etc., and, when
necessary, to call meetings of the Association. The com-
mittee, on the occurrence of vacancies in their number
through members leaving Vienna, will fill these up as
soon as possible. The office of the Association will be
at No. 12 Landesgerichts Strasse. It was agreed that
membership should be open to any British or American
ph3sician or medical student on payment of an entrance
fee of one gulden. Letters of inquiry, addressed to the
President or Secretary, will at once receive attention. —
The Lancet.

IMMUNITY AG.\INST ANTHR.\X.

The question of immunity against infectious diseases
is the question of the day. In many bacteriological lab-
oratories experimenters are working at that subject with
varying success. Since Pasteur's first publication on pre-
ventive inoculation against cholera of fowl, roiiget, an-
thrax and rabies, numerous experimenters have con-
firmed his statements, and the practical value of such
preventive inoculations has now been abundantly proved.

The whole subject, however, is still in its infancy, for
the way in which immunity is produced — the mechanism
of immunity, to borrow Professor Bouchard's happj' ex-
pression— is by no means clear. M. Pasteur, two years
ago, in a letter to M. Duclaux, suggested that immunity
against rabies in patients who had undergone his preven-
tive treatment might be due to a chemical vaccinating
substance secreted by the microorganism of rabies. There
are many facts in favor of this theory, though unfortu-
nately its truth has never been conclusively demonstrated.

In 1S87, Messrs. Salmon and Smith showed that if a
culture of the bacillus of hog cholera, after being steri-
lized bj- heat (58° C.\ was injected into an animal, the
latter acquired an artificial immunity against the bacillus
of hog cholera, so that when the living microorganisms
were injected they produced no symptoms. The demon-
stration of chemical vaccinating substances was not alto-
gether satisfactory until Charrin, in the same year, proved
that the introduction of a heated and filtered culture of
the bacillus pyocyaneus protected rabbits against the
inoculation of the living bacillus pyocyaneus. Roux and
Chamberland shorth- afterwards proved this to be true
for malignant cedema, whilst Chantemesse and Vidal were
able, b3' using a similar method, to protect mice against
the evil effects of the typhoid bacillus. The experiments
of the lamented Dr. Wooldridge on anthrax are also of
the greatest importance, as showing the protective power
of chemical substances.

The latest contribution to our knowledge of immunitj-
is the paper b}- Mr. E. H. H.\nkin, in this week's num-
ber o( ihe Journal. Mr. Hankin claims to have prepared
from the cultures of anthrax an albumose which, when in-
jected into mice or rabbits, protects these animals against
the action of the anthrax bacillus. Mr. Hankin's experi-
ments were made under the guidance of Professor Koch, at
Berlin and, as far as thej' go, appear to warrant us in think-
ing that he has discovered an improved method of vacci-
nating against anthrax. We must wait for a full account
of all his experiments, to enable us to form an opinion
as to the practical value of his work, but its scientific
interest will be at once evident.

Mr. Hankin concludes his paper b)- a .series of con-
clusions which are rather suggested than proved by the
facts he has published up to the present date. As his
paper is only a preliminary account of his investigations,
we must reserve further remarks until we are in posses-
sion of all the data on which his conclusions are based.
— Editorial in British Med. Journal.

THE HOSPITAL BULLETIN

The trustees of the Johns Hopkins Hospital have au-
thorized the issue of a monthly publication to be known
as the Hospital Bulletin. It will contain announcements
of cour.ses of lectures, programmes of clinical and patho-
logical study, details of hospital and dispensary practice,
abstracts of papers read and other proceedings of the
Medical Society of the Hospital, reports of lectures and
all other matters of general interest in connection with
the work of the Hospital. Nine numbers will be issued
annually. The subscription price will be *i. Subscrip-
tions may be sent to the publication agency of the Johns
Hopkins University, Baltimore, Md. — Maryland Medi-
cal Journal.

iSSg.]

PRACTICAL NOTES.

751

PRACTICAL NOTES.

THE INFLUENCE OF THE NERVOUS SYSTEM ON
RENAL FUNCTION.

The Lancet gives an abstract of Dr. Francesco
Spallitta's experiments, made with the view of
ascertaining whether the effects produced on the
renal secretion by lesions of the medulla oblongata
are due, as held by Ustimowitsch, Heidenhain
and B. Sachs, to the alteration of the blood-
pressure caused by the lesion, or, as supposed by
Eckhard, to some morbid change in the innerva-
tion of the kidnej-. The plan adopted was to
cut through the spinal cord at various levels, and
to watch the effect upon the secretion of urine.

In order to be certain that the urine found in
the bladder at the necropsy was secreted after the
spinal cord had been cut, a solution of iodide of
potassium was injected under the skin after the
operation, and the urine tested for iodine. The
results obtained were as follows :

1. Lesions of the cord at the base of the first
dorsal vertebra produce no changes in the renal
secretion.

2. Sections at the seventh cervical and first
dorsal vertebra permit the continuance of the
secretion.

3. Sections at the sixth, fifth or fourth cervical
vertebra allow the secretion to continue, but cause
the urine to contain a certain amount of albumen.

4. Sections at the third or fourth cervical verte-
bra arrest the secretion altogether.

5. Electrical stimuli applied to the cord in the
cervical region arrest the secretion entirely'.

The theory which seems to Dr. Spallitta to ac-
cord best with these facts is, that the effect on the
renal secretion of lesions of the cord is mainly
due to the destruction of special ner\'ous fibrillae
existing in the cord which govern the function of
secretion of urine. — Canada [.ancet.

TRE.\TMENT OF SPR.VINS.

It may be observed that a sprain is frequently
treated with a liniment advised by physicians.
It is, indeed, painful to see a phj-sician writing a
prescription for a sprain. There are but two in-
dications in the treatment of sprains : i . To pro-
voke rapid absorption of the fluid effused around
and within the joint ; and 2, to favor cicatriza-
tion of the torn parts hy immobilizing the articu-
lation. Xow, the modes of treatment hitherto in
vogue do not fulfil these two indications. Ma.s-
sage would seem to present some real advantages,
but it can be of little service in the case of severe
sprains, and mild injuries would probably do as
well under rest alone. An elastic bandage, the
depres.sed parts being covered with a layer of cot-
ton so as to prevent too great pressure over the
prominence, and therebj- causing sloughs, will
meet the first indication, and by its use in procur-

ing rest it will meet the second indication. This
bandage acts like massage in promoting absorp-
tion, and also secures immobility of the joint.
It is of equal service in sprains complicated with
rupture of points of insertion, whereas massage
would be productive of harm in ca.ses in which
splinters of bone were torn away. The practice
of relieving the mind of the patient by giving
him something to do in the way of applying
bad-smelling linaments is a pernicious one, and
really shows an unprofessional or unscientific
attendant.

THE CONDITIONS OF INTRA-UTERINE INFECTION.

Infection of the foetus before birth is a recog-
nized fact, but it is, perhaps, too readily assumed
that infective material ma}' pass from the ma-
ternal into the foetal blood by the normal chan-
nels of embryonic imtrition. Dr. Romeo Mangeri,
of Catania, believes this to be impossible. As
the result of wide study of the literature
of the subject and of original experiments,
he has come to the conclusion that no formed
elements naturally pass out of the mother's
blood into the foetal circulation. Cinnabar, In-
dian ink, carmine, and other materials were in-
jected into the jugular veins of animals advanced
in pregnancy, but in no case could any trace of
the substance employed for experiment be found
in the foetus. Passage of formed elements can
only occur when the maternal placenta becomes
diseased by inflammation, haemorrhages, etc. ; so
that the walls of the villi are destroyed. Only
under these conditions can septic or specific
organisms pass from the mother into the blood of
the foetus.

EATING BEFORE SLEEPING.

A recent writer says that the view that brain
workers should go supperless to bed is not good
advice. Most medical authorities of the day
think it wrong. It is a fruitful source of in-
somnia and neurasthenia. The brain becomes
exhausted by its evening work, and demands
rest and refreshment of its wasted tissues, not by
indigestible salads and "fried abominations,"
but by some nutritious, easily digested and as-
similated articles. A bowl of stale bread and
milk, of rice, or some other farinaceous food,
with milk or hot soup, would be more to the pur-
pose. Any of these would insure a sound night's
sleep, from which the man would awaken re-
freshed.

HEADACHES FROM ALCOHOL .\ND TOBACCO.

Dr. E. Lloyd Hughes recommends the fol-
lowing formula in headache from abuse of alco-
hol and tobacco :

B. Spir. ,\mmon. aromat f 3ss.

Spir. Chloroformi mx.

Aquam ad f ,^j.

S. — At one dose.

752

SOCIETY PROCEEDINGS.

[November 23,

SOCIETY PROCEEDINGS.

Medical Society of tlie District of Columbia.

Stated Meeting, March 2j, i88g.

Dr. S. C. Busey, President Pro Tem.

Dr. Robert T. Edes presented a specimen
and history of an

enlarged prostate gland.

The patient was a man set. 76, very corpulent,
of excellent habits in earlj' life, but of late j'ears
using a great deal of alcohol. In October, 1887,
he consulted a surgeon in London for urinary
trouble, and since that time has been constantlj'
attended by a male nurse, who has used the
catheter at intervals, usually of from two to three
hours in the night, but sometimes considerably
longer. He has had several attacks of haematu-
ria, attended with fever, and in the intervals the
urine has been profuse and purulent, but seldom
ammoniacal. He failed gradually without any
very marked new symptoms except increasing
stupor but not coma, until shortly before death.
After death the prostate was found greatly en-
larged in all directions, and, in addition, the mid-
dle lobe stood up as a distinct tumor in front of
the internal orifice of the urethra. In this neigh-
borhood there was much congestion and ecchy-
mosis, being probably the seat of the heemorrhage.
The urethra, through the prostate, was of full
size, and an instrument could be readily passed.
The ureters were somewhat dilated, and also the
pelves of the kidneys. The secreting substance
of the kidneys was but slighth- encroached upon.
The surface was somewhat granular, and thej'
presented to the naked eye the appearance of
fatty degeneration in patches.

Dr. Smith had presented a specimen some
years ago resembling that reported by Dr. Edes
to-night. It was an enlarged prostate and over
100 calculi were found in the bladder. An aged
colored man was taken on the street with a desire
to urinate, but could not. A physician passed a
catheter and a profuse haemorrhage followed.
Dr. Smith was then sent for and found him suffer-
ing greatly from an inability to pass water. The
bladder was distended and painful to pressure.
It was with difficulty that he passed a catheter.
Bloody urine was withdrawn and the bladder
washed out. Some time after the man suddenly
died, and at the post-mortem the prostate gland
was found to be very much enlarged and there
was a tear in the prostatic urethra.

Dr. J. Ford Thompson: If the diagnosis
could be made he preferred Harrison's operation.
Such patients usually suffer, from time to time,
from the obstruction, and there is probably some
dilatation of the ureters. In such cases he would

perform the median operation, puncture the blad-
der and remove the middle lobe of the prostate
gland ; or the same result could be accomplished
by epicystotomy. He thought that complete ex-
cision would have cured Dr. Edes' patient. Much
smaller enlargements would obstruct the flow,
and excision would be advisable.

Dr. Edes : There had never been any reten-
tion of urine in the case, and the man had seldom
gone more than four hours without having his
urine drawn with the catheter, as he had a con-
stant attendant for that purpose.

Dr. J. Ford Thompson presented a limb am-
putated for

ARTHRITIS OF THE RIGHT KNEE.

Sarah Pinn, ast. 12, colored ; father living,
mother dead, cause of death not known. The
patient was well up to one year ago, when she
fell and injured her right knee. After a day or
so she experienced no trouble until February,
1888, when it was noticed that her right knee
was somewhat larger than the left, and she also
complained of pain when walking. Her knee
gfraduall}' grew larger until her admission to the
hospital, September i, 1888.

Present condition : General health seems to be
good and she has the appearance of being well
nourished. Physical examination of knee shows
it to be about as large again as normal. On pal-
pation she complains of pain on the inner side
and a little below the joint.

October 14 — Complains of great pain in knee.
Was given morphia sulph. daily. Slight fluctua-
tion can be detected on outer side, just above
head of fibula.

October 16 — Patient was anaesthetized and an
incision made over the knee joint, beginning just
below the internal condyle of femur and passing
anteriorly across the middle of the patella to a
point corresponding on the outer side of the joint.
The patella was then sawn through and the leg
forcibly fixed on the thigh, which exposed the
articular surfaces of the tibia and femur. The
articular cartilages of the tibia were entirelj' gone
and those of the femur so much diseased that
they were removed with a saw. The internal tis-
sues of the joint were extensively diseased and
were all removed, including ligaments, leaving
the posterior ligament intact. A thin slice of ar-
ticular surface was removed by saw. After de-
nuding the articular surface of the tibia the
wound was irrigated with carbolic sol. 1-60. Two
drainage tubes were then inserted with counter-
openings above the knee externally and posteri-
orly. The denuded surfaces of tibia and femur
were then brought in apposition and held by two
silver wire sutures. After this the patella was
wired together and the wound closed with six silk-
worm gut sutures. The leg was then dre.'wed
antiseptically and placed in a plaster case.

1889.]

SOCIETY PROCEEDINGS.

753

October 17. — Owing to the fact that there was
considerable oozing after the operation the dress-
ings were removed and carbolized water injected
to check the hfemorrhage. It was again dressed
antiseptically.

October 22. — Drainage tubes removed; general
condition much better, but no evidence of union
between the bones.

November i. — General condition good; is gain-
ing flesh.

December i. — Patient not doing so well ; has
two sinuses in knee which discharges bloody-
looking pus. Temperature is of a hectic type.

January i, 1889. — No evidence of union be-
tween the bones.

January 15. — Patient was ansesthetized and a
semi-lunar incision made across the anterior sur-
face of the knee just below the patella. The leg
was then fixed, as in the first operation, and the
softened tissue around the joint all removed with
a sharp spoon. The wound was then closed with
six silver wire sutures, dressed antiseptically and
placed in a plaster case.

January 16. — Has been no evidence of shock ;
patient in good condition.

Februar>' 24. — Plaster cast removed ; still no
union between the bones ; temperature continues
to be of a hectic type.

March 10. — Is loosing flesh rapidly.

March 26. — At a consultation held the follow-
ing physicians were present: Drs. Lovejoy, King,
Johnston and Thompson. It was decided to am-
putate the limb immediately. The patient being
anaesthetized, the limb was amputated just above
the condyles (Long anterior flap method). The
stump was dressed antiseptically and patient put
in bed.

April 2. — Dressings removed ; nearly all of the
flap has united by first intention ; general condi-
tion and appetite good.

Dr. Thompson had referred to this case at the
last meeting, and had said that he thought am-
putation would be necessary'. At a meeting of
the Consulting Staff" of the Children's Ho-spital,
held March 26, it was unanimously decided to
amputate at once in order to give the girl the
best chance of life. Dr. L,amb would present a
section of the knee-joint at some future time.

Tri-8tate Medical Association.

First Annual Meetmg , held at Chattanooga, Tenn.,
October 75 and 16, iSSg.

(Concluded from page yi6.)

Dr. Cooper Holtzclaw read a paper entitled

REPORT OF TWO CASES OF LAPAROTOMY, WITH A
SPECIMEN.

Case I. — Female, married, aet. 20. History of

pelvic cellulitis two or three years previous, fol-
lowed by ascites which was evacuated several
times. Uterus immovable, tumor size of a hen's
egg, to right of Douglas' cul-de-sac and in rec-
tum, gut painful to touch and on defecation.

Diagnosis : Ovarian cystic degeneration. L,ap-
arotomy June 8, 1888. Both tubes and ovaries
adherent to all contiguous tissues. As many ad-
hesions as possible were broken up and diseased
tissue removed. Recovery slow ; at present date
good health.

Case 2. — Female, set. 19, unmarried. Historj':
January i, 1888, noticed small floating tumor in
the right iliac region, which gradually grew lar-
ger until she was as a woman at full term ; con-
siderable dyspnoea, irregular menstruation, ano-
rexia, emaciation; xyphoid cartilage dislocated
and painful ; uterus normal; urine normal; heart
normal but rapid and weak. Diagnosis: parova-
rian cyst. L,aparotoniy October i, 1889. Re-
moved large sac containing 2 gallons of fluid and
colloid substance ; pedicle small, short, and at-
tached to parovary. Patient discharged on fif-
teenth day.

Dr. J. F. IvYNCH, of Chattanooga, read a

report of A CASE OF LAPAROTOMY.

The patient was a widow get. 35. Had been
an invalid for 3'ears. The operation was per-
formed for pyosalpinx, which was ruptured in
the attempt to break down the extensive adhe-
sions and its contents emptied into the abdominal
cavity. After the operation the abdomen became
fearfully distended by an accumulation of gas in
the intestines. To relieve this condition teaspoon-
ful doses of Epsom salts were given everj^ hour,
enemata of turpentine and asafcetida were admin-
istered, and a tube passed some distance up the
rectum through which numerous injections were
given. Gas continued to accumulate and, hav-
ing exhausted all means of relieving the disten-
sion, Dr, Lynch feared intestinal obstruction, and
was preparing to operate again when, in the after-
noon of the fifth day, she had a copious action
from the bowels and the distension disappeared.
The operation was performed under strict anti-
septic precautions. The patient has entirely re-
covered.

These papers were discussed by Drs. G. A.
Baxter, R. J. Trippe and W. C. Townes.

Dr. Trippe related a case of ovariotomj' of Dr.
J. B. Cowan's. Cystic tumor of the right ovarj-
in a woman set. 25, single, domestic. Abdomen
very much enlarged but symmetrical. Aspiration
of a semi-solid, amber-colored fluid. The diagno-
sis of cystic tumor of the ovary was made, for
which the doctors operated. A multilocular cyst
of the right ovarj- was found, which was removed
with the tube. Two of the cysts had been rup-
tured and it was estimated that there was 100 lbs.
of fluid in the peritoneal cavit3-. The patient had

754

FOREIGN CORRESPONDENCE.

[November 23

an uninterrupted recover^' and was allowed to go
out of the room in three weeks. She has re-
mained well since and is earning her own living.
He also reported a case in which he had performed
laparotomj- for stab-wound of the abdomen on a
man set. 38, in wBich the transverse colon was in-
cised in two places. The incisions in the gut
were oblique. There was an escape of fsecal mat-
ter from the wounds, which were stitched with
catgut. The intestines had protruded from the
wound and had got in the mud, and afterwards
been covered with a blanket which had been used
for dogs to lie on. The exposure had been for
about an hour. The incision in the abdomen was
closed with a three line suture. The next day
there was a temperature of 101.5°, which lasted
but a .short time. The man was up in two weeks.

Dr. Frank Trester Smith, of Chattanooga,
read a paper entitled, Report of a Case of Persis-
tent Pupillary Membrane. The paper was illus-
trated with a drawing. No treatment was recom-
mended.

Dr. Reeves a.sked if the condition might not
be due to the result of an inflammation ?

Dr. Smith said that it was possible, but that
the inflammation must have occurred in ntero, as
there was no structure other than the pupillarj-
membrane that would leave a gprayish substance
on the capsule of the lens with threads running
to the anterior surface of the iris and attached to
the circulus iridis major, as in the case presented.

Dr. Max Thorner agreed that no treatment
was indicated and no other diagnosis possible
from the description of the case. He related a
case which he had seen in which an operation
was attempted but the result was not encouraging.

Dr. James E. Reeves read the original account
of Ephraim McDowell' s First Ovariotomy .

In an omnibus discussion which followed the
subject of hypnotism came up and was discussed
by Drs. G. W. Drake, J. M. Heard, W. C. Townes,
G. A. Baxter and R. D. Boyd.

After the transaction of miscellaneous business
the Association adjourned to meet again in Chat-
tanooga, October 21, 1890.

FOREIGN CORRESPONDENCE.

LETTER FROM PARIS.

(FROM OUR REGULAR CORRESPONDENT.)

Dr. Du Castel 071 Hie Treatment of Chronic Blcn-
orrhagia — M. Chauvean on Transformism in Mi-
cro-Biology — Dr. Clado takes up the Question
Whether the Liquids contained in the Herniary
Sac should contain Toxic or Irritating Matters :'

My letter in The Journal of August 3d last
contains a note of Dr. Du Castel on the antisep-
tic treatment of blenorrhagia in its acute stage.

I now forward another note by the same author
on the treatment of chronic blenorrhagia. This
note is the summary of a clinical lecture delivered
by the author at the Hopital du Midi, and which
is of some importance owing to the experience
acquired by him. After having tried a great
number of medications for this affection. Dr. Du
Castel has been led to the following conclusions :
Internal medication, so useful in acute cases, has
a verj' contestable action on blenorrhoea. The
balsamics have appeared to be of some utility, but
the mode of administration differs ; it is no longer
in high doses that they are administered, but in
small quantity and during a long time. The ver-
itable treatment of chronic blenorrhagia is the
local treatment. According to the experience of
Dr. Du Castel, the porte-caustic of Lallemand, the
topical remedies applied directly to the mucous
membrane b^' means of the endoscopic tube, as
also the medicamentous bougies and sprays, have
given certain results, but which appeared to him
inferior means as compared with the current
methods, injections, lavages and instillations.
The two first therapeutic means are chiefly indi-
cated in acute blenorrhagia, lavages appear more
efiicacious than simple injections, but the\' are of
more difiicult application. The solutions should
be relatively concentrated ; the caustic substances,
such as the injection that bears the name of Ri-
cord, or that of the three sulphates, are the most
efficacious. As regards the antiseptic substances,
they do not act so well as in acute urethritis. Of
all the agents employed locally, instillations de-
ser\-e the preference. As regards the solutions,
those of the nitrite of silver produce a cauteriza-
tion to the degree necessary to modify- the mucous
membrane : the strength of i to 50 parts often
suffices. This is the method practiced by Pro-
fessor Guj^on which Dr. Du Castel has adopted,
after having tried a great number of other means.
At a recent meeting of the Academy of Sci-
ences M. Chauvean, the well known veterinarian,
made an important communication on transform-

; ism in microbiology, in taking, for example, the
limits, the conditions and the consequences of the
variability of the "bacillus anthracis." It re-
sults from the researches of the learned experi-
menter that, thanks to the persistence of the ac-
tion of compressed oxygen on the cultures of the
bacillus anthracis in course of development, one
succeeds in creating races or types of less resist-

' ance than the primar)- bacillus, and which are
particularly .sensible to the influence of the atten-
uating agent which had procured for the bacillus
its new properties. If this influence of the atten-
uating agent is prolonged, the new types lose the
aptitude of vegetating in its contact. But, as
long as the bacillus does not pass the limits of
vegetability, it remains in the domain of patho-
genic agents. It loses, it is true, all virulent
property, but it preser\-es integrally the vaccinal

1889.]

DOMESTIC CORRESPONDENCE.

755

property and preserves it almost intact during the
whole duration of its existence. These new char-
acters are fixed and are easily entertained by cul-
ture in successive generations. Thus, in consid-
ering these types in themselves, without taking
into account their origin, they may be regarded
as forming one distinct species. It would not be
impossible that the special types of the bacillus
anthracis exist in nature with properties abso-
lutely identical with those of the created races,
and entertained in the laboratory.

In a memoir published in 1861, Prof. Verneuil
emitted the idea that the liquids contained in the
herniary sac should contain toxic or irritating
matters. In 1867 he caused the contents of a
herniary sac to be examined by Dr. Nepven, who
found micrococci. At one of the sittings of the
last Congress of Surgery, Dr. Clado, of Paris,
took up the question. A man aged about 30
years, vigorous, and the subject of a reducible
congenital hernia, was admitted into the Pitie
Hospital with the signs of a strangulated hernia.
He was operated on on the following day, sixteen
hours after the commencement of the accidents.
The temperature of the body was 36° C. at the
time of the operation. Death took place one hour
after. In the contents of the sac, examined im-
mediately, there were found numerous bacteria,
mobile, with which he made some cultures.
These bacteria were found again the next day in
the blood, the peritoneal serosity of the patient,
and in the incisions made in the viscera (the
spleen and the lungs). In the strangulated
knuckle there were the same microbes as in the
glands, the blood-ves.sels and lymphatics. The
cultures furnished one special bacterium, which,
cultivated at 28° C, proved to be inoffensive,
whereas when cultivated between 37° C. and 40°
C, it becomes mortal in a few hours. The inoc-
ulation of the blood of the patient produces the
death of animals in a very short time. In fine,
the inoculation with the serosity or with the
blood of animals caused death in series. The
microbe proved itself particularly pathogenic for
the guinea-pig and the rabbit. In the dog it pro-
duced vomiting, inappetence, followed by com-
plete recovery. The bacterium multiplied itself
with astonishing rapidity in the organism of the
animals. To explain the cause of death, partic-
ularly rapid death, in cases of hernia, nervous
exhaustion was suggested, the constriction of the
filaments of the great sympathetic nerve, the over-
distension of the abdomen with gas, visceral con-
gestion, particularly of the lungs, finally stercor-
haemia. Dr. Clado explains death in strangu-
lated hernia by the penetration into the economy
of a bacterium having for its starting point the
surface of the intestine. Visceral congestions,
frequently observed, are the result of the locali-
zation of the bacteria in the viscera, and particu-
larly in the lungs. Herniar>^ peritonitis and gen-

eralized peritonitis without opening in the intes-
tine are the result of the migration, through the
intestinal pariet)', of the bacteria into the peri-
toneum. Dr. Clado admits that the distension
of the intestinal knuckle b}' gas pushes these mi-
crobes into the thickness of the ulcerated mucous
membrane. a. b.

DOMESTIC CORRESPONDENCE.

" Professioual Oi-ganizatlon.''''

To the Editor: — Your editorial of September
28th on "Professional Organization" is not likely
to be without a response from the many physicians
whom it concerns. This is the age of organiza-
tions, and while every true member of the medi-
cal profession would decry an association having
for its chief aim the selfish advancement of the
individual or a favored few, yet we all have a
right to urge that which will bring the members
of our guild into closer relationship.

For many years the American Medical Associa-
tion has stood, in numbers and importance, far
beyond anj' other ; but now we have new organi-
zations which, though they may never rival the
national body, are yet representative and growing
larger each year. These societies, it seems to
me, are midway in the large distance which lies
between the American Medical and the State
associations, and are composed mainly of men
who are members of both.

These district societies are well organized and are
sure to continue. The question to be answered
is, shall their interests and that of the American
Medical Association be united ? That such union
would be of mutual advantage seems apparent for
several reasons.

1 . As already suggested, a better system of col-
lective investigation of disease could be insti-
tuted.

2. Questions which cannot fully be discussed in
the American Medical Association, for want of
time, could be referred to one of the branches.
This could be well done where questions arise
pertaining to variations of disease peculiar to cer-
tain latitudes or geographical sections.

3. The Journal of the Association would, b}-
the adoption of some such plan as suggested in the
editorial referred to, be strengthened and become
even more than at present the representative na-
tional journal.

4. There would be a better union and closer fel-
lowship among the members of the different so-
cieties, manj' of whom are unable to attend the
American Medical Association legularly.

Possibly five branches might be formed, one in
New England, one in the Middle States, another
in the South, and one on the Pacific coast, while
the Mississippi Valley Medical Association could

756

BOOK REVIEWS.

[November 23,

easily represent the territory implied by its name.
There is strength in the very thought of such a
wide-reaching organization. At the national
meeting and its branches we can have each year
a registration of 10,000 physicians as easily as we
now have one-fifth of that number.

It seems to me that, in justice to the thousands
of physicians in America, as welfas for the best
interests of the American Medical Association,
this question should be thoroughly discussed.
Respectfully,

Wm. Porter.

St. Louis, November 12, 1SS9.

BOOK REVIEWS.

Diseases of Women . A Manual of Non-Sur-
gical Gynecology Designed Especially for Stu-
dents and General Practitioners. By F. H.
D.WENPORT, A.B., M.D., Assistant in Gyne-
cology, Harvard Medical School ; Assistant
Surgeon to the Free Hospital for Women, Bos-
ton, etc. With 105 Illustrations. Octavo, pp.
xiv, 292. Philadelphia: L,ea Bros. & Co. 1889.

In this modest volume the author has endeav-
ored to set before the student the elementary prin-
ciples of the methods of gynecological examina-
tion, together with the simple forms of treating
the most common diseases of the pelvic organs,
and to assist the general practitioner in under-
standing and treating the gynecological cases of
his everyday practice. Surgical gynecology and
pathological anatomy have been omitted, for the
most part, with a view to make room for a de-
scription of many minor points which are often
wanting in other works. It is not too much to
say that the author has carried out his plan in an
admirable manner, with the result of producing a
thoroughly practical and useful work which, while
it commends itself particularly to the beginner,
contains much of value to the practical gynecol-
ogist ; thus his chapter on " Displacements of the
Uterus," which includes the methods of diagno-
sis, the use of the probe, and the instructions for
measuring the vagina and applying pessaries,
would do credit to a very much larger and more
pretentious treatise. The work is certainly a very
attractive one, and is of a character to encourage
the hope that another and enlarged edition will
soon be required.

Transactions ok the Louisiana State Medi-
cal Society, held at New Orleans, April 9,
10 and II, 1889.

The report of the work done by the Louisiana
State Society for the past year speaks well for the
earnestness and zeal of its members. The papers
read were numerous, interesting and varied in

character. Three of the most extensive papers
were read by Dr. Joseph Jones, who discussed at
length the subjects of the care of the insane, the
relations of quarantine to commerce and the ac-
tion of antipyretics in febrile diseases. These are
notable papers and deserve a careful reading. In-
teresting contributions to surgery were made by
Dr. R. Matas on " Multiple Subperiosteal Sarco-
ma of Skull" and " Circular Enterorrhaphy ;"
by Dr. G. B. Lawrason on "Two Cases of Hj^s-
terectomy ; " and by Dr. E. Souchon on "The
Drilling of Capillary Holes through the Skull for
the Purpose of Exploration with the Hypodermic
Needle."

Saunder's Question-Compends, No. i, Es-
SENTIAI.S OF Physiology. Arranged in the
form of questions and answers ; prepared espec-
ially for students of medicine by H. A. Hare.
B.Sc, M.D., Dem. of Ther. and Instructor in
Physical Diagnosis in the Univ. of Penn., etc.,
etc. Second edition, revised and enlarged ;
pp. X, 193. Philadelphia : W. B. Saunders.
London : Henry Renshaw. Melbourne : Geo.
Robertson & Co. 1889.

While open to manj' of the criticisms which
assail medical compends designed for students,
this little work is deser\dng of much praise as
being a very excellent one of its class. Students
no doubt often abuse themselves by doing super-
ficial work and glossing over their real ignorance
with a little of the more easily acquired knowl-
edge ; but, nevertheless, if properlj- used such
books may be made to greatly lighten the tasks
of the already overburdened under-graduate.
We do not hesitate to pronounce this such a
book. Not the least of its many excellencies is
the admirable selection of the illustrations, which
are uniformly above reproach both in accurac}' of
design and mechanical execution.

Transactions of the Iowa State Medical
Society. Vol. VII, 1886- 1889.

This volume of Transactions covers the work
done b}' the Society in four years. It comprises
sixty-one papers, nearly all of which maj' be said
to be rather meagre, as may be judged by the fact
that they find plenty of room in a book of only
564 pages. The work accomplished is verj- good
as far as it goes, but the Society evidently needs
tonic treatment to prevent premature decay. From
such a magnificent State as Iowa it is not too much
to expect the very best of work.

Physician's Leisure Library — Dyspepsia. By
Frank Woodbury, M.D. Pp. 86. Detroit:
Geo. S. Davis.

This is an excellent thesis reviewing the new-
est knowledge that has been acquired and that is
pertinent to the subject. The book is not a sys-
tematic treati.se but rather a fresh, interesting and

1889.]

NECROIvOGY.

757

suggestive one. Both the symptomatology and
treatment are discussed. Dr. Woodburj' insists
upon defining dyspepsia as a general disease which
is due to poisoning of the system with the prod-
ucts of imperfect digestion and of gastric fermen-
tation. In the closing chapter the subject of di-
etetics for dyspeptics is considered.

The American Armamentarium Chirurgi-
CUM. Imperial 8vo. 1889. New York: George
Tiemann & Co.

We are in receipt of a copy of this finely printed
and handsomely bound volume. It contains 862
pages, 3,400 engravings, and descriptive matter
of surgical instruments and appliances. The
text is fuller than is usually found in trade cata-
logues, and is a credit to the enterprizing firm is-
suing it. The work is supplied to the profession
at about the cost of the binding.

Transactions of the Americal Surgical As-
sociation. Vol. VII. Edited by J. Ewing
Mears, M.D., recorder of the Association.
Philadelphia, 1889.

The elegant typography and binding of this
volume are fully justified by the valuable material
which it contains. Fifteen articles fill the 217
pages of the book. Nine of these are chiefly or
entirely devoted to the reporting of cases, and the
remainder are for the most part systematic studies.

Dr. Stimson advocates the attempt to ligate
separately the arteries in pedicles of abdominal
growths instead of treating the stump as a whole.

An article on digital divulsion of the pylorus
for cicatricial stenosis, by Dr. J. M. Barton, is in-
structive and timely.

Dr. McGraw, of Detroit, contributes to the his-
tory of gunshot wounds of the intestines.

Dr. Maurice H. Richardson reports upon the
surgical treatment of gangrenous hernia in four
cases that he observed.

The papers read before this Association are of
a high order of merit, as would be expected from
ihs personnel of the Society, and the present vol-
ume will be a valuable addition to the surgeon's
library.

Wood's Medical and Surgical Monographs.
Vol. Ill, No. 3, Sept., 1889. William Wood
& Co., publishers, New York.

This number contains the following excellent
monographs: "Congestive Neurasthenia or Nerve
Depression," by E. G. Whittle, M.D.; "The Art
of Embalming," by Benj. Ward Richardson,
M.D.; " The Etiology, Diagnosis and Treatment
of Tuberculosis," by Dr. H. von Ziemssen; "Psy-
cho-Therapeutics, or Treatment by Hypnotism,"
by Dr. C. Lloyd Tuckey; "Sexual Activity and
the Critical Period in Man and Woman," by Dr.
lyouis DeS6re.

NECROLOGY.

Mr. George Buck.

The Chicago College of Pharmacy announces
with regret the death of its President, Mr. George
Buck, of the firm of Buck & Raynor.

Mr. Buck was born in Rochester, England, in
1827, and previous to coming to the United States
had received a thorough training in pharmacy.
Arriving in New York in the summer of 1855 he
was engaged for J. H. Reid & Co., then the lead-
ing retail firm in Chicago. He remained with
this firm as prescription clerk until 1859, when,
with Mr. Raynor, also an employe of J. H. Reid
& Co., he started in business near the corner of
Clark and Washington streets, then a residence
neighborhood. The early success and continued
prosperity of the firm were due largely to the ad-
mitted competency and integrity of its members.

Mr. Buck was an early and consistent advocate
of thorough pharmaceutical education, being one
of the charter members of this college and having
from the first taken a prominent part in its man-
agement. He was also prominent in the move-
ment to secure for Illinois the enactment of a
pharmacy law, his efforts in that direction dating
from 1870, ten years before a law was finally se-
cured.

He was the first president of the State Board
of Pharmacy, and had been president of this col-
lege continuously since 1886.

He was widely known and universally respect-
ed, both by the profession and the people, as a
man of high moral worth and sterling integrity,
and his death is universally regretted,

Chicago, October 7, 1S89.

Dr. James W. Kei-r.

Dr. James W. Kerr died at his residence in
York, P., on Monday June 10, 1889, in the 76th
year of his age. He was born in Lancaster
County, Pa., and graduated in medicine at the
University of Pennsylvania in 1840. He was an
Assistant Surgeon in the late war, and a mem-
ber of the American Medical Association since
1848. J- s- M.

j Dr. Alexander R. Blair.

; Dr. Alexander R. Blair died at his resi-
! dence in York, Pa., on Thursday, July 16, 1889,
in the 63d year of bis age. He was born in
Lancaster County, Pa., and received his degree
of M.D. from the Jefferson Medical College,
Philadelphia, in 1853. Dr. Kerr and Dr. Blair
were the organizers of the York County Medical
Society and members of it at their death. They
were members of the State Medical Society. Dr.
Blair joined the American Medical Association in
1858. He also ser\'ed as Assistant Surgeon dur-
I ing the late war. !• S. m.

758

MISCELLANY.

[November 23, 1889. 5

MISCELLANY.

Paris Exhibition. — Wm. R. Warner & Co., the well-
known manufacturing pharmacists of Philadelphia, were
awarded a silver medal at the Paris World's Fair iu recog-
nition of the excellence of their pills and effervescent
salts. This is the thirteenth World's Fair medal that
Warner & Co. have received.

He.\lth in Michigan. — For the month of October,
i88g, compared with the preceding month, the reports
indicate that scarlet fever, puerperal fever, influenza,
pneumonia, diphtheria, pleuritis and t5'phoid fever in-
creased, and that cholera infantum, cholera morbus, dys-
entery, cerebro-spinal meningitis, diarrhoea and measles
decreased in prevalence.

Compared with the preceding month, the temperature
in the month of October, 1SS9, was much lower, the ab-
solute humidity was considerably less, the relative hu-
midity was slightly less, the day ozone and the night
ozone were less.

Compared with the average for the month of October
in the three years, 1SS6-8S, inflammation of brain, diar-
rhcea, typhoid fever, pneumonia and puerperal fever were
more prevalent, and cerebro spinal meningitis, cholera in-
fantum, membranous croup, diphtheria, erysipelas and
measles were less prevalent in October, 1S89.

For the month of October 1889, compared with the
average of corresponding month in the three years 1886-
'88, the temperature was lower, the absolute humidity, the
relative humidity', and the day and night ozone were less.

Including reports by regular observers and others, diph-
theria was reported present in Michigan in the month of
October, 1889, at 63 places, scarlet fever at 54 places, ty-
phoid fever at 113 places, and measles at 15 places.

Reports from all sources show diphtheria reported at
29 places more, scarlet fever at 34 places more, typhoid
fever at 66 places more, and measles at 8 places more, in
the month of October, 18S9, than in the preceding month.

Chicago ; Dr. E. H. King, West Liberty, la. ; Br. Wm.
Creighton Woodward, Philadelphia ; Dr. A. G. Ochsner,
Chicago; Thomas Leeming & Co., New York; Dr.
Charles H. Haningan, Olympia, Wash.; W. H. Schieffe-
lin & Co., New York ; Henry G. de Forest, Long Island,
N. Y.; Dr. W. B. Anderson,' Rice's Crossing, Tex.; Dr.
A. E. Prince, New York ; Dr. Samuel P. DufEeld, De-
troit, Mich.; Dr. Irving D. Wiltrout, Hudson, Wis.;
Lehn & Fink, New York ; Dr. J. C. Buchanan, Wiuns-
boro, S. C; E. Steiger & Co., New York ; Dr. Charles
E. Davis, Fort Wayne, Ind.; Dr. Wm. D. Babcock, Los
Angeles, Cal.; Dr. J. M. Barrier, lUawara, La.; Medical
& Surgical Sanitarium, Battle Creek, Mich.

LETTERS RECEIVED.

Dr. T.
Denver,

Movius,

D. Crothers, Hartford, Conn.; Dr. G. H. Gibson,
Col. ; Dr. J. W. Emmons, Sparta, Wis. ; Lutz &
New York ; Codman & Shurtleff", Boston ; I.
Haldenstein, New York ; S. R. Niles, Boston ; C. N.
Crittenton, Fairchild Bros. & Foster, New York ; John
H. Berry, Boston ; Dr. \. F. Stifel, Wheeling, West Va.;
Dr. James L. Taylor, Wheelersburg, O.; The Physicians',
Dentists' and Druggists' Insurance Association, Chicago;
Dr. E. Cutter, New York ; Dr. M. C. Farrar, Fort Madi-
son, la.; O. H. Merrill, Corrinna, Me.; Dr. A. L Hum-
mell, Philadelphia ; Dr. W. E. Casselberry, Chicago ; A.
A. Marks, New York ; Dr. H. Judd, Galesburg, 111.; W.
P. Cleary, New York ; Dr. J. H. Maine, Fort Wayne,
Ind.; J. H. Bates, New York ; Dr. John N. Mackenzie,
Baltimore, Md. ; B. Westerman & Co., New York ;
Charles H. Phillips Chemical Co., New York ; William
R. Warner & Co., Philadelphia; Dr. Roeth, Boston;
Gross Medical College, Denver, Col.; Dr. Joseph D.
Couch, Somerville, Mass.; Dr. B. J. Loomis, Marshall-
town, la.; Dr. L. Round, Dighton, Kan.; Dr. E. F. Brush,
Mount Vernon, N. Y.; Dr. J. H. Williams, White Pigeon,
"'i-h.; Dr. P. R. Hardie, Hampton, N. C; Dr. E. M.
Nelsonl'l- I^o"is, Mo.; Dr. F. B. Davidson, Fleetville,

p r j)r. icJ.ph A. White, Richmond, Va. ; Dauchy &

Co New York Dr. Charles C. Browning, New York' ;

,, ''^ R. Amnieian, Colorado City, Col.; Dr. J. T.

Wilson Sherman, i-.; E. B. Treat, New York ; Dr. W.

TVI ilarsha, Decatur,' ; Scott & Bowne, New York ;

rir Henrv O. Marcy, >ston ; Ira Perego & Co., New
York- Dr- L. H. ^Hng, Indianapolis, Ind.; The
Guaranty Investment Cox^ew York; Armour & Co.,

Official List of Changes in the Stations and Duties of
Officers Serving in tlie Medical Departtnent, U. S.
Army, frotn November g, i88g, to Noveviber 15, i88g.

Capt. C. N. B. Macauley, Asst. Surgeon, is granted leave
of absence for one month, to take effect about the 29th
iust. Par. 2, S. O. 166, Dept. of the Missouri, Ft.
Leavenworth, Kan., November 8, 1S89.

The following changes in the stations of medical ofiicers
serving in this Department are hereby made, viz. :

Capt. L. W. Crampton, Asst. Surgeon, from Ft. Lyon,
Col., to Ft. Sheridan, 111.

Capt. W. H. Corbusier, Asst. Surgeon, from Ft. Hays,
Kan., to Ft. Lewis, Col.

First Lieut. F. J. Ives, Asst. Surgeon, from Ft. Lvon,
Col., to Ft. Sill, I. T. Par. 3, S. O. 167, Hdqrs. D'ept.
of the Missouri, Ft. Leavenworth, Kan., November 9,
T889.

By direction of the Secretary of War, Capt. Louis M.
Mans, Asst. Surgeon, having relinquished the leave of
absence on surgeon's certificate of disability granted
him in S. O. 249, October 25, 1889, from this office, will,
upon being relieved from duty at Ft. Porter, N. Y., as
directed in S. O. 242, October 17, 1889, from this office,
proceed without delay to Ft. Stanton, N. M., and re-
port in person to the commanding officer, Dept. of Ari-
zona. Par. 8, S. O. 261, A. G. O., Hdqrs. of the Army,
Washington, November S, 1S89.

By direction of the Secretary of War, the following as-
signments of officers of the Medical Department (re-
cently appointed") are ordered:
First Lieut. Charles Willcos, Asst. Surgeon, will report
to the commanding officer at Ft. Columbus, N. Y., for
duty at that station.
First Lieut. Harlan E. McVay, Asst. Surgeon, now at Ft.
Mackinac, Mich., will report in person to commanding
officer of that post for dut)-.
First Lieut. Euclid B. Frick, Asst. Surgeon, will proceed
from Philadelphia, Pa., to Ft. Keogh, Mont., for duty
at that station.

Official List of Changes of Stations and Duties of Medi-
cal Officers of the U. S. Marine-Hospital Service,
for the Three Weeks Ending November 9, iSSg.

Surgeon George Purviance, granted leave of absence for

twenty-one days. November 8, 1889.
Surgeon H. W. Austin, to inspect unserviceable property

at St. Louis Marine-Hospital. November 4, 1S89.
Surgeon J. M. Gassaway, relieved from duty at New Or-
leans, La.; to rejoin station at Cairo, 111. October 23,

1S89.
P. A. Surgeon C. E. Banks, granted leave of absence for

thirty days. October 28, 18S9.
Asst. Surgeon J. B. Stoner, ordered to Vineyard Haven,

Mass., for temporary- duty. Novembers, 1889.
Asst. Surgeon A. W. Condict, ordered to Cairo, 111., for

temporary duty. November 4, 1SS9.
Asst. Surgeon G. M. Guildras, ordered to Washington,

D. C, for temporarv duty. November 8, 1S89.
Asst. Surgeon J. F. Groenevelt, ordered to New York,

N. Y., for temporary duty. November 5, 18S9.

THE

J ournal of the American Medical Association.

EDITED UNDER THE DIRECTION OF THE BOARD OF TRUSTEES.
PUBLISHED WEEKLY.

Vol. XIII.

CHICAGO, NOVEMBER 30, 1889.

No. 22.

ADDRESSES.

THE AMERICAN ACADEMY OF
MEDICINE ;

ITS OBJECTS ; ITS SIGNS OF PROMISE AND ITS

OBSTACLES ; ITS FIELD OF WORK ; AND

SOME SUGGESTIONS LOOKING TO AN

INCREASE OF ITS EFFICIENCY.

Address of the President delivered at the Annual Meeting in Chicago,
Ills., .\ov. rs. iSSg.

BY LEARTUS CONNOR, A.M., M.D.,

OF DETROIT, MICH.

Fellows of the American Academy of Medicine:
— By one of those strange freaks that make the
action of otherwise clear headed people unac-
countable, 5'OU last j-ear elected me to the office
of 3-our chief sen-ant. As I was unavoidably ab-
sent from the session during which this action
was taken, I did not learn of it until many hours
after you had adjourned. Hence, nothing was
left me other than to endeavor to understand and
execute your wishes. Respecting the outcome of
my ser\-ice you are all in position to judge. The
new plans of operation, proposed bj' Dr. Gerrish
last year and adopted by the Academy, called for
the appointment of several new committees,
whose reports speak for the wisdom of the changes
and the faithful service of these committees. In
general it seems to me that the changes, and the
individuals, who at much personal sacrifice have
rendered them so successful, deserve the full ap-
proval of the Academy.

For the first time in its historj- the Academy
holds a meeting in the West. For the first time,
it comes into personal contact with the mighty
material forces clustering about the great lakes,
the vast rivers of the American Continent, the
boundless prairies, and the pure breezes that
starting far up in the heavens \iy the tops of the
Rockies, sweep for thousands of miles over fertile
plains. For the first time, it gazes upon the
mar\'ellous civilization that has sprung, like
Aladdin's lamp, in the vast garden that is
bounded by the great lakes, the Gulf of Mexico,
the Alleghanies and the Rocky Mountains.
Within this area, is being developed a civiliza-
tion having the largest and most favorable con-
ditions for gigantic growth, untainted by the dis-

turbing influences of Europe or Asia, as the
obstruction of vast mountain chains separate it
from read}- access to the great ferries which ply
the Atlantic and Pacific. Here, if anywhere,
will appear the t}'pical American. Here, if any-
where, will be seen the greatest difierentiation
from all other peoples and races on the earth, and
the most perfect blending of all tj-pes under the
influence of the governing Anglo-Saxon direc-
tion. Here, if anj^where, will be seen the pro-
duct of the richest soil, the most varied climate,
the most perfect air, the purest water, the grand-
est forests, and the most majestic rivers. Here
men and women do and dare all things iu their
efforts to bring under subjection, the countless
natural riches everywhere found in such pro-
fusion. Into this atmosphere, most typically
represented in this its largest city, the American
Academy of Medicine for the first time comes.
That it will grasp some idea of the medical needs
of this superb region, and be able to initiate such
schemes as will result in their early supply, is as-
sured. That the Fellows will better appreciate
the problems before them, see additional grounds
for encouragement, and appreciate more definitely
the obstacles to be met and overcome, is our hope.
Within this vast area is a teeming population,
the parent of millions who within a short time
will occup)- these fat places. The medical pro-
fession throughout it are in a plastic state of de-
velopment. Now, better, than ever after it can
receive and execute lessons of its matchless op-
portunities, and the measures requisite for their
best improvement.

Some have said that the American Academy of
Medicine is founded upon a new idea, a "fad"
born of an aristocratic modern notion. As a fact,
we find that Hippocrates standing at the dawn of
historic medicine, urged earnestly that ' ' the pre-
liminary training of medical men be made as
broad and as deep as possible." Farther, by pre-
cept and example the same idea has been main-
; tained by all the famous medical men from Hip-
pocrates to Alonzo Clark, as was abundantly'
shown in the eloquent and scholarly address of
Dr. George Jackson Fisher, last year. We, the
lineal descendants of the worthies, are simply en-
deavoring to maintain the faith once delivered to
the "fathers," thousands of years ago. Our

760

THE AMERICAN ACADEMY OF MEDICINE. [November 30,

missiou is to galvanize into life, the truth of the
importance and value of a preliminarj' education,
that has become obscured bj^ the overshadowing
influence of commercialism. We strive to aid in
the establishment of such conditions as will en-
sure the possession by everj- medical man of such
general knowledge of literature, science, art and
trade in their broadest as well as narrowest re-
lations, so that he may rank as a real teacher,
companion and friend of the cultured and the un-
cultured. We rejorce that the medical profession
contains large numbers of such men, but the
Academy would have them universal, the rule
not the exception. The change which the attain-
ment of this end -would make, is illustrated bj' the
change which occured in the classes of the
Harvard Medical School during the inter\'al from
1870 to 1880. On the former date it will be re-
membered that this school raised its standard of
preliminary- requirement, and proportionately its
general curriculum. In brief it began to teach
modern medicine in a rational manner. Presi-
dent Elliot in describing this change says : Until
1870 the students in the medical class of Harvard
were noticeably inferior in bearing, in manners,
and in discipline to the students in other depart-
ments ; now they are indistinguishable from other
students." He adds, "a corresponding change
in the medical profession at large would be
effected in twenty years if all the medical schools
of the country would institute a reasonable ex-
amination for admission. Under the present
order of things, the American Physician and
Surgeon ma}' be, and often is, a coarse unculti-
vated person, devoid of intellectual interests out-
side of his own calling, and quite unable to speak
or write his mother tongue with clearness and ac-
curacy." To set into operation agencies which
will enable all medical students to rank with any
other professional students in gentlemanlj' bear-
ing, and supplant the coarse ill bred, ignorant
physician by one who can comprehend the in-
tellectual forces operating in the communitj'
about him, and who can meet on equal terms any
individual who has become possessed with the in-
tellectual training of his time, such is the mis-
sion of the Academ)-.

Then, if ever such a time comes, will the de-
gree of doctor of medicine be an introduction and
passport to any and every class in any communit}'.
Then, medical men will take rank among the
leaders in all things pertaining to the best in-
terests of the communities in which they live.
Until then the physician's diploma avails for
naught except as a license to practice medicine,
in some States. Its general worthlessness be-
comes more and more apparent as State after
State refuses to accept it because of the lack of
uniformity of the knowledge which its possessor
may have acquired. Until a change is brought
about such as the Academy seeks, each doctor

must introduce himself, pass his individual ex-
amination before the guardian Board of the State
in which he desires to live, and before the cul-
tured people in the community among whom he
casts his lot. Having passed these examinations
successfully, he occupies a place in the com-
munity such as his personal merit has won just
as does the blacksmith or farmer. The London
Lancet stated the case as follows ; "If medicine
is to acquire and sustain a high respect for its
membership, such as is given men of science, art
and other professional callings, its membership
must be equipped with all the richer learning
which is required to hold its own in a world that
is dail}' becoming more cultured, and will
certainl}- demand more of its medical advisers.
Its members must have large phj'sical and mental
energy, capacity' for long continued efforts, an
unselfish devotion to their work, and a high
moral life. The practitioner of the future must
know more than his father knew, and know it in
a different manner. Here and there one may
leap over all obstacles, and in spite of unfortunate
antecedents mount to the front rank. But the
vast majorit}' of the medical profession, can reach
that rank onlj' by the most thorough and syste-
matic cultivation of every phj-sical, mental and
moral faculty before they enter upon the study of
medicine. Then if ever the physician must
make the acquaintance of the great world of lit-
erature, philosophy, art, poetry, language, etc.,
which has been growing out of the labors of
countless hosts who have lived, and by their toils
made it possible for us to accomplish more than
they in the short span of human life. At such
time or never the student must master the ob-
jects and forces, beneath the earth's surface,
upon the earth's surface, and above the earth's
surface. By microscope and telescope, and all
other scopes, bj' retort and test tube, by heat,
light, electricity, chemical force and gravitation,
he must follow the great teachers into the re-
vealed mysteries of nature. Only thus can he
come to know something of himself, and of the
human beings whose ills he would learn to pre-
vent, remove or alleviate. Only by such training
can he hope for a manly development, which will
rank him with the best educated men of the
world." To increase the number of those who
shall thus stand as the representatives of medical
science and art, is the crowning glorj- of the
Academy's labors.

But the objection is made such development
will not pay ; it costs too much time, too much
monej'-, for the return in fees. To this I reply
that the history of medical men shows clearly :

I. Those, who enter upon the study and prac-
tice of medicine for the fees they hope to receive,
have made a fatal mistake. They had better, at
once, devote their time and energies to .some call-
ing in which it was possible to accumulate large

1889.]

THE AMERICAN ACADEMY OF MEDICINE.

761

fortunes. The pure tradesmen has no place in [
the temple of medicine more than he has in the
temple of religion, He may don the horse's
skin to cover his own, but the donkey's ears will
stick out and betray him. He ma}- be sure that
at some time the Master will enter and drive from
the Temple " the money changers and those who j
sell doves." |

2. The highest honors, the largest fees, the
most enduring renown, the greatest glory, have,
during all historic time come to such physicians
as have, first and last, sought the uplifting of the
profession to which they belonged. In the
language of the Great teacher "those who have
sought the Kingdom of God, have also had
added to them all other earthl}' things." In
brief it is certain that medical men developed
and equipped as we have desired, would reap the |
very highest fees, the most distinguished honors
that earth can give. We trust that this Academy ;
may in the near future make plain to the world ;
that its principles once fully enforced b}^ the pro- j
fession, would be attended bj- a vast increase of
the solid cash.

It is fitting, from time to time, to look over the
field in which we labor and note the progress
made in its cultivation, and the signs of promise :
for the future. Of these I note a few for our en- j
couragement. In truth it must be said, that the
Academj' is but one of numerous agencies, all
striving toward the accomplishment of the same
end, by diverse routes. All of these we cordially
welcome, and wisely .seek to increase in efficiency
and to multiply.

1. It will be remembered that last year the
College of Phj-sicians and Surgeons of New York,
placed in active operation a preliminary examin-
ation of considerable severity. The result shows
that its classes maintained a size entirely un-
expected, though gratifj'ing to the friends of an
increased preliminary education. In some other
medical colleges the increase of preliminary re-
quirement was attended bj' equall)' satisfactorj'
rssults.

2. Better than this because of larger scope and
indicative of a wider interest in preliminary' edu-
cation, is the action of the last New York State
Legislature in enacting the following :

" Before the regents of the State of New York,
or the trustees of any medical school or college
within this State, shall confer the degree of
doctor of medicine upon any person who has not
received the baccalaureate degree in course from
a college or universitj- duly authorized to confer
the same, thej^ shall require him to file with the
secretary or recording officer of their university
or college, a certificate showing that prior to
entering upon the study of medicine, he passed
an examination conducted under the authority,
and in accordance with the rules of. the regents
of the University of the State of New York, in

arithmetic, grammar, geography, orthography,
American History, English Composition, and the
Elements of Natural Philosophy, and such certifi-
cate shall be signed bj^ the secretary of the re-
gents and countersigned by the Principal or
Commissioner conducting the examination."

This enactment shows that the principle for
which the Academy contends has been adopted
by the State of New York. The examination is
low, and the enactment imperfect in some details,
but as a whole it is a great step in advance. We
can rely upon the spirit which prompted, and the
intelligence which formulated the enactment to
eliminate imperfections, and advance the require-
ments as public sentiment shall desire.

3. It is meet that the Academy should take
heart, because the enemies of the Illinois State
Board of Health failed to accomplish its ruin this
year. Its position, that no diploma will be rec-
ognized as entitling its possessor to practice medi-
cine in Illinois unless given by a medical college
which requires a definite preliminary examina-
tion, still remains the law of this State, and is
enforced. The service of this board in teaching
the doctrine of the absolute necessity of some
preliminary requirement of medical students be-
fore entering upon college training, has been of

I incalculable value. It is doubtful whether any
moral suasion would have been so effisctive, with
the medical colleges, the medical profession, and
the laitj- and other State Boards of medical exam-
iners. As the pioneer of teaching this doctrine
by law it will ever retain the gratitude of such as
are able to appreciate its difficulties. Profiting
by its success and failure, other boards have been
established upon a higher plane, but all cheer-
fully acknowledge their debt of gratitude to this
board.

4. The results exhibited by the Minnesota
State Board of Medical Examiners, under the
last phase of its development, are especially en-
couraging. Under the old Act, Minnesota li-
censed in 1885 one hundred and forty-six physi-
cians. During the following two years the State
rapidly increased in population, and yet under
the last Act only one hundred and forty per year
were licensed during the two following years. At
the examination held October, i88g, of seventeen
applicants only twelve were licensed. From this
statement we are prepared to hear that Minnesota
has but one physician to thirteen hundred people,
while in the rest of the States it is affirmed that
one physician exists to every five or six hundred
people.

The last Act, in brief requires all persons, de-
siring to begin the practice of medicine in Min-
nesota, to pass a scientifically practical examina-
tion by a Board independent of all medical schools.
No candidate is admitted to examination unless
he presents a diploma from a medical school that
requires a preliminar}' examination upon the fol-

\

762

INJURY TO THE MIDDLE EAR CAVITY.

[November 30,

lowing branches : English grammar, composi-
tion, geography, algebra, phj'sics and natural
sciences, together with one of the following
languages: Latin, French or German. In ad-
dition, the college must require attendance upon
at least three full courses of instruction of not
less than six months duration, before confer-
ring the degree of doctor of medicine. The prac-
tical result of this law has been to restrict the
number of new men who have entered upon the
practice of medicine in Minnesota, and verj- greatly
elevate the general and special training of the
new members. It has also given a stimulus to
medical colleges in their efforts to advance the
standard of preliminary' requirement. It must
be that in the near future the profession of Min-
nesota will possess a higher grade of general cul-
ture and .professional acquirement than in the
past, or than is possessed by other States. As
this accords with the aims of the Academy, it
can rejoice in such tangible proof of progress.

5. In Montana, Virginia, North Carolina, etc.,
there are also laws bearing upon the increase of
the preliminar\- requirements of medical students.
While these are less radical than the Minnesota
Acts, they contain the seed which is sure to grow
until they have equalled if not surpassed the
foremost.

6. At the late meeting of the American Medi-
cal Association Dr. Millard, so long actively en-
gaged in the reformatory work in Minnesota,
presented a scheme urging the adoption of such
measures as would result in the adoption, by each
State, of the Minnesota Acts. His idea was re-
garded with favor by those present. . That diffi-
culties attend its speedy realization does not ren-
der it less appropriate that we should accept it as
an indication of the development of our cherished
principles. We are ready to grant that law can-
not accomplish all the reform we seek, still we
must admit that law can do much in numerous
directions otherwise unattainable. It can lay its
heavy hand upon the wilful transgressor, and
make him respect the forms of propriety. The
discussion of such laws incident to their formula-
tion in each State, to their passage through the
legislatures and to their enforcement, compel at-
tention from millions of the laity, and thousands
of the profession, who otherwise would not give
the matter a moment's thought. Medical colleges
would thus learn that they cannot with impunity,
for trade, prostitute the profession to which they
belong. The law can make it profitable for the
colleges to adequately increase their preliminary
and other requirements.

7. The pharmacists, at their last annual meet-
ing, bewailed the low condition of the general
culture of their craft, and endeavored to formulate
some plan by which such culture could be in-
creased. They sought to have the professional
side of their calling occupy a more prominent

share of attention. The preliminary,' requirement
suggested as fitting for those who desired to enter
upon the study of pharmacy compares favorably
with that of most medical colleges, which enforce
any preliminary examination. Thus in manj- di-
rections the spirit of reform is abroad. While it
works slowl}', it is surely coming to the front.
{To be concluded.)

ORIGINAL ARTICLES.

THE POSSIBLE DANGER OF INJURY TO

THE MIDDLE EAR CAVITY BY THE

USE OF NASAL ATOMIZATION,

ILLUSTRATED BY THREE

CASES.

Read in the Section of Laryngology and Otology at the Fortieth An-
nual Meeting of the A merican Medical Association, held at
Ne^t'port,Jutie, 1889.

BY C. W. RICH.\RDSOX, M.D.,

OF WASHINGTON', D. C.

In calling attention to the few facts which I
am about to lay before j'ou, I am aware of my
trespassing upon what might be called sacred
territory and, therefore, do not come before you
with ill-advised and hastily drawn conclusions. I
know I shall meet with considerable skepticism,
: for such is usuallj' the lot of those who lay bare
\ possible injurious effects of previously considered
harmless therapeutic agents, especially after they
] have become the cherished idol of the whole pro-
ifession. I can but think that the skeptics will
be vastly in the minority when I have summed
' up the result of my labor. I shall first give you
several illustrative cases, followed by several ex-
l periments and conclusions. The object of this
j paper is to call your attention to the possible dan-
ger of injury to the middle ear as a result of na-
sal atomization, especiallj- if such pressure is di-
rect, as in the Davidson and Snowden atomizing
tubes. Two of these cases developed in my own
practice during the last year. Latterly I have
I been more guarded in the use of spraj's and the
! amount of pressure used, and, on this account,
have not had the misfortune to meet with any
further mishaps.

Case I. — That of a woman 27 3'ears of age ;
married. Came to me during the month of De-
cember on account of a postnasal catarrh attend-
ed with the secretion of an excessive amount of
mucus. On the loth of Januan,' I admitted her
to my consultation room, immediately after dis-
missing a patient having an atrophic rhinitis, on
whom I had been using a spray of high pressure
to remove the adherent mucus from the nasal
cavities. I began the treatment on this day, as
usual, by the spraying of the nasal passages with
a modified Dobell's solution. I forgot the high
pressure, and as I began to spray the left nasal

1889.]

INJURY TO THE MIDDLE EAR CAVITY.

763

cavity she involuntarily drew back, made an at-
tempt at respiration, immediately followed by an
explosive cough. I quickly cut off the spray.
Quickl}' recovering her power of speech she re-
marked that she experienced a sensation as
though the sprayed fluid had entered directly
into her left ear. I assured her that it was im-
possible for any of the fluid to have entered the
ear, and after pursuing the treatment in a more
cautious manner dismissed her. About 11 o'clock
of the same evening I was somewhat surprised at
receiving a summons to call at her house at once,
I was informed that her ear had given considera-
ble annoyance since leaving my oflSce. Her pain
was great and radiated over side of head and
along course of Eustachian tube; remitted almost
entirely during next day, and on the third dis-
appeared. Effusion rapidly set in and was at-
tended with considerable deafness, roaring in the
ears and resonance of voice. The appearance of
membranes I did not note, but remember them as
being these of a typical case of otitis media acuta.
Case 2. — This case occurred in a gentleman,
single, 45 years of age. This patient consulted
me during the winter on account of a great
hoarseness from which he had suffered since con-
tracting a cold .several weeks before. On exam-
ining his larj-nx I found a marked paralysis of
the thyro-arytenoidei interni and considerable
congestion of the vocal cords. On investigating
further I discovered quite a severe pharyngitis
and naso-pharyngitis, while in the right nasal
cavity there existed a spur, cartilaginous, com-
pletely blocking that cavity. His voice was re-
stored and the pharyngeal trouble improved as
much as could be expected with the nasal de-
formity still existing. In March he returned and
requested that I should remove the septal spur.
I operated on the 2d of March, using cautery
knife, with the happiest result — perfect and all
sufficient nasal respiration through the right cav-
ity. Everything progressed favorably until the
14th ; the septal wound had almost completely
healed, and nowhere was there evidence of any
inflammatory trouble. On this day I used a lit-
tle greater pressure in air compressor, in order to
remove the small crusts that had formed around
the edges of the .septal wound. While using the
spray the patient remarked, "Why, doctor, that
certainly entered my ear." Being quite positive
that my patient had not erred in judgment I ab-
stained from further treatment. Before dismiss-
ing him I made a post-nasal examination and
found this cavity in quite a normal condition —
no evidences of any acute inflammatory trouble.
I expected trouble, and was not disappointed.
On the morning of the 15th the patient called at
my office, his facial expression giving unmistak-
able evidence of a night spent in great suffering.
He stated that at about 12 o'clock of the previous
evening he was awakened by a severe pain in his

right ear, which increased so in its intensity as
to be almost unbearable. He described the pain
as of a throbbing character, being intensified by
clearing of the throat, coughing and deglutition.
Tenderness was manifested by pressure in the
angle between mastoid and ramus of lower jaw,
but there was complete absence of spontaneous
pain over the mastoid region, nor could any be
elicited by pressure. No objective noises. Ex-
amination of hearing : Tuning fork showed that
bone conduction was better upon affected side.
Politzer's Hormesser, R. ||, E. \%. Inspection
of auditory canal: R. E. canal filled with a mass
of cerumen ; L. E. showed same condition as on
right side, but not so great. Cerumen was readily
removed by very gentle syringing, a very mild
degree of force and the use of only a small amount
of water being sufficient to float out the masses.
After removal of cerumen the hearing distance
was as follows : R. E. f|, E. E. -fl. The mem-
brane of the right ear now being subjected to ex-
amination presented the following evidences of a
marked inflammation : The central portion of
the membrane, that corresponding to the position
of the manubrium, presented the condition of in-
tense injection. The processus brevis and the
manubrium were completely obscured by an in-
tense swelling and .injection of the membrane,
which had the appearance of an inverted cone,
the apex corresponding to the umbo, and the
base to the area of the foramen of Rivini. The
anterior, inferior and posterior segments were al-
most free from anj' inflammatory evidence. With-
out further remark one will readily see that our
patient had a well developed and intense inflam-
mation of the middle ear cavity. He responded
poorly to treatment, but eventually, after consid-
erable suffering, made a perfect recovery.

Case J. — Dr. L., consulted me on the 19th of
February of this year on account of a severe pain
in the right ear. He was constantly annoyed by
more or less obstruction to free nasal respiration.
On the previous evening the nasal obstruction
had given him considerable inconvenience, and
in order to relieve the uncomfortable sensation he
resorted to the use of an astringent spraj'. The
spraying fluid consisted of a 5-grain solution of
tannic acid. A few hours after this treatment he
developed a severe pain in his right ear. On ex-
amination I found well-marked evidences of art
acute inflammation of the middle ear cavity,,
which rapidly responded to treatment.

In this connection, and as directly bearings
upon this subject, I will here offer three or four
cases reported by Dr. Ring in the A'. }\ Medical
Record oi h.M%Vi^\. 11, 1888. These cases appeared
under the title, "Four Cases of Acute Inflamma-
tion of the Middle Ear from the Use of Roosa'.s;
Bulb Nasal Inhaler." Dr. H. P. Allen, of Co-
lumbus, ably criticised the deductions made by
Ring, and showed that he had erred in supposing

764

INJURY TO THE MIDDLE EAR CAVITY.

[November 30,

the otitis media to be due to the inoffensive bulbs
of Roosa. As I wish to show the relationship
these cases have to the subject in hand I will
give a short sj-nopsis of the treatment adopted
previous to the invasion of the otitis media. In
Dr. Ring's first case he used a spra}' of Dobell's,
iron and glycerine to the posterior wall of the
pharynx, and afterwards inflated, using Politzer's
bag with Roosa's attachment. In case 2 he
sprayed nasal cavities and inflated, as before. In
case 3 he sprayed nose, pharj-nx and throat with
Dobell's, and then inflated as in cases i and 2.
In all three of these cases we have the use of the
spra5^ followed by the inflation of the middle ear
by Politzer's method. We here report six cases
of acute inflammation of the middle ear seeming-
ly due to the use of the nasal spray. It remains
for us not only to subject them to careful analysis,
but also to ascertain, by direct experimentation,
whether a spray under usual pressure is capable
of entering the middle ear. It will be necessary,
first, to consider the reflex muscular movement
excited in the naso-pharj^nx by the impact of
spray ; and the minimum of pressure necessary to
develop in order to inflate the middle ear cavit}'.

During the act of spra3'ing, the fluid, more or
less irritating, impinges against the posterior wall
of the pharynx and, as a result of this irritation,
excites the following muscular movement, viz :
Ver}' frequentl}' the soft palate contracts imme-
diately ; again it remains immobile for a few sec-
onds, or shows only a slight degree of contractil-
itj', until there is a tendency of the fluid, which
has undergone condensation, to flow into the oral
portion of the pharynx, when the palati muscles
cause a rapid and vigorous contraction of the soft
palate, making a complete separation of the nasal
from the oral pharj-nx. It is hardly necessary- to
mention that the palati muscles not only exert
their action upon the soft palate, but also cause a
shortening and dilatation of the mouth of the
Eustachian tube. These two factors, the separa-
tion of the nasal from the oral portion of the
pharynx, and the shortening and dilatation of
the tube, are essential elements to the entrance of
air or fluid through the Eu.stachian tube into the
middle ear cavitj'. In inflation of the middle ear
by Politzer's method these two factors are essen-
tial when occurring in conjunction with and
simultaneous to the compression of an elastic air
bag, the nozzle of which is inserted in one nostril
while the other is closed, in order to prevent the
outward escape of air.

The maximum of pressure one is capable of
producing with a Politzer air-bag of a capacity of
300 grams is one- half of an atmosphere, equiva-
lent to a pressure of one-half kilogram. Politzer
states that with a pressure ofo. i of an atmosphere
air is capable of entering the middle air cavity.'
\Ve have now the minimum of pressure one is

" Ohrenhcilkiinde." Vol. I, p. 1S17.

capable of evolving from a Politzer air-bag, and
the minimum of pressure by which air can be
forced into the middle ear cavity. The amount
of pressure one ordinarilj- uses in order to produce
a spray varies from lo to 25 pounds, according to
the exigencies of the case ; a spraj^ of 25 pounds
I would consider one of high pressure and verj'
rarely to be used. It is to be distinctly' under-
stood that I am here referring to the danger at-
tending the use of the direct pressure spray. It
would be difiicult to prove that there was suffi-
cient pressure remaining, after loss by resistance
and in escapage from opposite nostril, to equal
the minimum of pressure necessarj' to cause the
entrance of air into the middle ear cavity ; 3'et I
hope, by the following simple experiment, to
prove that such a pressure exists, if not with un-
obstructed, at least with partly obstructed nasal
passage during the maximum of the spraying act.

In order to obtain the momentum of a sprayed
fluid as it passed from the mouth of the atomizing
tube it was necessary to construct the following
simple device : I first selected an ordinary 8-
ounce wide-mouth bottle, into which I placed 3
pounds of mercury. This bottle was stoppered
with a vulcanized rubber cork, through which I
caused two holes to be bored. Through the
larger of the openings I passed a barometer tube,
its lower extreraitj- coming almost in contact with
the floor of the bottle. Through the other open-
ing I passed a hard rubber tube, bent at right an-
gles ; this penetrated 2 centimetres within the
calibre of the bottle. Applying cork to mouth
of bottle, tubes in position, the apparatus was
ready for use.

In order to ascertain if there was anj- loss in
momentum in the spra}', due to resistance in the
conducting medium, and also where this loss oc-
curred, I instituted the following two sets of ex-
periments :

In the first set of experiments I connected the
conducting rubber tube of the air compressor di-
recth' to the hard rubber tube of my device.
After the above connection had been made I in-
troduced a pressure of i atmosphere (i kl.) in
my air compressor. It was now m^- intention to
learn whether the existence of i atmosphere of
pressure in the air compressor was capable of cre-
ating suSicient momentum — the momentum pro-
ducing sufficient pressure — to raise a column of
mercury 76 cm. On turning on the stopcock,
all connections having been made, the niercurj'
rapidlj' rose in the tube to the height of 76 cm.,
where it remained stationan,-, showing that there
was sufficient momentum to overcome the atmo-
spheric pressure ; or, in other words, the pressure
at mouth of tube was as great as in air compres-
sor, there being no appreciable loss in momen-
tum.

In my second series of experiments I interposed
between the hard rubber tube and the rubber tub-

1889.]

INJURY TO THE MIDDLE EAR CAVITY.

765

ing of the air compressor an ordinary Snowden
atomizing tube, all other conditions remaining
the same. In this experiment the mercury rap-
idly ascended the barometer to the height of 54
cm. We observe here a considerable loss of mo-
mentum, due to the resistance created in the
atomizing tube. The loss is equivalent to nearl}^
one-third of an atmosphere. Calculating from
this the amount of momentum existing with the
use of a pressure of 12'.- pounds in the air com-
pressor, the pressure ordinarih' used, we find that
it is sufficient to raise a column of mercury 44
cm. in height, nearly equivalent to two-thirds of
an atmosphere — a pressure greater than one is
capable of generating from a Politzer air-bag.
Other conditions being present, we have here
produced more than sufficient pressure to cause
an inflation of the middle ear cavity. The other
conditions are the separation of the oral from the
nasal pharynx, the shortening and dilatation of
the Eustachian tube, and sufficient obstruction in
the opposite nostril to interfere with the egress of
sprayed fluid. It would be impossible to prove
by dynamics, even with all these conditions exist-
ing, that sufficient pressure was generated within
the naso-pharynx to cause the penetration of a
sprayed fluid within the middle ear. It is hardly
to be conceived that there would be any greater
loss of pressure, by resistance in the nasal pas-
sages, than takes place in the atomizing tube,
leaving us, approximately, a pressure of more
than one-third of an atmosphere, more than suffi-
cient, according to Politzer, to cause an inflation
of the middle ear cavity. I submitted my experi-
ment to Dr. E. T. Fristoe, professor of chemistrj'
and natural philosophy in the Columbian Univer-
sity, and he concurred in my conclusions. Al-
though dynamics cannot be of anj' further assist-
ance, we can gain from the following experimen-
tal cases' positive testimony in this connection.
At this time, as my dynamical experiments lacked
a certain amount of positiveness, not enough to
quell the doublings of the skeptic, and while
looking about for further means of demonstrating
these facts, the happy idea occurred to me of
making use of living material.

One does not care to toy with his private pa-
tients, but the exigencies of the case were such,
and a possibilitj' of harm so remote, that I con-
cluded to make such use of them. This idea
seized upon me more forcibly as I saw my way
clear, in treating these cases, to resort to a little
collateral and at the same time harmless observa-
tion of the effects that w^ould be produced by
special modes of procedure. The cases that I
utilized were two of otitis media .suppurativa
chronica, attended with complete destruction of
the membrana tympani, and in which it was nec-
essary to use the spray in treating a co-existing
rhinitis. These patients had patulous Eustachian
tubes. It was only necessary to slightly vary mj-

usual course of treatment in order to carry out
the experiment I had in view. Previously I had
never sprayed the nasal cavitj' after inflating. It
was now my intention, after inflating and thor-
oughly drying out themiddle ear cavity — a cav-
ity minus the outer wall — to again spray the
nasal passages and note if there then existed any.
moisture. On following out this line of investi-
gation in both of raj' cases I found not only
moisture, but the actual existence of several drops
of the sprayed fluid in the anterior inferior por-
tion of the tympanic cavity. Again, I introduced
a sufficient quantity of powdered boracic acid
after drying out both cavities, to fill out the ex-
isting remnant of tympanum. I now used the
spray in the nasal cavity, and, on examining the
ear, found that the boracic acid had become moist
throughout.

These two illustrative cases, one with and one
without artificial obstruction of the nasal cavity,
in conjunction with the actual phj'sical demon-
stration of the amount of pressure generated by a
spray, show in a most conclusive manner that a
sprayed fluid is capable, under certain conditions,
of penetrating the middle ear cavity through the
medium of the Eustachian tube.

Even admitting, though, that there is not suf-
ficient pressure produced to cause the entrance of
air into the middle ear, no one will deny the entrance
of the sprayed fluid into the mouth of, and a certain
distance within, the dilated cartilaginous portion
of the Eustachian tube. Immediatelj' after the
spraying of the nasal cavities, and before the
sprayed fluid has had sufficient time to undergo
condensation, the patient resorts to the clearing
of the nostrils, more or less violently. The clear-
ing of the nasal passages is always, unless there
is a constriction or obstruction of the Eustachian
tube, however produced, attended with inflation
of the middle ear cavity. This inflation is suffi-
cient, I claim, to drive any spray or fluid, which
may have lodged within the lower portion of the
tube, into the middle ear cavity. While the con-
dition just mentioned is capable of producing an
acute otitis media — the fact of its not being more
frequently produced not militating against this
occurrence — yet I do not admit that this was the
manner in which it occurred in the cases above
illustrated, but simply refer to this in order to
call attention to a further danger to be thought
of in connection with promiscuous and continued
spraying of the nasal and naso- pharyngeal cavi-
ties. To me there is no doubt that the sprayed
fluid entered, directly through the tube, the mid-
dle ear cavity in the ca.ses imder consideration ,
and that the irritation produced by the fluid was
the cause of the subsequent otitis media.

On many occasions I have had patients state
that they had experienced a sensation, during
the spraying, in the ear, which caused them to
suppose that the fluid had entered the middle ear

766

INJURY TO THE MIDDLE EAR CAVITY.

[November 30,

cavitj^ without producing any deleterious effect ;
and I do not doubt but that other larj'ngologists
can recall similar experiences. Subjecting the
first case to analj-sis, we cannot see what other
cause than that of the spraying can be assigned
as the producing agent. The pharj-nx and the
.naso-pharj-nx were devoid of all evidences of an
acute inflammation, and remained so throughout
the histor}' of the case. There was no treatment
excepting the spraying of the throat, and we
have the positive statement of the patient that she
experienced a sensation as though something had
entered the middle ear. In the second case we
have a recent operation, — twelve days since — the
wound being in a healthj' condition, nearl3'
healed, showing no evidences of inflammation,
considerablj^ removed and not in the line of con-
tinuity. No treatment was resorted to after the
patient indicated the possibility of the entrance
of the spraj'ed fluid into the ear. The third case
is so simple as not to require analysis. The occa-
sional occurrence of inflammator\' changes in the
middle ear in connection with operations upon
the septum narium has given rise to the thought
that possibl}', in most of these cases in which
otitis media acuta or suppurativa occur as a se-
quelae, thejr might owe their origin to the spray-
ing subsequently' resorted to, rather than to the
operation. There seems to me no plausible rea-
son why an operation from 2'.. to 5 cm. anterior
to and on the opposite wall of the nasal cavity
from the orifice of the tube should give rise to an
inflammation extending into the middle ear cavity.

We call attention to these facts not with the
intention of decrying the use of the spray — I can
not conceive how we can replace this valuable
cleansing and curative agent — but simply to call
attention to certain dangers which may attend
injudicious use of high pressure or indiscriminate
employment of this agent. The douche produces,
as all know and as first called attention to by
by Roosa^ otitis media suppurativa ; but its use-
fulness is undoubted, and there are cases in which
its application becomes an absolute necessity.
St. John Roosa's calling attention to this fact has
not driven the douche into oblivion — it has only
caused a suspension of its indiscriminate use and
limitation to its proper sphere of usefulness.
Many other valued agents and methods are at
times attended with disastrous results ; calling
attention to these effects only makes one more
cautious in their employment. Such is mj' sole
intention in connection with this paper.

Before closing nij' paper I wish to call attention
to another condition which the continued and in-
di.scriuiinate use of the spray may not only aid in
the production of, but po.ssibly in certain cases
be the direct producing agent, /. c, otitis media
hypertrophia. To me it would be verj' interest-
ing to follow a number of cases in which the

= Archives of Ophthalmologj' and Otology, Vol. I, No. i.

spray had had liberal use, in order to ascertain
whether there was any subsequent impairment of
hearing. I shall follow this line of investigation
where possible, and hope, by calling attention to
it, that others may be stimulated in the same di-
rection. The manner in which the spray could
aid in the production of this condition we can
readily see — it does not rest upon an emptj' h}'-
pothesis. The difiiculty would rest in separating
this cause, should it be so, from others acting
simultaneously.

Dr. Mackenzie said he believed that fluid
may enter the ear in any method of cleansing the
nose, and that the danger does not pertain espec-
ially to the spraj'. He narrated a case of double
otitis media resulting from the use of intra-nasal
spray. His remarks did not apply to the nasal
douche.

Dr. Wright indorsed Dr. Mackenzie's remarks
with the exception that auto-douching o/ie?i gives
rise to otitis media, but spraying rarely, and that
he has never seen trouble resulting from the use
of the post-nasal douche in the hands of the phy-
sician, while it should never be given to a patient
to use himself.

Dr. H. H. Curtis said that in cases of middle
ear complication following the use of the nasal
douche he had observed that the trouble was
usuall}' brought about by allowing the fluid to
enter through a free nostril and flow out through
one contracted by a stenosis.

Dr. Mackenzie said that all who had much
experience in the treatment of nasal disease had
met with accidents such as that described by Dr.
Richardson. There is no method by means of
which fluids are introduced into the nares by
which the liquid may not enter the middle ear.
The accidents from sprays were, however, of not
sufiicient frequency to warrant extraordinary care
in the method. He related illustrative cases.

Dr. C. W. Richardson : I called attention
to these few facts as much for the information
of the members present as for the purpose of call-
ing to 3'our consideration a few points which I
was obliged to omit from mj' paper on account of
limited time. I wish to refer to the indiscrimi-
nate manner in which hand ball sprays are so
frequently placed in the hands of the laity, and
the possible danger resulting from this evil prac-
tice.

Faith-Curing of Contagious Diseases Sup-
pressed.— The Board of Health of Matteawan,
N. Y., having encountered a case of diphtheria
that was being neglected by some faith-curing
practitioners, declared an immediate quarantine,
which was maintained by the police. A reputa-
ble physician was put in charge of the case, and
the child began to improve.

1889.]

STAMINA.

767

STAMINA.

Read in the Section of State Medicine, at the Fortieth Annual Meet-
ing of the American Medical Association, June, tSSo.

BY A. N. BELL, A.M., M.D.,

OF BROOKLYN'. N. Y.

The object of this essay is to reduce the sig-
nification of the words "susceptibility,;' " predis- 1
position" and "heredity."

In the progress of bacteriological knowledge,
there is too little attention paid to the organic
conditions of health, and the resisting power of the
system in conflict with antagonistic forces.
Thirty years ago, while engaged in the study of
" Living Things," the writer had occasion to ob-
sen-e : " Man's life is inseparably linked with the
plants and animals which coexist with him, and
these are the issue of long anticipations and i
preparations, where all the changes produced in
other objects occur according to a relation exist-
ing among the substances changed. Latitude,
elevation, nature of the soil, degree of cultivation,
relative position in regard to mountains, forests,
rivers, etc. , and general aspect of the neighbor-
hood, all modif}' the condition of man, and prove
his adaptability by such effects as serve to make
him understand his relations to what is around
him. We cannot prevent the dews of heaven,
nor the heat of the sun, nor the progress of de-
composition ; but we can understand the course
and order of natural phenomena, we can trace
out the laws that govern them and ascertain our
relations to them.'"

The reward of man's cosmopolitan nature and
free agency is the progress of human welfare,
even though won at the cost of impaired health
and premature death by those who do the most
to promote it. But the influence is reciprocal.
Man reacts upon nature no less than nature upon
him. Indeed, the changes effected in natural
phenomena by human agency are the striking
characteristics of conditions promotive of, or in
conflict with human health everywhere. This
reciprocal action should, above all things else,
make the progressive man alive to the impor-
tance of constructing and sustaining his ability to
contend against the antagonistic forces — both
natural and artificial — with which his sphere of
life is everywhere intimately associated. And in
the application of this knowledge he will learn
that health is .something more than mere freedom
from disease. Health is opposed to disease and its
causes by the relative integrity, strength and
vigor of all the organs and functions of the body,
fortified by such conditions as the human organ-
ism depends upon for its fabrication and re-
sistance. For example : Two individuals, the
one endeavoring to live by rule, and having much
to say about the " laws of health," afraid to run

^ " Knowledge of Living Things with the Laws of their Exist-
ence," bv K. N. Bell, A.M., M.D. Bailliere Brothers. New Vork,
i860.

upstairs because it makes the heart beat more
rapidl}', hurries the respiration and fills the lungs;
can't eat cheese because it constipates the bowels,
nor cherries for the contrary reason ; never drinks
water, or but very little, with meals ; can't take
a glass of milk at bedtime, or a hot roll for
breakfast, because such food always sets heavy
on the stomach ; never eats bacon or pork, and
eschews fat meat of all kinds ; takes an hour at
meals and always leaves off hungr}' ; would not
take a cold bath for anything ; who prefers the
weight of a thick furlined overcoat or cloak to a
light one and a brisk walk on a cold day ; and
sundry other postulates promotive of tenderness.
And the other — the reverse : Who is neither
afraid to hurry at his meals or to his business ;
not only runs up .stairs, but a long hill, or if in a
hurry, forty rods or more after a railroad car ;
who has taught his stomach, as he has his arms,
legs, heart and lungs such lessons in gymnastics
as not to be too dainty, and to profit by the varia-
tion ; who satisfies hunger and thirst ; when
among Romans, live as they do ; finds hog,
hominy and hot bread digestible, wholesome and
nutritious ; has, in short, never tried to live by
any rule, except temperance in all things and
protection against the extremes of weather Both
of such persons may be equally free from disease,
but is it necessary to add that the power of the
latter to resist it in every respect — whether it be
inhaled, swallowed, inherited, or by exposure to
inclement weather — is greatly in favor of the well-
nourished and the strong ? And the relative im-
munity depends not upon predisposition, but
upon stamina.

With regard to certain infectious diseases to
which children are especially liable, in part,
doubtless, because of their greater functional ac-
tivity, but chiefly because their power of re-
sistance has not yet become sufiiciently fortified
— for it is well known that adults generally who
have not encountered those diseases in childhood
rarely contract them subsequently — the same
relative immunity exists ; the strong and vigor-
ous child is much less likely to contract them
than the feeble ; and the convalescent, those who
are particularly feeble from any one of such dis-
eases, are well known to be the most of all liable
to attack and to succumb from another. And of
pulmonar>' consumption, the most prevalent and
the most fatal of all diseases, who does not know
that enfeeblement invites it ? That individuals
are less and less liable to it — whether traceable to
hereditary taint or otherwise — in proportion as
coddling has been avoided, appetite for whole-
' some fat food cultivated, cold bathing habitual,
protective but loose clothing worn, and exercise
I in the open air unrestrained ? By the main-
tenance of the.se conditions all the processes of
healthy organization are promoted and the con-
stitution fortified against tubercle bacilli as in

768

STAMINA.

[November 30,

like manner against other disease germs, no mat-
ter whence the quarter or at whatever age of the
individual exposed ; and no less against diseases
not attributable to germs. And the more if we
accept MetschnikofPs theory of the ofBce of the
leucocytes or white blood corpuscles, for these iu
both number and strength depend upon proper
nourishment. "In health," says Kirkes, "the
proportion of white to red corpuscles, which,
taking an average is about i to 500 or 600, varies
considerably, even in the course of the same day.
The variations appear to depend chiefly on the
amount and probablj' also on the kind of food
taken, the number of leucocytes being very con-
siderably increased by a meal, and diminished
again on fasting. Also in young persons, during
pregnancy, and after great loss of blood, there is
a larger proportion of colorless blood corpuscles,
which probably shows that they are more rapidly
formed under these circumstances. In old age,
on the other hand, their proportion is di-
minished.^ "

No good observer will fail to recognize the co-
incidence of the condition which diminishes the
proportion of leucocytes and the increased lia-
bility to disease — that of fasting ; or note the no
less remarkable coincidence, the diminution in
the number of the leucocytes and increasing in-
firmity of old age. The leucocyte or colorless
blood corpuscle is an avuvba, the simplest type of
a living thing ; a jelly-like mass of protoplasm,
of the same consistence throughout, which pos-
sesses the property of moving about and capturing
its prey by changing its form bj^ the protrusion
of first one part of its body and then another,
and of extemporizing a stomach by wrapping
itself around any nutritive particle with which it
comes in contact and digesting it. On account
of this peculiar property and apparent function
of the leucocytes Metschnikoff has conferred upon
them the name of phagocytes — eaters — as expres-
sive of their most distinctive feature, and of the
process in general, phagocytosis.

" It has long been known," says Dr. William
Osier, ^ "that foreign bodies such as ligatures,
portions of dead bone and other substances, may
be completely removed by leucocytes.

"Nowhere in the body do we have such a facil-
ity for studying the action of phagocytes as in
the organs of respiration, in which, with the cilia
of the bronchial mucosa, they share in the work
of cleansing the air-passages ; and of the.se two
important agencies it is hard to say which plays
the more important part in the expulsion of those
particles of foreign matter which, in cities at
least, we constantly inhale. There are several
groups of cells engaged in this work : The ordi-
nary mucus corpuscles ; the alveolar epithelium ;

= Kirke's Hand Book of Physiolojfjf, vol. i, pa^e 79.
1 Address before the Alumni Association of Belleviie Hospital,
New York, .^pril 3, 1889.

the connective tissue- elements of the pulmonary
stroma, and the leucocytes of the lymph tissue
in the bronchial, tracheal, mediastinal glands.

" The examination of the morning sputa of a
cigarette smoker, or of a person who has been
exposed to a dusty atmosphere, shows very
clearly that no small proportion of the carbon
grains is included within protoplasm. The free
granules are abundant, but almost everj- leucocyte
has its little load which it has picked up on its
road from the finer tubes to the trachea.

" It is possible to conceive, under certain con-
ditions, of the air cells gradually filling, were it
not for the activit)' of phagocytes, derived largely
from the alveolar epithelium, which stands, as it
were, at the gateway of the lymphatic circulation.

" In dwellers in the countrj', as well as in wild
animals, breathing an air comparatively pure, the
cilia and the phagocytes in the air-passages ap-
pear quite able to prevent access of the carbon
grains to the lung tissue ; whereas in the dwellers
in the cities, and in animals kept in confinement,
the impurities in the air are so abundant that
these agents are insufficient, and sooner or later
the grains penetrate the air cells.

"The steps in this process described may be
followed in the lungs of any town dweller, but
to see in perfection the remarkable activity of the
pulmonary phagocytes, one must study the early
stages of anthracosis, particularly in those excep-
tional cases which we see occasionally when a
miner has been killed by accident or dies of
acute disease. It is not, I think, too much to
say that the larger part of the pigment contained
in lungs, almost, if not quite, black, is enclosed
in protoplasmic cells.

"A physiological process in which phagocytes
play a leading role, is the removal and disin-
tegration of the red blood corpuscles which have
lived their life and are no longer fit for work.
The cells containing the red blood-corpuscles,
which are found in the bone marrow and in the
.spleen, however much opinion may differ as to
their mode of origin, cannot, I think, be re-
garded in any other light than as phagocytic ele-
ments with this definite function.

" In the mature body we have seen that in the
lungs, in the intestines, and in the blood-making
organs, the phagocytes have most essential func-
tions ; but the question of chief interest to-day
relates, not so much to this normal process about
which there has never been much doubt, as to
the supposed part which these cells take in pro-
tecting the body against the invasion of parasites.

"Metschnikoff has studied a number of dis-
eases, erj'sipelas, anthrax, relapsing fever, and
tuberculosis, with a view of finding facts in sup-
port of this theory, and his communications
within the past four years have been numerous
and elaborate.'

••Published chiefly in Virchow's Archiv.

1889.]

STAMINA.

769

' ' In erysipelas the cocci are attacked first by
the leucocytes filling the lymph spaces, which
rapidly proliferate and actively eat the micro-
organisms. Not alone do the colorless corpuscles
act as phagocytes, but the fixed connective tissue
cells assist in an important manner. In cases of
recovery he found that behind the advancing
cocci the leucocytes were crowded with parasites,
which showed evidences of digestion and destruc-
tion. The connective tissue cells do not appear
to attack the cocci, but are chieflj' concerned with
the absorption of the inflammatorj' exudate, even
taking up the leucocytes which have died. In
fatal cases there was enormous development
of micrococci, the majority of which lay free in
the tissues not enclosed in the phagocytes.

' ' As we might suppose, the views of Metschni-
koff have met with sharp criticism in many
quarters, and from no one more ably and at
greater length than from Baumgarten.' While
not denying that the leucocytes eat the bacteria,
he claims that the process is by no means uni-
versal, and is carried on so unequally, that we
can scarcely speak of an active warfare waged
against the parasites.

' ' Metschnikofi" states that in malaria the para-
sites are attacked chiefly in the spleen and
the liver by the larger phagocytes existing
in these organs, and to a much less extent by the
leucocytes in the circulating blood

which more presently), using exertion, cropping
grass, at war with vegetables, etc. If it gets a
luxurious pasture it dies of repletion. If it gets
too little it dies of inanition. To keep itself
healthy it must exert itself for its food ; this, and
perhaps the avoiding its enemies, gives it exer-
cise and care, brings all its organs into use, and
thus it acquires its most perfect form of life. I
have witnessed this effect myself, and that is the
reason why I choose the rabbit as an example.
An estate in Somersetshire, which I once took
temporarily, was on the slope of the Mendip
Hills. The rabbits on one part of it, viz., that
on the hillside, were in perfect condition, not too
fat nor too thin, sleek, active and vigorous, and
yielding to their antagonists, myself and family,
excellent food. Those in the valley, where the
pasturage was rich and luxuriant, were all dis-
eased, most of them unfit for human food, and
many lying dead on the fields. Thej' had not to
struggle for life, their short life was miserable,
and their death early ; they wanted the sweet
uses of adversity — that is, of antagonism.

" The same story may be told of other animals.
Carnivora, beasts or birds of prey, live on weaker
animals ; weaker animals herd together to resist,
or, by better chance of warning, to escape beasts
of prey ; while they, the herbivora, in their turn
are destroying vegetable organisms.

" I now come to the most delicate part of my

"We see then, in malaria very little evidence subject, viz., man (I include women of course)

in the blood favoring a theory of phagocytosis ;
certainly no such campaigning on the part of the
leucocytes as might be expected from the pres-
ence, in such numbers, of foes so destructive to
the red corpuscles."

Dr. Osier concludes that: "While phagocy-
tosis is a wide-spread and important physiolog-
ical process throughout the animal kingdom, and
while it undoubtedly plays a most important part
in many pathological conditions, the question of

Is man exempt from this continual struggle?

"It is needless to say that war is antagonism.
Is not peace so also, though in a difi"erent form?
It is a commonplace remark to say that the idle
man is worn out by ennui, i.e., by internal an-
tagonism. Kingsley's " Do-as-you-like " race —
who were fed by a substance dropping from trees,
who did no work, and who gradually degenerated
until they became inferior to apes, and ultimately
died out from having nothing to do, nothing to

an active destructive warfare waged by the body i struggle with — is a caricature illustrative of the

cells against the microorganisms of disease must
still be considered an open one. ' ' {Medical News.)
Whatever may be the final verdict with regard
to the antagonism of the phagocytes to disease
germs generally, it appears to be clear that their

matter.

"As, with food or exercise, deficiency is as in-
jurious in one as is excess in another direction,
so, as affecting the mind of communities, as I
have stated it to be with individuals, the effect of

proportion and their energy are in direct relation I a life of ease and too much repose is as much to

with the vigor of the organism, and dependent
upon the same sustaining conditions.

Sir Wm. R. Grove, F.R.S., the distinguished
author of "Antagonism," (the subject of a lec-
ture delivered at the Royal Institution of Great
Britain, April 20, 1888,) after alluding to Prof.
Metschuikoff's theory, says :

' ' Let us now consider the external life of
animals. I will take as an instance, for a reason
which you will soon see, the life of a wild rabbit.
It is throughout its life, except when asleep (of

5Loc. cit.

be avoided as a life of unremitting toil. The
Pitcairn Islanders, who managed in some way to
adapt their wants to their supply, and to avoid
undue increase of population, are said never to
have reached old age. In consequence of the
uneventful, unexcited lives they led, they died of
inaction, not from deficiency of food or shelter,
but of excitement. They should have migrated
to England ! They died as hares do when their
ears are stuffed with cotton, i.e., from want of
anxiety. We have hope in our suffering, and in
the mid-gush of our pleasures something bitter
surges up."

770

OBSTETRIC FORCEPS.

[November 30,

" We look before and after,
And pine for what is not ;
Our sincerest laughter

With some pain is fraught ;
Our sweetest songs are those which tell of
Saddest thought."

I Xatuie. )

With reference to heredity especially (as too
commonly understood'), in the face of what has
been brought forward, while it has undoubted
significance with reference to certain constitu-
tional diseases, it is, notwithstanding, amenable
to the same organic forces as feebleness of consti-
ttition in general ; dependent more upon parental
feebleness and unhealthful regimen in early life
than upon specific tendency. The offspring of
poorlj- nourished, dyspeptic parents, for illustra-
tion, are scarcely less liable to pulmonary con-
sumption than the offspring of those affected
with that disease ; and the offspring of dninkards !
and of those who use narcotics to excess are well {
known to be fully as liable to insanity, epilepsy
and idiocy as they are to inebriety. Indeed, -
hereditary feebleness of constitution is the pre- j
vailing "predisposition" to disease, and this, |
associated as it frequently is with inadequate!
nourishment and neglectful regimen during child- j
hood, accounts in a great degree for the excessive 1
mortality which obtains in infancy. 1

But in advocating more attention to personal
regimen as the chief means of cultivating consti-
tutional stamina and thus increasing the power |
of resistance to disease, which it is the purpose
of this paper to urge, there should be no diver-
sion from the effort to destroy the foci of disease
germs and to maintain healthful surroundings.
It should always be borne in mind, however, that
the ability of the practical sanitarian to success-
fully cope with infectious disease-germs and their
foci, and to maintain his own immunity, is the
same as that of other per.'^ons : in proportion
to the power of resistance, based upon constitu-
tional and cherished stamina.

WHEN SHOULD THE OBSTETRIC FOR-
CEPS BE USED? AND WHAT FORM
OF INSTRUMENT IS REQUIRED?

Read in the Section of Obstetrics and Gynecology at the Fortieth

Annual Meeting of the American Medical Association,

held at .Veu'por/, R. /., fune, iSSg.

BY WILLIAM S. STEWART, A.M., M.D.,

PROFESSOR OF OBSTETRICS AND CLINICAL GYNECOLOGY IN THE
MEWCOCHIRrRGICAL COLLEGE PHILADELPHIA, PA.

The question as to when the obstetric forceps
should be used follows on the assumption that
there are times when they are required. Taking
for granted this necessity let us briefly refer to it,
enumerating in the first place the circumstances
and conditions which do nof justify the applica-
tion of the blades.

The forceps should never be used simply to

gratify nervous patients, interfering nurses or
meddlesome women, nor to save the time of a
practitioner, busy or otherwise. The possibility
and comparative ease of applying the blades
within the partiallj- dilated os is no indication
that even the most careful use in such cases may
not result in the rupturing of the cervix and
other soft parts, exposing the patient to the im-
mediate dangers from haemorrhage, septicaemia
and the various inflammatory conditions, and as
well the possibility of life-long suffering.

The indications for the use of the obstetric
forceps may be enumerated as follows :

I . Where speedy deliverj' is necessary in the
interest of either mother or child ; as in eclamp-
sia, haemorrhage, exhaustion, prolapse of the
cord, etc. 2. Where the ordinarj' forces of labor
are insuflicient to overcome the obstacles to de-
liverj- ; as in narrowing or partial obstrtiction of
the birth-canal within certain limits, uterine in-
ertia, large foetal head, malpositions, and where
the head is engaged in the pelvis and there has
been no advance for some time, the " rebound "
during the interval between the diminishing
pains having ceased.

In addition it is of importance in all cases be-
fore applying the forceps to be assured of the ex-
istence of the following conditions: i. That
the membranes are ruptured. 2, That there is
complete dilatation of the os and retraction of the
cervix. 3. Knowledge of the position of the
presenting part. 4. Emptiness of the bladder
and bowel.

What form of Obstetric forceps should be etn-
ployed ?

The general answer is to use the form best
adapted to, the case if possible. It must be ad-
mitted, however, that each practitioner has ac-
quired by repeated experiences a certain degree
of skill in the use of his choice of instrument,
notwithstanding its imperfections. But it is not
mj' purpose to refer to the list of instruments
which have been more or less in use since the
time of Chamberlen's invention, either by con-
demning one or extolling another, but rather to
call your attention to some mathematical princi-
ples which should be taken into account in the
construction of the obstetric forceps.

It is a trite, but no less tnie saying that
" necessity- is often the mother of invention" —
with myself it has been the long felt necessity
for certain unfulfilled requirements in the ob-
stetric forceps in use that has led to investigations
and experiments in this direction. My chief ob-
jection to the instruments in use has been the
crossing of the handles, which, as we are all
aware, necessitates the application of the right
blade first in order that they may be locked.
When the ca.se is one of ordinary position of the
head (first position, or left occipito-anterior) there
is usually no difficulty in applying the blades in

1889.]

ETIOLOGY OF YEI.LOW FEVER.

771

the regular order ; but it has been my experience,
as it has no doubt many times been yours, that
when the head is in the second position (right
occipito-anterior) or is jammed into the right side
of the pelvis, after applying without difficulty
the first or right blade of the instrument the in-
troduction of the other was not possible without
great risk of injury to mother and child. In
every case that I recall, after removing both
blades and reversing the order of their introduc-
tion no difficulty was encountered till recrossing
in order to lock was found impracticable without
equally great risks of inflicting injury. An in-
strument made with the crossed handles reversed
would undoubtedly be suitable in these cases, but
for ordinary purposes it would not avail.

After much thought and study on this subject,
not taking into account the blades, but handles
to which any form of blade could be attached,
and admitting of the application of either blade
first, the instrument which it is my privilege and
honor to present for your inspection and consid-
eration is the result. The improvement, as has
been said, is in the handles alone, and it is to this
that your attention is called.

as to limit the compression to a degree corre-
sponding to that of the average instrument.

As an additional safeguard in malpositions
and irregular curvatures of the pelvis, the princi-
ple joint is not a fixed one, but allows of slight
forward and backward movements of the blades
in order that there may be a better adaptation to
the head as well as the pelvis ; provision has also
been made so that when with other instruments

' locking would not be possible, these handles ma}^
be secured and traction attempted, there being at
the same time a slight vertical freedom of the
blades to admit of the adjustment to the head be-
coming more perfect. When the locking can be
made absolute from the first this motion does not

! exist. The advantages then secured in the lock-
ing are effected by means of a coned hub with a
winged nut attached at the principal joint on the
right arm of the instrument.

In twenty-six cases,' all of which, undoubtedly,

I required instrumental delivery, I have used these

t forceps with results which were indeed surprises,
both on account of the facility with which they

I were applied — either blade first, the slight amount
of traction required in all of the cases, and the
entire absence of any disfigurement to the children
or evidences that in a single instance the com-
pression had been too great.

It is my conviction, gentlemen, that when the
obstetric forceps is required the use of this instru-
ment will be attended with fewer risks to the
mother, greater safety to the child, and much less
difficulty and anxiety to the accoucheur.

It was found necessary in constructing such an
instrument, in order to avoid the difficulties aris-
ing from the crossing of the handles, to do away
entirely with this form of handle, and return to
the parallel handles improved by the addition of
a second joint, and a hand piece so fitted that
the necessar>' traction and compression can be
made by a slight effort on the part of the op-
erator.

The force employed is thus a conjoint one
effected by means of a double lever, and is every-
where equal in amount to the resistance offered.
The amount of traction necessary in the use of
this instrument has been found by actual experi-
€nce both on the manikin and the living subject
to be very slight, and the compression just
enough to keep the blades from slipping off the
head, thus the amount of compression instead of
being regulated by the grip of the operator as in
the cross-handle instrument, is in every case con-
trolled by the amount of resistance offered, so
that in all ordinary cases there is little or no pos-
sibility of danger from this source. In certain
cases, however, unusual force may be found
necessary, and in order to avoid the risk of crush-
ing the foetal head by the increased compression
resulting the toggle joint has been constructed so

RECENT RESEARCHES RELATING TO
THE ETIOLOGY OF YELLOW FEVER.

Read at the Meeting of the Anierican Public Health Association iit
Btooklyn, N. }'., October 2j, 1889.

BY GEORGE M. STERNBERG,

MAJOR AND SURGEON U. S. A.

[Abstract for The Journal.]

The investigation in which I am engaged un-
der instructions from the President of the United
States, and in pursuance of authority of an Act
of Congress approved March 3, 1887, "making
appropriations for sundry civil expenses of the
government," is not yet completed. The cul-
tures which I have brought with me from Havana
will require further study, and extended compar-
ative researches will be necessary before a definite
conclusion can be reached as to the specific etio-
logical relation of one or the other of the micro-
organisms which I have obtained from yellow
fever cadavers, principally from the intestines.

Owing to the facts mentioned and the limited
time at my disposal, I can only give a brief gen-

* since reading the above I have applied the forceps, in all, the
thirty-fourth time up to date, with the same degree of satisfaction
and success.

772

ETIOLOGY OF YELLOW FEVER.

[November 30,

eral statement of the present status of the inquirj'
in which I am engaged and of the methods of
research which have been employed. But in my
final report a detailed account will be given of
the various microorganisms encountered and of
the numerous experiments made upon the lower
animals.

Having remained in Havana from the middle
of March until the first of September of the pres-
ent year, I have had ample opportunity to obtain
all the material necessary for a thorough research
by modem culture methods. Thirty autopsies
have been made in typical cases of yellow fever,
most of which occurred among Spanish soldiers
admitted to the military hospital in that city.

My cultures have been made for the most part
in flesh-peptone gelatine, and in agar-agar jelly
containing.five per cent, of glycerine ; numerous
cultures have also been made in sterilized blood
serum, in veal broth, and in agita coco. The last
mentioned medium I used to some extent during
my visit to Havana in 1879, as a member of the
Yellow Fever Commission of the National Board
of Health. During the past summer I have used
it extensively, and find it to be an extremely val-
uable culture-medium, which is as transparent as
water, and yet contains a large amount of nutri-
tive material. It has a specific gravity of 1020
to 1025, a slightly acid reaction, and contains in
solution a considerable amount of glucose. Both
aerobic and anaerobic cultures have been made
in the various media mentioned, into which have
been introduced blood obtained from one of the
cavities of the heart, material from the interior of
the liver, the spleen, and the kidney, urine drawn
through the walls of the bladder, and material
from the stomach and intestines.

A method which has also been pursued in the
entire series of cases consists in the preser\'ation
of a piece of liver or kidney, the size of a man's
fist, in an antiseptic wrapping, by which the ex-
terior is surely sterilized and the entrance of germs
from without is guarded against. Such a piece
kept in the laboratory for forty-eight hours as a
rule preserved its fresh appearance and had no
odor, but upon cutting into it it was found to con-
tain numerous and various microorganisms. The
cut surface had a decidedly acid reaction. The
microorganisms found under these circumstances
were bacilli of various species, and corresponding
with those found in the contents of the intestine.
They have been isolated by the use of Esmarch
tubes and carefully studied. Possibly one or the
other of them may be the veritable yellow fever
germ, but up to the present time no -satisfactorj'
evidence has been obtained that such is the case.
The bacilli which have been found most con-
stantly by this method are :

A large, motionless, anaerobic bacillus, resem-
bling in its morphology the bacillus of malignant
cedema. This is very commonly present and is

conspicuous by reason of its abundance and di-
mensions. In my list of microorganisms encoun-
tered it is designated by the letter " N. "

The bacterium coli comtnunc of Escherich, very-
common.

A motile, non-liquefying bacillus, resembling
bacterium coli commune in its morphology-, but
more pathogenic for rabbits and guinea pigs, a
facultative anaerobic, very commonly present —
my bacillus x.

A short motionless bacillus with stained ends,
in chains, resembling the bacillus of Babes, a
facultative anaerobic, not pathogenic for rabbits
or guinea pigs ; found in a limited number of
cases only — my bacillus o.

The presence of these various microorganisms
in liver obtained at an autopsy made soon after
death, and preser\'ed in an antiseptic wrapping,
may be taken as evidence that they were present
in small numbers at the moment of death, but
the examination of " smear- preparations" made
immediately after death, and culture experiments
made at the same time, show that they are not
numerous, and in a considerable proportion of the
cases the result of such immediate examination of
the fresh liver tissue has been negative.

It is an interesting fact that material from a
piece of liver kept as described, and containing
the microorganisms referred to, is very pathogenic
for guinea pigs when injected subcutaneouslj' in
small quantities, 2 to 5 minims, whereas the fresh
liver tissue may be injected in considerable amount
without producing any noticeable eflfect. This
pathogenic power is due to the microorganisms
present, and especially to my bacillus "N" and
my bacillus "x." Details of experiments will
be given in my final report.

Material from the intestine, also, which con-
tains the same microorganisms is very pathogenic
for guinea pigs.

At the close of my address I shall exhibit upon
the screen photo-micrographs of the bacilli re-
ferred to, and also of the various microorganisms
which have been claimed to be the specific germs
of yellow fever, viz.:

The micrococcus of Dr. Domingos Freire, of
Brazil ; his so-called cryptococais zanthogcniats.

The tctragenus febris Jiava: oi Dr. Carlos Fin-
lay, of Havana.

The liquefying bacillus of Dr. Paul Gibier —
my bacillus "g."

I may say with reference to the micrococcus of
Freire that I have not encountered it in any of
my cultures from the blood and tissues of yellow
fever cadavers, and that my extended observa-
tions fail to give the slightest support to his
claim.

The yellow fever germ of my friend Dr. Carlos
Finlaj', of Havana, which I have named miao-
coccus tctragetius versi tills, is one of the most com-
mon atmospheric organisms in the city of Ha-

1889.]

THE CLINIC.

773

vana. I have frequentlj' obtained it in cultures I
made from the surface of bodies of patients in
the hospitals in that city, and also in Vera Cruz,
but it is not present, unless by rare exception, in
the blood and tissues of 5'ellow fever patients.

The liquefying bacillus which Dr. Paul Gibier
isolated from the intestine in a limited number of
cases, I have also obtained from the same source
in about one-third of my autopsies, but it is not
constant, and when present is not abundant. I
see no good reason for supposing that it is the }
specific infectious agent in the disease under con-
sideration.

THE CLINIC.

ON BLOOD DISEASES.
BY FRANCIS DELAFIELD, M.D.,

PROFESSOR OF THEORY AND PRACTICE OF MEDICINE JaND PATHO-
LOGICAL ANATOMY IN THE COLLEGE OF PHYSICIANS AND SUR-
GEONS, NEW YORK.

[Reported for The Journal.]
SIMPLE AN.EMIA.

Case I. — This girl, gentlemen, says that she is
18 years of age; that four j'ears ago, when she
was 14 years old, she began to feel sick. When
asked in what way she was sick she replied that
she felt tired and weak, and her legs were swollen.
She also felt sick at the stomach, and threw up
sometimes. Her neighbors told her that she
looked white. She improved and was better for two
months, and then worse again; then she improved
again, and has been going on in this way, from
better to worse, and from worse to better, ever
since. She says that at present she has no head-
ache and is not sick at the stomach. At one time
she spat up some blood. Her feet are but little
swollen at present. When asked whether she
feels any pain, she places her hand over the left
side.

The urine has a specific gravity of 1.015; it
contains no albumen ; it contains phosphates.
The blood has been examined ; the haemoglobin
is 20 per cent., the blood cells number 1,714,000
to the cubic millimetre. There is a systolic mur-
mur, heard loudest at the second left intercostal
space.

We have, then, a case apparently of simple
anaemia, but one differing somewhat from the or-
dinary^ examples of this disease ; differing from
them principally in its long continuance and in
the severity of the symptoms. Yet, after all,
there is nothing in the history of the case to take
it out of the class of simple anaemias.

The girl, as some of you have heard her saj-, is
18 years old now, and she began to have the same
symptoms which she has now four years ago.
Those symptoms have continued during a large
part of the entire four years. They are observa-

ble in a marked degree at the present time. They
have been the ordinary symptoms of simple anae-
mia in young women. There is the pallor of the
face which we should expect to find ; there has
been headache, disturbance of the stomach, nau-
sea and vomiting, constipation ; and there has
been disturbance of the menstrual function, con-
sisting in irregularity and scantiness of the flow.
There has been the disposition to dropsy, cedema
of the legs occurring as far back as four years
ago, but not present in any marked degree now.
The disposition to bleeding has been present in
slight degree. In her case apparently it has not
been from the stomach. She has coughed up a
little blood from time to time. Whether the
blood comes from the throat, the bronchi or the
trachea, we do not know ; but the disposition to
bleeding from the mucous membranes belongs to
the disease. We do not know whether she has
had any febrile movement. It is ver\- probable
she has had, for in marked anaemia there is very
apt to be some febrile movement.

When we come to the actual condition of the
blood at the present time we find it about as bad
as it is likely to be in these cases of simple anae-
mia. The haemoglobin is 20 per cent. We some-
times find it down to 18 per cent, in cases of
simple anaemia, but 20 per cent, is a very small
proportion, and it means a verj' well marked case
of the disease. In the same way with the red
blood cells ; it is quite possible in milder cases of
simple anaemia to have no diminution of the red
blood cells, although the quantity of the haemo-
globin is decreased, but the moment we meet the
more severe cases we find also a diminution in the
number of the red blood cells. In this case the
number is diminished in a very maked degree ; it
is below 2,000,000, instead of being 5,000,000, in
the cubic millimetre.

So that we have both an old and a very decided
case of anaemia, yet I should have no hesitation
in saying that it is one of simple anaemia, although
the disease has lasted so long, and the changes in
the blood are so marked at the present time. I
should not consider it a case of pernicious anaemia.
The difference in the prognosis is very great in
these two conditions. If this girl has only a sim-
ple anaemia she will get well; if she has pernicious
anaemia she will not get well. So that the impor-
tance of the diagnosis as regards the prognosis
of the case is verj' great indeed. But, as I said,
I should have no hesitation whatever in pronoun-
cing her case one of simple anaemia, and in assert-
ing that, if placed under proper conditions, she
will get well. I should feel quite certain of it,
and I imagine that the onlj' reason why the dis-
ease has continued so long is simply the want of
proper treatment. The girl has kept about ; she
has probably consulted a physician from time to
time, has been under treatment for a short time,
and then, without getting really better, has gone

774

THE CI<INIC.

[November 30,

back to work, and thus the condition has been
protracted during all these 3-ears.

For this girl to get better, she must have the
proper treatment, and she must also live in the
proper way. The medicinal treatment is very 1
simple. It consists in the administration of iron
in large quantities, usually in the form of Blaud's
pills, which contain the sulphate of iron. We
give these patients of Blaud's pills anj'where from
six to twentj'-four a day. The}' should receive j
enough ; a small quantit}' is of no ser%ace.

Besides the administration of iron in large quan-
tities you should have the patient inhale oxygen
gas ten or fifteen minutes twice a daj\ In the
third place, the bowels must move every day, [
which may be induced by an enema or some sim- ^
pie laxative. That constitutes the medicinal part j
of the treatment, and it is exceedingly elBcacious.
Yet, after all, it is altogether empirical. We do
not know wh}- it is that these large quantities of
iron are so useful. It evideutlj- cannot be bj- sim-
plj' supplying the patient's blood with iron, for
we have to give a great deal more than is neces-
sary for this purpose. So of the inhalation of
oxygen, I do not think that theoretically verj'
much can be said for it, but practically it is a
very important part of the treatment. Then,
again, with regard to the constipation — of course
anybody is better off for not being constipated,
but it makes a greater difference with these pa-
tients with anaemia whether they are constipated
or not than it does with others. If they remain
constipated j-ou do not get the good effects which
j'ou ought from iroe and ox5'gen. Thus with re-
gard to these three points in the medicinal treat-
ment, each one of them is empirical ; we do not
know as well as we would like why the patients
improve under them, yet every day's experience
shows how much they do.

As to the feeding, I should put this patient upon
one solid meal a day, composed of meat and of!
bread and butter, and during the rest of the twen-
ty-four hours I would feed her on milk alone.

With regard to the mode of life : as this girl is
now, I should put her to bed. She is too sick to
be up and about. She will improve more rapidly
for a time if in bed than if she is allowed to be up.
By and by, after the blood had begun to improve,
she could begin to get up and go about. Now,
all this can probabh' be done for this girl if she
enters a hospital, and that will be the best place
for her. It will take, probably, two or three
months before she will be well enough to go to
work. By the end of two or three months, one
can saj' beforehand with considerable certainty,
that the blood will have changed in about this
way : In.stead of having 20 per cent, of haemo-
globin, it will have about 80 per cent. She will
not come up to the normal, but she will have 80
per cent, instead of 20 per cent. Instead of hav-
ing 1,714,000 red blood cells to the cubic centi- ,

metre she will have between 4,000,000 and 5,000,-
000. The blood will have returned to nearly its
natural condition ; the other sj-mptoms will have
disappeared. There will no longer at that time
be any disposition to nausea and vomiting. There
will be no disposition to bleeding, she will no
longer be short of breath, she will feel strong and
well, and able to go to work. That is what we
can promise in such a case with ver>- great confi-
dence. But this case being an aggravated one,
it is necessarj' that all parts of the treatment
should be carried out. It will not be enough to
give this girl some iron and let her go to work.
She needs rest in bed ; she needs diet, besides
iron, oxygen, and enemata to relieve constipation.

PERNICIOUS AN.^iMIA.

Case 2. — This old gentlemen was at our
clinic on March 21, 1889, and the diagnosis at
that time was, not of simple anaemia, but of
pernicious anaemia. The examination of the
blood then showed that haemoglobin was down
15 per cent. — a very small quantit}-. The red
blood cells were down to 1,662,000 — after all not
very much less than in the girl who has just
gone out. Taking the man as he was last March
and the girl as we have seen her to-day, and
there is not very much difference in the composi-
tion of the blood in the two cases. In the man
the haemoglobin was 15 against 20 in the girl,
and 1,662,000 red blood cells against 1,704,000.
There was no increase in the white blood cells at
that time.

He was put upon the use of tincture of chloride
of iron and of arsenic. On the 21st of March the
treatment was begun, and on the 5th of April the
haemoglobin had got up to 22 per cent. On the
20th of April it was 27 per cent., on the 25th it
was 22 per cent., and on the 7th of May it was
28 per cent. On the 13th of May the red blood
cells had increased to 2,425,000, and the haemo-
globin had increased up to 40 per cent. Thus
you see that there was a very substantial im-
provement in the condition of the blood under
the administration of iron and arsenic, from 15
up to 40 per cent, of haemoglobin, and from one
million odd up to two million odd of red blood
cells. During this time the man had no fever,
and no haemorrhages. He felt so much better
that he went back to his work, and continued to
work until a month ago. Then he came back to
the clinic with a return of the same symptoms,
but much weaker,

The examination of the blood made to-dai%
shows that the haemoglobin is 20 per cent., and
that the red blood cells are below 1,000.000, in
fact down to 300,000. That is a very- small
number, indeed. It is not often we get below
1,000,000 to the cubic millimeter. The urine has
a specific gravity of 1.015 ; it contains no albumen
and no sugar.

1889.]

THE CLINIC.

775

Now, this man presents about the same S3-mp-
toms as the girl we just saw. The changes in
the blood are of about the same kind, only differ-
ing in degree. L,ike her, he has had loss of
strength, dj'spnoea, and other sj-mptoms, but he
has not had a disposition to bleed. Although
the clinical histor}^ was much the same in the two
cases, yet I had no hesitation when I saw this
man in March, in saying that he had pernicious
anfemia instead of simple auEemia, and there is ,
still less reason for doubting that diagnosis at the
present time.

Now these cases of pernicious anaemia are
sometimes capable of temporarj- improvement,
but the rule is that the improvement is not only
temporary', but it never goes beyond a certain
point. The blood does not get anywhere near
back to the normal. It gets better, but it does
not get anywhere near the normal : and after im-
proving for a time, the condition of the blood be-
gins to grow worse, and the patient's general
condition changes for the worse. 1

The treatment of these patients then is not
nearly as satisfactory as the treatment of the '
cases of simple anaemia. The iron alone seems
to do them but little good. The drug that we
rely most upon is arsenic ; arsenic given in con- '
siderable amount during the twenty-four hours.
Although the administration of arsenic consti-
tutes the principal part of the medicinal treat- ,
ment, yet there also seems to be an advantage in
adding to it iron, the inhalation of oxygen, and
something to relieve constipation if it exist. j

Here, again, the treatment is altogether em- !
pirical. We know of no very good reason why
arsenic should be of benefit to these patients ; we
know of no very good reason why iron should
not be of as much use to these patients as it is to
patients with simple anaemia ; nor do we know of
any very good reason why oxj'gen should not be
of as much use to these patients as in cases of
simple anaemia. But a very little experience will
show you the practical difference, that the cases
of simple anamia get well under a certain plan of
treatment, and that the cases of pernicious anae-
mia never do anything better than improve some-
what and then get worse again ; and each time
that they get worse they are worse than thej'
were the time before.

It is very commonly believed that in simple
anaemia the change in the blood is due to a di-
minished formation of red blood cells and a di- :
minished production of haemoglobin, and that in
pernicious anaemia the cause of the change in the
blood is increased destruction of the red blood
cells. One observer in particular has gone so far
as to locate the place of destruction of the red
blood cells in pernicious anaemia in the liver.
He believes that in that organ there is constantly
going on an excessive destruction of the red
blood cells, and that that is the reason for the

change seen. All these considerations, however,
are so far theoretical ; but of one thing we can be
certain, and that is the practical difference between
a case of simple anaemia and one of pernicious
anaemia. But here, again, there are a good manj'
physicians who believe that pernicious anaemia is
practically nothing but a bad simple anaemia ;
that if you have simple anaemia bad enough, you
can be said to have pernicious anaemia. This I
do not think is true. I think the two conditions
are absolutely separate and have nothing to do
with each other. At all events, for practical pur-
poses we find that the prognosis and the effects
of treatment are altogether different in the two
cases. I would advise this man to enter the hos-
pital again.

After the patient had left the room Dr. Dela-
field continued :

I am very much afraid, however, that when he
goes into the hospital this time he will remain
there. He has reached the period of his disease
now at which we are not likel}' to get even tem-
porary improvement. With such an excessive
diminution in the number of the red blood cells I
should not hope for any real improvement at all.
The man can be made comfortable, but that is
all, I should suppose that he would not be likely
to live through the winter. He may be carried
off by some intercurrent disease, to which he is
more liable than other persons; or he may die, as
some patients do, simpl}' in a condition of very
great feebleness.

PSEUDO-LEUC^MIA (?)

Case J. — This voung woman was sent to the

clinic as a case of pseudo-leucaemia, orHodgkin's
disease. She says she has been unwell eight
months. We observe a tumor near the angle of
the inferior maxilla on the left side, which, she
says, has been present about two years. It is an
enlarged lymphatic in that part of the neck.
Some of the other glands in that region are also
enlarged, but they do not extend beneath the
clavicle. Those on the other side are not en-
larged. She says that eight months ago, or in
March last, she began to suffer from pains which
she describes as commencing in the region of the
sacrum and radiating down to the knees, both in
front and back. Sometimes a week would pass
when she would not have the pains ; then they
would come on and continue day and night. She
vomited at times, and then would lose her appe-
tite ; at other times her appetite has been pretty
good. She has been troubled with dizziness a
good deal, and has been short of breath, but she
says she has not coughed and has not spat up
blood. There was no swelling of the feet. She
remained in bed most of the time from last March
until two months ago. She lost flesh, but is now
much better than she has been. Her blood has
I been examined to-day. The percentage of haem-

776

THE CLINIC.

[November 30,

oglobin is 65, There is no increase in the num-
ber of the white blood cells ; the count of the red
blood cells has not yet been made. For two
•weeks she has been taking Fowler's solution,
three minims up to seven minims seven times a
day.

I doubt whether one would be justified in
classifying this case among those of Hogdkin's
disease. There seems to be no affection of the
glands except those in the neck. This tumor,
by the by, ought to be removed. It is very loose
and movable ; the deeper glands are not large or
numerous, and I think there can be no question
but it would be wise for her to have it removed
as soon as possible. It is quite independent, it
seems, of her other troubles. Such glandular
enlargements are never good things to have and
should always be removed, especially when it can
be done as readily as in this case. M}- assistant
had examined the other glands of the body and
did not find them enlarged. Two weeks ago he
thought he was able to make out some enlarge-
ment of the spleen, but he is no longer able to
do so.

The histor}^ is just one of those which we get
now and then, especialh' from women, in which
we find it very difficult to tell how much atten-
tion to pay to the symptoms which they lay most
stress upon. She had nothing to attract her at-
tention until two 3-ears ago, when she noticed an
enlargement on the lower part of the face, which
went on to increase in size, and is evidentl}- an
enlarged gland, due either to simple or tubercular
adenitis. She went along with this enlarged
gland, but feeling perfectly well, until last March.
Then she felt so weak that she went to bed, and
she began to have severe attacks of pain which,
so far as I can make out from her statement, be-
gan in the sacrum. From there they would ex-
tend down the thigh, but not following the course
of an}' particular nen-e ; she felt them, she said,
throughout the entire thigh down to the knees.
When she had these attacks of pain she also had
vomiting and inability to take food. When she
did not have the pains she did not have to vomit.
Sometimes she would have the pains every day,
sometimes she would skip a week, and lately she
had not had them for a month or so. The at-
tacks of pain, the weakness, and the disturbance
of the stomach seem to have been the prominent
symptoms. Two months ago she got a little bet-
ter, but not much. Then she came here to the
dispensary and has been coming seven weeks.
She was given arsenic, and during her attendance
at the dispensary she has improved a good deal.
She now feels a good deal better.

When we look at her the general appearance
is not particularly bad. She is flushed, of course,
with the excitement of being here, but her color
is not bad. She is in moderate flesh ; she says
she has gained in weight lately. There is noth-

ing to call attention to the heart, lungs, or any
of the viscera. The heart's action is rapid, but
there is no murmur.

This is a sort of case which is more common in
private practice than it is in cases which we see
here. I should be disposed to class it with the
patients, especially women, who suffer a great
deal, sometimes in one way, sometimes in another,
without really having any definite disease of any
part of the body. I do not mean to say that
the sufferings of these patients are imaginary ;
they are perfectly real. They are sick ; they re-
quire treatment ; and yet you can not ascribe the
sickness to any of the ordinary categories. They
are very often somewhat anaemic ; they have a
diminution in the quantity of haemoglobin, but
yet the}' are not typical cases of simple anaemia.
They do not behave in the same way, by any
means. There is a change in the composition of
the blood ; but, as said, they do not fall into the
class of cases of simple anaemia. When they
have pains they are very apt to have them as
this young woman has had them — in the wrong
place ; I mean the place that does not belong to
any of the regular kinds of pain. Instead of hav-
ing pain beginning in a particular place and be-
having in a way which pains do that belong to
diseases we know of, they get up some queer ir-
regular pain, as in this girl. It hurts as much,
evidently, yet it is equally evident that it does
not belong to the pains which have a real cause.
I mean by real cause something like inflammation
of a nerve or of bones, or pressure upon a nerve.
It is evident from this young woman's description
that her pain can not be due to any such cause
as that ; it is one of the cases of irregular pain.

Of course, to be at all certain about such a case
as this you should see it more than once. You
should ask a good many questions which I do
not care to ask her here. The moral condition
comes into play largely ; and so far as treatment
is concerned, they are cases for management
rather than anything else — the moral manage-
ment, the regulation of the diet and of the mode
of life. The particular medicine which you give
them is not of so much con.sequence, so long as it
is not opium or bromides (or the different drugs
given for nervous troubles). The change in the
blood, the anaemia which these patients have,
does not, as a rule, respond very readily to the
use of iron ; it responds much more readily to the
mode of life, to diet and exercise. Nor does it
respond verj' well to the use of arsenic. This
drug is sometimes of ser\'ice, sometimes it is not.
Since it seems to have been of benefit in this case
we will continue it.

MALARIAL POISONING.

Case j<. — The case of this young man is a per-
fectly straightforward one of malarial poisoning.
He works on board one of the steamers which

1889.]

MEDICAL PROGRESS.

777

ply between here and the West Indies, stopping
at different points, for a longer or shorter time,
where the severer forms of malarial disorders pre-
vail. He was in a hospital at Jamaica, but got
better and came out again. His illness dates
back seven weeks ; during more or less of this
time he has had headache, has vomited, has not
cared for his food, has felt hot, but has not had
chills. His temperature was taken five days ago,
when it was 102° F. ; to-day it is 98°. His urine
has a specific gravity of 1.025; 't contains no al-
bumen. On physical examination we find his
spleen distinctly enlarged; the liver, on the other
hand, is not enlarged. His blood has been ex-
amined and found to contain a large number of
crescent-shaped pigmented bodies.

The man has acquired not intermittent nor re-
mittent fever, but a form of malarial poisoning
which we commonly call malarial cachexia, in
which the main change is in the general condi-
tion of the patient. Such patients may have a
little fever, but it is not a prominent symptom.
They lose flesh and strength, and they may have
the characteristic changes in the blood.

MEDICAL PROGRESS.

Chrysarobin in H.emorrhoids. — Dr. Kos-
OBUDSKi, writing in the Riisskaya Meditsina on
Unna's plan of treating haemorrhoids with chr5^s-
arobin, says that he has employed it — or a modi-
fication of it — in twenty-two cases, and has found
it on the whole very satisfactor)'. He does not,
however, employ quite such strong preparations
as Unna. His plan is to wash the hsemorrhoid with
a weak carbolic or creolin lotion, and then to drj'
it well with cotton wool, after which he applies
three or four times a day an ointment consisting
of chrysarobin S parts, iodoform 3 parts, extract
of belladonna 6 parts, and vaseline 150 parts.
For internal piles suppositories are employed,
which are composed as follows : Chrysarobin, i
grain; iodoform, '4 grain; extract of bella-
donna, }i grain ; cacao butter, 30 grains ; glycer-
ine sufficient to enable the mass to be made into
the form of a suppository. If there is much
haemorrhage a tannin suppository must be used.
After three or four days of this treatment the pain
and haemorrhage disappear, and after three
months or so the haemorrhoids are found to have
almost completely shrivelled up. — Lancet.

Paratyphlitic Abscess. — Dr. J. F. Jen-
kins, of Tecumseh, Mich., at a meeting of the
Michigan State Medical Society, related a case of
paratyphlitic abscess. Paul P., aet. 10 years,
had an attack of paratyphlitis in December, 1886,
following catarrhal pneumonia. In fact, before

he began to convalesce from the pneumonic
trouble, the symptoms of paratyphlitis began to
manifest themselves. He was at that time con-
fined to the bed about three weeks with the dis-
ease, which eventually terminated in resolution.

The patient enjoyed good health until June 2,
1888, when Dr. Jenkins was again called to see
him. He complained of pain in the right iliac
region, and in that locality pressure elicited a
great deal of tenderness. The bowels were con-
stipated, and during the course of the disease
there was more or less tympanites. There was
occasional!}' a slight degree of nausea, but he
seldom or never vomited. Disuria was trouble-
some at various periods of his illness, and during
the same period priapism was occasionally ob-
served. The right thigh was flexed upon the
body during the course of the disease. This was
a marked condition in the first attack. He fre-
quently complained of pain extending from the
hip to the knee. The pain in the bowels was
never severe, and only required a limited amount
of anodynes to control it. The temperature
ranged from 100° F. to 103° F. He seldom or
never complained of being chilly. During his
illness his appetite was moderate and he slept
tolerably well.

July 19, nearly seven weeks from the date
when his illness commenced, the patient was
placed under chloroform by Dr. L. G. North.
Dr. Jenkins brought the right limb, which had
been flexed, into a straight position, which re-
vealed an elongated tumor in the iliac fossa
about the size of a walnut ; and by the use of the
hypodermic syringe, demonstrated the fact that
the tumor contained pus. He made an incision
into the tumor, and nearly eight ounces of very
offensive pus was evacuated from it. A moder-
ate sized drainage tube was introduced and ex-
tended to the bottom of the cavity of the abscess.
It may be well to mention here that this cavity
was never rendered aseptic. The patient hence-
forth rapidly recovered, notwithstanding the
weather at that season of the year was extremely
warm. This boj' onl}' a short time since passed
through his third attack of paratyphlitis, and
the formation of the second abscess, the symp-
toms being similar to the previous attacks already
mentioned.

His illness commenced on April i, of this year,
and a week from that date, he was again placed
under the influence of chloroform by Dr. North,
and an incision made into the abscess, and the
contents evacuated. Dr. Jenkins then introduced
his finger into the cavity in order to determine
whether there was anything that he could detect,
which produced the abscess, but with a negative
result. It was afterwards carefully washed out
with carbolized water, and a drainage tube in-
serted deep enough to reach the bottom of the
cavity. During several days afterwards it was

778

MEDICAL PROGRESS.

[November 30,

syringed out with carbolized water, and ten days
after evacuating the abscess the wound healed
and the patient was able to sit up.

The abscesses above described and operated
upon, were extra-peritoneal. The first abscess
was not operated upon until nearly seven weeks
had elapsed from the commencement of the at-
tack of paratj-phlitis ; from the fact that the pa-
rents would not consent to an earlier operation.
The principal factor in producing this Fabian
policy in their minds, and in Dr. Jenkin's, was
that the first attack of the disease terminated in
resolution, after an illness of three weeks. The
second abscess was opened on the seventh day
from the commencement of the attack, and the
patient made a rapid recovery.

The great difficulty is to diagnose between an
extra- and an.intra-peritoneal abscess. In either
case it is an all important factor to determine
when to operate. The history of the case, the
condition of the patient, the use of the hypo-
dermic syringe, or the aspirator, will go far in de-
termining the necessity of an operation which, in
many cases, if performed sufiicientl}- early, will
in all probability save the life of the patient, or
on the other hand, by prolonging the date of an
operation may jeopardize his life.

Disinfection of the Birth-Canal. — In or-
der to secure complete disinfection of the vagina
and cervix, Doderlein and Ginther have made
made many experiments. The employment of
simple mechanical measures, such as scouring
with the finger and irrigation with sterilized wa-
ter, has proved inadequate. The finger anointed
with vaseline to enable it to reach the various
vaginal folds, has given no better results. Irri-
gation with solutions of sublimate and carbolic
acid have only produced incomplete disinfection,
while they have the disadvantage of leaving the
mucous membrane dry and harsh. Contrarj^ to
Steffeck (who does not like creoline), the writers
have obtained their best results with creoline.
Their method is to annoint the finger with a lu-
bricant mixed with creoline, and then rub and
scour carefully the mucous membrane of the gen-
ital passages with it. This is followed by copious
injections of a 2 per cent, solution of creoline.
After this operation the mucous membrane re-
mains soft and supple, while the vagina has al-
ways been found to be free from all germs. —
Maygrier, Jicv. dcs Sc. Med.

Treatment of Svphilis by Subcutaneous
Injections of Mercurial Preparations. — H.
Leloir and M. A. Tavernier have adminis-
tered, during the last two years, 1573 injections
in the treatment of syphilis. The cases were
treated as follows : Eight hundred and seventy-
five with calomel in suspension in vaseline oil
(i to 12); 642 with the yellow oxide suspended

in oil of vaseline (i to 12) ; 56 with gray oil ac-
cording to Neisser's formula (vaseline oil 40, ethe-
rial. tincture of benzoin 5, purified mercury 20).
The injections of calomel and the yellow oxide
(half a Pravaz syringeful) were repeated every
eight days, the needle being thrust deeply in the
muscles of the fossa behind the trochanters :• the
injection of the gray oil (one-third of a syringe-
ful) was given everj^ nine daj's in the buttocks.
The punctures were covered with mercurial plas-
ter. These injections are especially useful in
cases of erythematous eruptions or the eruptions
of resolving syphilomata on the integument ; they
possess the sole merit of acting rapidly, not to
say harshly. Their action upon mucous surfaces
is almost ;///. They are more apt to be followed
by recidives than are inunctions, and are less cer-
tain than the latter in their efiects. The}' should
not be used in non-resolving syphilomata in cer-
ebro-spinal and visceral syphilis, or in cases of
pregnant women or in children. They are espe-
cially applicable in the treatment of prostitutes,
while in ordinary private practice their use is
attended with serious inconveniences. — Gazette
Med. de Liege.

Hydrastis in Membranous Dysmenorrhcea.
— Dr. Fr.anz Jord.\n relates in a Hungarian
medical journal an interesting case of most obsti-
nate membranous dysmenorrhcea, in which after
many years had been spent in trying all manner
of different methods of treatment, hydrastis
canadensis rapidly effected a cure. Dr. Jordan
employed the liquid extract of hydrastis cana-
densis, twent5'-five drops of which he ordered
twice a day. This very soon began to produce
an appreciable effect, and after a short time the
medicine was required onl}- at the time of men-
struation or for a few days previously, the loss of
blood becoming very light, and the pain disap-
pearing altogether. — Lancet.

Disinfection of Sick Rooms. — According to
Keldych {Journal de Med., Sept. 22, 1SS9). an
adequate disinfection of rooms may be secured by
saturating the air with eucalyptol, a disinfectant
that is not dangerous to inhale, and that has no
injurious effect upon furniture. Keldych has
shown that an examination of the air of clinical
lecture rooms, when thus treated, proves it to be
free from bacteria which can be cultivated upon
gelatine. Moved cultures can still be produced,
but the action of these upon the higher animals,
though not well understood, appears to be harmless.

Precocious Menstru.\tion. — Dr. A. J. Ja-
cob, of Hernando, reports the case of a child
four years of age who has been menstruating for
two years. The child, a negro, was exhibited at
the local Medical Society and found to be healthy;
its breasts are well developed and the pubes cov-
ered with hair. — Memphis Med. Monthly.

1889.]

EDITORIAL.

779

Journal of the American Medical Association

PUBLISHED WEEKLY.

Subscription Price. Including Postage.

Per Annum, in advance $5-oo

Single Copies 10 cents.

Subscription may begin at any time. The safest mode of remit-
tance is by bank check or postal money order, drawn to the order
of The Journal. WTien neither is accessible, remittances may be
made at the risk of the publishers, by forwarding in Registered
letters.
Address
JOURNAI. OF THE AMERICAN MEDICAL ASSOCIATION,
No. 68 Wabash Ave.,

Chicago, Illinois.
All members of the Association should send their Annual Dues
to the Treasurer, Richard J. Dunglison. M.D., Lock Box 1274, Phila-
delphia, Pa.

London Office, 57 and 59 Ludgate Hiu:,.

SATURDAY, NOVEMBER 30, 1889.

A NEGLECTED PHASE OF ENURESIS NOCTURNA.
So much is continually appearing in medical
journals on the subject of enuresis nocturna, and
so many remedies are being recommended as
wholly reliable and efficacious in its treatment,
that it would appear almost superfluous for us to
refer to it. And j-et, if we examine all this litera-
ture, we will see that it has a very one-sided

bromides or other sedatives; so that, in considera-
tion of the prejudicial manner in which this sub-
ject is generally treated, it seems that there is
still room for discussion directing our attention
more in the channel of a judicious inquiry- into
its causation and pathology, which naturall}- calls
for a clear perception of the anatomy and phj-si-
ology of the parts.

First with regard to the mature type, as pre-
sented by the adult male.

The detrusor and sphincter muscles of the vesi-
cal system are innervated from two sources : The
detrusors, those contained within the bladder
walls, are supplied from the sympathetic system,
and are, therefore, involuntary ; the sphincters,
two in number, of which the external is formed
by the compressor urethrse (A, fig. i), the inter-
nal by the ring of muscle making up the base of
the prostate (B, fig. i), are supplied from two
sources : the external one is supplied entirely
from the spinal cord, and is, therefore, entirely
voluntary; but the internal or prostatic sphincter,
while possessing some voluntary fibres, is com-
posed, mainly of involuntary muscle. As a re-
sult of this the process of collection and voidance
of urine is carried out in this waj':' We will
imagine fig. i to represent an empty bladder.

Figure i.

aspect ; that (except in cases arising from reflex
irritation or organic lesions, whose treatment is
indicated b}- the discover)' of such a cause — a
class which we do not propose to consider here)
nearly all of the remedies advised are used either
empirically, or their use is based on the idea that
the origin is invariably, as Trousseau declared,
a neurosis, an excessive irritability, or exaggerat-
ed tonicity of the muscular fibres of the bladder,
subser\'ient to a hypersensitive condition of the
mucous membrane of the organ ; and the little
sufferers are accordingly dosed in progressively'
increasing quantities with belladonna, atropia,

Figure 2.

Both sphincters are then closed and the point of
separation between the bladder cavity and the
urethra is clearly defined. But as urine accumu-
lates in the bladder, it gradually lifts up and dis-
tends the vesical walls until the amount of dis-
tension reaches a certain degree, when the urine
pressure becomes sufficient to divulse, to a slight
extent, the urethral opening, allowing some of
the urine to trickle into this prostatic portion,
soon distending it also. It is then that the desire
to urinate is first felt. But if it is not convenien t
for the person to answer the call at that time, his

I "Gonorrhoea der Sexualorgane," Finger, iSSS.

78o ENURESIS NOCTURNA. [November 30,

will acts on the sphincter — the external one more But it may be contended that this is not neces-
especially — which remains contracted until such sarily so — that the hyperexcitability first referred
time as he is willing to pass his water. Then ■ to will explain this phenomena equally as well,
the bladder is in a condition about like Fig. 2, What do we know about "hyperexcitability" or
and the cavities of the prostate and bladder are irritability of the bladder ? That wherever there
merged into one. When the person does wish to 1 is such a condition, it manifests its presence in
pass his water, the external sphincter and that unmistakable terms. There is frequency of uri-
part of the prostatic muscle located at its apex | nation, by day as well as by night, with pain that
relax their Tigil and open up a passage for the admits of no dallying when the call to urinate is
urine. j felt. What man with an inflamed or irritable

That all this is true may be proved in various ! bladder-neck dares to disregard the signal of
ways, the simplest being to introduce a catheter i accumulated urine?

when the bladder contains only a small amount On the other hand, do we hear the little sub-
of urine, mark the length of the catheter within jects of nocturnal incontinence make an^- com-
the urethra just when the first drops of urine ap- plaints of this sort? If we listen attentively to
pear, then wait till the bladder is quite full and his or his mother's description of the trouble, we
repeat the experiment, when it will be found that will probably soon disabuse ourselves of pre-
fuUy three-quarters of an inch less of tubing will j formed ideas of excitability, etc. The complaint
be required now to "strike water" than vias is s\mp\y oi an inabilily to hoM -water. There is
necessary in the first experiment, showing the j no pain, no urgent desire to urinate, other than
shortening of the urethra in consequence of the that produced by the remembrance that unless
encroachment of the bladder cavity on it. So he take the proper care, the consequences of pa-
that the power of voluntarily holding a bladder- rental wrath will follow the soiling of his clothes,
ful of urine depends not so much on the strength To be sure, we must admit that there are some
of this internal sphincter as it does on the strength cases for which irritability, in consequence of
and amount of control which the person has over hyperacidity of the urine, or some such transient
the external one. But, on the other hand, that \ condition, must be held accountable, but such
the external needs the support and reenforcement cases are as short-lived as their causes, and are
of the internal or prostatic sphincter, is proved ^ not to be classed with those under discussion.
by the very affection under discussion. I Concluding, then, that enfeeblement of the re-

in early infancy the retentive function is almost tentive powers is the raison d'etre of the malady,
nil, and incontinence is therefore natural, phj'sio- our object should naturally be to combat this de-
logical. Later, in childhood, the boy is educated I feet. The administration of strychnia, rhus aro-
up to and practices control over his sphincter, matica, ergot, etc., probably has a certain value
the external voluntarj' one, the only one as yet in this respect ; but the remedy, reliable above all
in working order, which he manages very well 1 others, and the one that has done much to sub-
during the day, when urination is frequent and stantiate the views just presented, is that of elec-
calls are promptly met ; but at night, when his tricity, applied not by placing one pole on the
will-power is banished in the land of dreams, the perineum and the other on the abdomen, in the
urine surprises the slumbering sphincter, steals vague hope that, guided bj- a kind Providence,
past it and escapes into the bed. But with the the current may pass through the enfeebled mus-
development, towards puberty, of the prostatic j cles ; but it should be conducted through them by
tissue and the accession of involuntary sphincter means of an insulated electrode introduced into
action, such incontinence, whether nocturnal or the urethra after the manner commonly employed
diurnal, ceases ; the involuntary comes to the in treating strictures with electrolysis. Guyon,
assistance of the voluntary', bears its share of the the originator of this method, directs that each
burden, and the infantile annoyance becomes a seance be not longer than two or three minutes
nonentity. Should it persist after this epoch, we 1 in duration, and not too frequent. Only the
must attribute it to a continued weakness or lack sphincters are to be galvanized. The female
of development on the part of one or both of the urethra, surrounded as it is by sphincter muscle
sphincters. I throughout its extent, is treated by passing the

1889.]

TOPICAL TREATMENT OF DIPHTHERIA.

781

electrode slowly back and forth from meatus to
vesical neck.

Successes with this method, in both male and
female patients, have been obtained and reported
by GuYON,^ Jamin' and others, whose names we
do not now recall, and success in each case was
forcibly emphasized by previous records of re-
peated failures with other established and ap-
proved plans.

We do not wish to be understood as advocating
this as an invariably appropriate treatment for
infantile incontinence, but our object is simply to
express a belief that it is too little used in many
cases in which close questioning and a definite
diagnosis would point to it as the only rational
method.

THE TOPICAL TREATMENT OF DIPHTHERIA.

There is a widespread and seemingly well
grounded belief in the primarily local nature of
diphtheria. If the belief be true, local treatment
is demanded, and that at the earliest possible mo-
ment. And although the question of the local
nature is one of great importance, the practitioner
ought not to permit his own skepticism to master
his method of treatment. Much of the danger
inherent in the disease lies in the possible exten-
sion of the diphtheritic process into the lower
respiratory passages. If, therefore, there is a
method of topical treatment which will arrest the
development of membrane and prevent its exten-
sion without doing injury to the patient, that
remed)' should be employed in every case. The
doubt which exists m the minds of some practi-
tioners as to the possibility of attaining this end,
and the diversity of opinion among others as to
how the end may be attained are, in one sense,
unfortunate ; but they have no doubt had the ef-
fect of stimulating investigation.

Almost every remedy and every conceivable
combination of remedies has had its advocates.
Lunar caustic, one of the earliest applications, is
now seldom emploj'ed, except at the commence-
ment of the disease when the membrane is yet
very limited in extent. Morell Mackenzie
pronounces caustics dangerous and astringents
harmful, and prefers as a topical application a
solution of chloral hydrate. Corrosive sublimate,
the best of all parasiticides, should, a priori, be
the best agent for local application, and it has of

2 " Le9ons Cliniques sur les Mai. des Voies Urinaires," p. 211.

3 Journ. de Med. de Paris, No. 15, l88g.

late been used by many with much success, but
it must obviously be used with due caution.

In the American Journal of the Medical Sciences
for November, Mulhai.l, of St. Louis, proposes
washing out the throat with about a cupful of an
antiseptic solution by means of an ordinary house-
hold syringe at inter^'als not exceeding three
hours in length. A diluted mixture of carbolic
acid and compound solution of iodine is recom-
mended as best suited to the purpo.se. The au-
thor asserts that the method of treatment may be
practiced with impunity even on very young chil-
dren ; but we should fear for the result in less
skilful hands.

Dethil's treatment with turpentine, tar and
resin should not be lost sight of, for we have com-
bined in it both local and systemical treatment of
the patient, and disinfection to some extent of the
apartment or the entire dwelling. A more agree-
able if not more efficient mode of procedure is
that of J. Lewis Smith, who recommends the
constant ebullition of a mixture of eucalyptus oil
and turpentine in the proportion of 2 drachms to
8 ozs. in a quart of water. Schmiedler has more
recently practiced the local application of pure
turpentine.

We have repeatedly seen permanent arrestation
of all throat symptoms follow the thorough appli-
cation of the solution of subsulphate of iron (Mon-
sell's solution), as practiced by Whittaker, of
Cincinnati, and reported by him in 188 1, after its
successful use in a series of nineteen cases. The
method consi.sts in passing a brush or pledget of
cotton saturated with the solution up into the
post-palatine space, permitting the spontaneous
muscular contraction which follows to express
the medicament, thus causing an inundation of
the entire mucous membrane. The application
is attended with no danger of injuring the mucous
surfaces and is followed by no more serious conse-
quences than retching and sometimes vomiting.
In this application we have probably the combined
action of an astringent and a parasiticide. As an
astringent, its use is indicated to retard the growth
of membrane and to prevent the absorption of pto-
maines. As a parasiticide, it is directed against
the supposed cause of the disease. Whittaker is
quoted as having recently reiterated to the Acad-
emy of Medicine his confidence in the method.
Favorable reports have appeared from other sourc-
es also, rendering it highly proper that the remedy
should receive a thorough trial.

782

EDITORIAL NOTES.

[ November 30,

EDITORIAL NOTES.

HOME.

• Hygiene and Physicai, Culture at Get-
tysburg.— The parents of the late Dr. Charles
H. Graff have donated the sum of $25,000 to the
Pennsylvania Hospital, Gettysburg, for the pur-
pose of endowing a professorship of hygiene and
physical culture in that institution.

Southern Gynecological Association. —
The Southern Surgical and Gynecological As-
sociation closed its annual session in Nashville,
Tenn., on the 14th inst. The next meeting will
be held in Atlanta, Ga. Dr. George J. Engel-
mann, of St. Louis, was elected president ; Dr,
B. E. Hadra, of Galveston, Texas, first vice-
president ; Dr. Duncan Eve, of Nashville, Tenn. ,
second vice-president ; Dr. W, E. B. Davis, of
Birmingham, Ala., secretary, and Dr. Hardin P.
Cochrane, of Birmingham, Ala., treasurer.

The Central Texas Medical Association
will meet in Waco, Tuesday, January 14, 1890,
for which meeting the following programme has
been appointed : "Cerebro-Spinal Meningitis,"
by Dr. J. C. J. King ; " Pneumonia," by Dr. C.
T. Young; "Haemorrhoids," by Dr. J. E. Brown;
"Cystitis," by Dr. W. C. Blalock ; "Diseases In-
cident to Dentition," by Dr. J. M. Witt.

North Texas Medical Association. — The
next meeting of this Association will be held in
Gainesville, Texas, beginning on Tuesday, De-
cember 10, 1889, and continue for three daj's.
The meeting will be called to order promptlj' at
7:30 o'clock P.M. The arrival of the trains late
in the afternoon occasions the selection of this
hour, in order that valuable time may not be lost.
The following programme has been issued :

Section on Practice ofMedicitte. — ' 'Exophthalmic
Goitre," by Dr. T. M. Taylor, Sherman; "Val-
vular Lesions of the Heart," by Dr. M. C. Mc-
Bride, Lebanon; "Acute Articular Rheumatism,"
by Dr. J. D. Bedford, Honey Grove.

Section on Obstetrics and Gynecology. — "Puer-
peral Fever," by Dr. O. H. Caldwell, Dodds ;
"Diagnosis and Treatment of Pelvic Cellulitis,"
by Dr. J. E. Gilcreest, Gainesville; "The Most
Desirable Position for a Woman in Labor," by
Dr. Alonzo Sims, McKinnej-.

Section on Surgery. — "Traumatic Cataract,"
by Dr. R. H. Chilton, Dallas; "The Indications
in the Surgery of the Larynx and Trachea," bj'

Dr. E. W. Rush, Paris; "Surgical Cases, Includ-
ing Two Cases of Laparotomy," b}- Dr. J. M.
Inge, Denton.

]'olunteer Papers by Request. — "A New Arti-
ficial Drum Membrane," b}' Dr. H. N. Spencer,
St. Louis; "Herpes Progenitalis," by Dr.G. Frank
Lydston, Chicago, 111.; "Extirpation of the Ileo-
Caecal Junction," by Dr. J. F. Hooks, Paris;
"Cerebro-Spinal Meningitis," by Dr. S. D. Moore,
Van Alstyne.

foreign.

Dr. G. Gr.\nville B.\ntock; has been elected
an Honorary Fellow of the American Association
of Obstetricians and Gynaecologists.

First Aid in the Italian Army. — The
.Italian Minister of War has requested the medical
department to draw up a programme of instruc-
tion in the elements of medicine and surgerj^
suitable for use in militarj- schools. It is in-
tended that all cadets and non-commissioned
ofiicers shall make themselves competent to give
first aid in cases of accident and other sudden
emergencies.

The American Hospital at Teheran. —
The United States Minister to the court of the
Shah, recently laid the corner stone of an Ameri-
can hospital at Teheran. The funds for its erec-
tion have been raised partly in the United States
and partly in Persia. Dr. W. W. Torrence, of
Teheran, was the originator of the movement.

The Scientific Grants of the British
Medical Associ.\tion. — We learn from its offi-
cial organ that Dr. Sidne}- Martin has, on the
recommendation of the Scientific Grants Commit-
tee, been reappointed by the Association one of
its research scholars for one year. The following
additional grants have been made by the Council
in accordance with the recommendation of the
Scientific Grants Committee : Mr. Haukin ^"50
to continue his investigations into the nature of
an albumose that has been obtained from anthrax
cultures under certain conditions ; Dr. R. Kirk
^10 for a research on alcaptonuria and on the
distinction between albumen and mucin in the
urine, and some other points in connection with
proteids in that fluid ; Dr. J. R. Bradford ^15 for
some experiments on the action of the cortex
cerebri on the vaso-motor sj-stem ; Dr. H. H.
Ashdown ^10 for a continued research upon ab-
sorption from the bladder.

1889.]

TOPICS OF THE WEEK.

783

TOPICS OF THE WEEK.

THE ANATOMY OF THE FUTURE.

Some years ago au elderly professor of anatom}' ex-
pressed his thankfulness that in the branch he taught
there was no harassing progress. Physiology and chem-
istry, he said, were undergoing changes from one daj' to
another, but anatomy was always anatomy, a bone was
always a bone, and there was no wearisome struggle to
keep up with the rushing progress of the times. And
such is the view of anatomy entertained by many of the
profession. Not a few of us think, when we look back
over a number of years spent in active practice, that we
started on our journey with much more baggage than
was necessary in the way of memorized anatomical
truths; that we could have done with a smaller quantity,
but that that smaller quantity should have been better
selected. We question whether the anatomy taught in
our colleges to-day is the anatomy- of the future. Is it
not rather a result of the labor of successive generations
of book-writers, each showing more eagerness to add
new facts to the mass than to examine into and verify
the old ones ?

The anatomy of the future will not resemble that
taught now. The scope of the subject requires enlarg-
ing, and for the narrowing memory work done to-day a
broad view of the whole must be substituted. In other
words, the student should first acquire a knowledge of
general and comparative anatomy, and subsequently
study its application to the human body. To begin work
with the descriptive anatomj' of man is working back-
ward. Such a course has been likened to the study of
an ultimate twig of a tree by a person who is ignorant of
the character of the larger branches, of the trunk, and of
the soil on which the tree grew.

Embryology urgently demands attention as a neces-
sary introduction to the study of the parts of the body
and as a subject the knowledge of which is of direct prac-
tical advantage in daily professional life. Observe how-
important has become the anatomy of the embryo in
connection with the study of disease. The disposition of
the layers of the embryo must be clearly understood to
enable one to understand the structures of the body and
the diseases developing in those structures. Studies
such as these lighten the student's task. Take, for in-
stance, the arrangement of the great vessels in the root
of the neck. The disposition of these structures is
learned commonly by the study of a scheme or diagram,
perhaps by the friendly aid of a cunningly devised "tip."
The relations of these vessels could, by the study of de-
velopment, be so impressed upon the student's mind as
never to be forgotten. Can any of our readers forget
what a bugbear the peritoneum was ? Can 5-ou put 3-our
hands on your hearts and say that you thoroughly under-
stand all about it now ? And j'et, when the peritoneum
is studied from its early and simple state there will be
no longer anj' difficulty either in comprehending or re-
membering the arrangement of its folds.

The very great advance made of late years in the studv
of nervous diseases renders a change in anatomical teach-

ing very necessar3\ In our day the anatomy of the ar-
teries was paramount, and the nervous system occupied
a position of secondary importance. Yet the nerves,
their cutaneous distribution, their communications with
central ganglia and with one another, are matters of
daily, almost hourh", consideration in the round of a
doctor's visits, while of the arteries, over which we spent
such time and such labor, there is rarely occasion to
think. The practitioner is constantly meeting with ner-
vous manifestations the correct interpretation of which
renders a clear knowledge of nerve distribution necessa-
ry, while it is possible for him to practice for the whole
course of his natural existence without ever being called
upon to tie an artery. Should such a demand be made,
he will seize the bleeding point in the wound, secure it,
save his patient, and then go home to study the vascular
system afterward. The statement has been made, we
think by the late Dr. Fothergill, that the chances of an
ordinarj' practitioner being called upon to tie the subcla-
vian are almost equal to those of his meeting his death
by lightning stroke.

To render the study of anatomy attractive and at the
same time thoroughly useful, a complete change in our
present system is called for, and teachers will soon have
to consider the importance of comparative anatomj- and
of embryology as introductory studies, and the necessitj-
of putting the nervous system in its proper place as the
most important department of the human body, and not
waste their energies in teaching the relations of arteries
with which the student is unlikel}' ever to have anything
to do. — Editorial— A'. F. Med. Jour.

THE PULSE IN DISEASE.

While the clinician is accustomed to feel the pulse of
his patient in order to add to his knowledge concerning
the case before him, we think that he rarely does so be-
cause he expects to gain more than a general idea of the
state of the circulator}- apparatus, and with no attempt
on his part to go deeper and determine the causes which
produce the changes which he is so apt to note in his
daily life.

We have already called attention in an earlier number
of the Magazine to the stimulating influence which heat
exercises in moderate amount upon the heart and its
nervous ganglia, and have shown how the rapid pulse of
fever is due to a simulation of the cardiac accelerator
nerves. We are accustomed to regard a rapid pulse as a
concomitant of fever and to do no more, forgetting how
the sudden fall of a high temperature maj- be followed
by a cardiac failure, not due, as some have supposed, to
exhaustion, but to the withdrawal of the accustomed
stimulation. From the studies of Brunton and others,
we may have seen this fundamental fact concerning the
pulse proved by the most positive experimentation.

The causes of collapse in the course of au acute dis-
ease such as scarlet fever, for example, are not so largely
due to general exhaustion as we suppose. It is a matter
of common-stock knowledge that excessive stimulation
of any portion of the bod}' means exhaustion. In a
fever the high-bounding pulse of the early stages denotes
not only an increased action of the heart, but also an in-

784

TOPICS OF THE WEEK.

[November 30,

crease in the blood-pressure, from the excitement of the
vaso-motor centre in the medulla. Under these circum-
stances the high fever suddenly drops, producing col-
lapse, or, the fever continuing, a palsy ensues from ex-
cessive action. Such a result does not evidence nervous
failure, but circulatory break down. Similarly the soft,
compressible pulse of the person whose muscles are re-
laxed and flabby, evidences general lack of tone.

We have the several causes of rapid pulse. Fever, by
its heat, exhaustion of the vagus, imperfect cardiac ac-
tion, by which the tissues are strained and call for more
blood, and finally relaxation of the blood-paths, whereby
the resistance to the heart is decreased, and the heart
rushes on unhindered and pumping into a huge expanse
of blood-vessels.

The causes of the slowing of the pulse are equally
numerous. The diminuation of pulse-rate by cold so
seldom influence the heart in daily life as to be an un-
known factor, but the vagal irritation and high arterial
pressure are constantly at work, and it is often the part
of the physician to relieve the spasm of the blood-
vessels rather than to give stimulants to support the
heart. By remembering facts such as these, we are often
able to treat diseased states with not only a better ap-
preciation of the requirements of the patient, but also
with a clear understanding of the reasons for each and
every change of treatment. — University Med. Magazine.

THE SPECULUM IN ANCIENT SURGERY.
Dr. Ali Cohen, of Groningen, describes, in the Ned-
erland Tidschrift van Geneeskunde, a remarkable passage
in the Talmudic treatise called the Niddah. The physi-
cian is there instructed, when it is uncertain whether
hemorrhage proceeds from the vagina or the uterus, to
introduce a " siphopheroth " into which a " mechul " is
introduced bearing "mouch." When the " mouch " is
found, on retraction, to be covered with blood, that shows,
according to the Niddah, that the hsemorrhage is uterine.
It is expressly stated that the apparatus does not wound
the patient in any way. The "siphopheroth" was a
cone of lead; its orifice was bent inwards, so as not to
wound the vagina. The term is manifestly corrupted
from the Greek. The "mechul" was a long wooden
rod, and "mouch" signifies a preparation very like
charpie. Thus the mechul and mouch were the equiva-
lents of the speculum forceps and wool. The siphophe-
roth was not the strict homologue of the speculum, but
rather a contrivance meant to guard against a source of
fallacy respecting the .seat of hemorrhage in pelvic dis-
ease. It is not stated that the instrument was designed
for direct inspection of the cervix. Facts of this kind,
unearthed by Dr. Cohen, are of considerable interest.
They show that the sound scientific methods and ideas
which prevailed in the old civilization of the Mediterra-
nean basin were not confined to the Egyptians, Chaldees,
and Graeco Roman nationalities, but also certainly flour-
ished in Judea. Historians are fond of tracing the arrest
of true scientific research, so marked in the Middle Ages,
to the blending of Gneco-Roman and Semitic ideas, so
favorable to humanity in other respects. That very
blending brought about more than one enlightened and

philanthropic religious system. L,ogically, it should have
aided science. But science remained in abeyance till the
Renaissance. The fault probably lay not in Christian
and Jewish systems of civilization, but in the intellect of
the Teutonic and Latin nations, which was insufiiciently
developed during the Middle ages to appreciate science.
— Brit. Med. Journal.

THE GRAPHIC ARTS IN MEDICINE.

On Friday, November ist, a meeting was held in the
large theater of the medical school of St. George's Hos-
pital, with Sir Prescott Hewett in the chair, to inaugurate
a society for the encouragement of the pictorial and al-
lied arts amongst past and present students of the hospi-
tal. In opening the meeting the Chairman expressed
his opinion of the extreme value of drawing and painting
to the medical man, not only for the actual results pro-
duced, but also, if seriously followed, on account of the
value of the training. He then related how his pre-med-
ical career had been passed in a French studio, and how
the training had developed his accuracy of sight, and of
what great importance this had been to him in his surgi-
cal work. Referring to photography, he mentioned that
its importance was becoming daily more and more recog-
nited, both in clinical and museum work, and reminded
his hearers that modem photography owed its recent
great progress to the enthusiasm of amateurs. Dr. Dick-
inson formally moved : "That a society be formed in
connection with St. George's Hospital for the purpose of
encouraging sketching, painting, engraving, modeling,
carving, photography, and the arts of representation in
general." One of the ways in which it was proposed to
attain this end was to hold a meeting of the society at
least once a year, at which members should exhibit any
of their productions that could be inchided under the
above headings. The meeting closed, after the election
of officers and council, with a very cordial vote of thanks
to Sir Prescott Hewett for taking the chair, and the so-
ciety is fortunate to have secured him as its first Presi-
dent. Past students of St. George's who may be desirous
of joining the society are requested to send their names
to Dr. Penrose, the Honorary Secretary, at the hospital.
— British Medical Journal.

VIRCHOW AND THE DARWINIAN THEORY.

According to the Vienna correspondent of the British
Medical Journal, in Professor Virchow's presidential ad-
dress at the recent meeting of the Anthropological Con-
gress, the Darwinian theory was referred to, and he said
that the intermediate link that should bring man and the
ape into connection — the proper " prosanthropos " — had
been sought for in vain. It was impossible even to de-
termine the descent of single races from others ; and it
could be asserted that among the ancient races tliere was
none that stood in any nearer relationship to the ape
than ourselves. There was no tribe of people in the
world that we were unacquainted with ; and not one of
the known tribes could justly be considered ape-like, ap-
pearances common to apes — such as prominences of the
skull — being insuflicient evidence of relationship. There
was evidence that in the course of 5,otX) years no re-
markable changes of type had taken place. This adds
to the evidence of the impassibility of the chasm between
the highest type of anthropoid ape and the lowest type
of man. — New York Medical Journal.

1889.]

PRACTICAL NOTES.

78;

PRACTICAL NOTES.

b

BACTERIA IX WATER.

Water ruaj- appear clear, yet swarm with bac-
teria, nor does freezing much lessen the danger of
water, since manj' bacteria are unaffected by
freezing. Ice sometimes contains the bacteria of
typhoid fever, indeed it maj' be nothing short of
a congealed emulsion of bacteria with which we
can inoculate ourselves. The protection of water
from pollution by sewage is a problem which con-
cerns everybody. Absolute safety can only be
obtained by the use of ice artificiall}- frozen. —
Dr. C. G. Jackson.

THE TREATMENT OF ECZEMA,

Dr. Unna, of Hamburg, publishes in the
Monat. fi'ir Derm., a paper on the Diagnosis, Eti-
ologj-, and Treatment of Eczema. He says that
even before the experimental cultivation of bacilli
exact clinical observation had distinguished a
number of entirely different types of eczema, and
he thinks that each different t3-pe will be found
to require a different mode of treatment. The
type most frequently seen in Hamburg is sebor-
rhceic eczema, and the parasite causing it is the
same which in the first instant produces pityriasis
capitis. Those persons who suffer from sebor-
rhoeic eczema of the head, including those affected
with pityriasis capitis, are apt to suffer from the
same kind of eczema on other parts of the skin.
Dr. Unna has repeatedlj' pointed out that we
possess a series of valuable remedies for the treat-
ment of seborrhceic eczema in all its forms — viz.,
.sulphur, resorcin, chrysarobin, and p5'rogallol.
Of these remedies resorcin is the best, as being
the least likely to produce local or general ill
effects. It may also be used in an alcoholic or
watery solution, or in the form of ointment,
paste, soap or powder. Dr. Unna's favorite
formula is a solution of three drachms of finely-
powdered resorcin with an equal quantity of gly-
cerine in 6 ounces of spirits of wine, diluted with
four times the quantity of water or chamomile
tea. A thin layer of cotton wool well moistened
with the solution is applied, covered with some
waterproof material, and fastened b}' a bandage.
These applications are particularl}- useful when
the treatment is prolonged, or when it is carried
out by night. They are, of course, impossible
in general eczema of adults, but not in that of
infants. Dr. Unna describes an especialh- im-
portant effect following the application of resorcin,
viz., a swelling of the epidermis, by which all
painful fissures are healed in a single night. In
order to insure healing, he advises that the skin
should be anointed after the removal of the
bandage, and that washing with soap should be
avoided. A few people suffer from a resorcin
idiosyncrasy ; this is, however, very rare, as he

has only met with it ten times in five years' ob-
servation, during which time he has seen 2,000
cases. He remarks that his treatment is not
adapted to those cases of long-existing eczema in
which strongly infiltrated of thickly-indurated
patches occur. — Lancet,

IODOFORM GAUZE IN POST-PARTUM HAEMORRHAGE.

Dr. O, Piering, assistant in Prof. Schauta's
obstetric clinic in Prague, has published his ex-
perience in the employment of Diihrssen's plan
of plugging the uterus with iodoform gauze for
post-partum haemorrhage due to an atonic condi-
tion of the organ. Diihrssen recommends that,
when post-partum haemorrhage comes on, the
bladder should be emptied, and forcible friction
and intra-uterine irrigation of hot or cold water,
along with ergotinin hypodermic injections em-
ployed ; that if the haemorrhage still continues,
the cavity of the uterus should be filled with
iodoform gauze, the irritation produced by this
setting up active and permanent contraction.
The method has, according to Diihrssen, the ad-
vantages of great certainty, complete harmless-
ness, and facilit)' in its performance. Olshausen,
Veit, and Tehling, however, say that the contrac-
tion set up is not always permanent, and that the
method is not so free from danger as Diihrssen
believes. In consequence of these conflicting
views. Dr. Piering resolved to give the method a
trial, and he details several cases in which he em-
ploj'ed it with complete success. In no case was
anj^ harm done by it. He advises that resort to
the plug should not be too long delayed, and he
prophesies an important future for the plug of
iodoform gauze in post-partum haemorrhage. —
La nee t.

COOLING OF THE BODY BY SPRAY.

Dr. S. Pl.^Czek, following up some laboratorj^
experiments by Preyer and Flashaar, on the
effect of spraying a considerable part of the body
surface of animals with cold water, has applied
the spray for the purpose of reducing febrile
temperatures in human beings. In the case of a
man suffering from phthisis, whose temperature
was high, he found that by spraying about a pint
of water at between 60° and 70° F. over his body
the temperature fell to normal, and continued so
for several hours. Again, a similar method was
satisfactorily applied in the case of a girl with
diphtheria. In the healthy human subject the
spray lowered the temperature nearly 2°, and in
animals which had been put into a condition of
septic pyrexia by injections of bacteria the tem-
perature was reduced to normal by the spraj-.
By keeping healthy guinea-pigs and rabbits some
hours under spra\' and using from half a pint to
a pint of water at the temperature of the room —
^4° to 62° — the temperature of the animals fell
several degrees.- — Lancet.

786

SOCIETY PROCEEDINGS.

[November 30,

SOCIETY PROCEEDINGS.

Tlie American Academy of Medicine.

Thirteenth Annual Meeting, held at the Leland

Hotel, Chicago, on Wednesday and Thursday,

November ij and i:f, i88g.

Dr. lyEARTus Connor, of Detroit, in the
Chair.

The officers for the year 1888-9 were the fol-
lowing :

President — Dr. lyeartus Connor, Detroit, Mich.
Vice-Presidents — Drs. Peter D. Keyser, Philadel-
phia, Pa.; L. Duncan Bulkley, New York, N. Y. ;
Theophilus Parvin, Philadelphia, Pa.; George J.
Fisher, Sing Sing, N. Y. Secretary and Treasurer
— Dr. Richard J. Dunglison, Philadelphia, Pa.
Assistant Secretary — Dr. Chas. Mclntire, Jr.,
Easton, Pa. Council — Drs. Traill Green, Easton,
Pa.; Lewis H. Steiner, Baltimore, Md. ; Henry O.
Marcy, Boston, Mass.; Benjamin Lee, Philadel-
phia, Pa.; Albert L. Gihon, U. S. Navy; R. S.
Sutton, Pittsburgh, Pa.; Lewis P. Bush, Wil-
mington, Del.; Frederic H. Gerrish, Portland,
Me. ; Leartus Connor, Detroit, Mich. ; Peter D.
Keyser, Philadelphia, Pa.; L. Duncan Bulkley,
New York, N. Y. ; Theophilus Parvin, Philadel-
phia, Pa.; George J. Fisher, Sing Sing, N. Y. ;
Richard J. Dunglison, Philadelphia, Pa.; Charles
Mclntire, Jr. , Easton, Pa.; Hosmer A. Johnson,
Chicago, 111.; Gershom H. Hill, Independence,
la.; Justin E. Emerson, Detroit, Mich.
First Day.

After the reading of the minutes of the last an-
nual meeting, and a verbal report of the Council,
the Academy proceeded to elect a large number
of Fellows, each applicant for admission having
been endorsed by a Fellow of the Academy.

The President appointed the following Com-
mittee on Nominations : Drs. Traill Green, G. H.
Hill, and Alonzo Garcelon.

The following Reports were read from standing
committees : Report of Committee on the Re-
quirements for Preliminary Education in the va-
rious Medical Colleges of the United States and
Canada. By Dr. J. E. Emerson, Chairman.

Report on Laws Regulating the Practice of
Medicine. By Dr. Richard J. Dunglison, Secre-
tary of the Academy.

This comprehensive report was chiefly the out-
come of an extensive correspondence with gentle-
men in the various States and Territories of the
United States and in Canada who were directly
interested in the subject, officially or otherwise,
and who.se names had been suggested to him by
the distinguished Secretary of the Illinois State
Board of Health. It gave, therefore, a very ac-
curate and interesting view of the working of
such laws in the regions indicated. It alluded to

the action of the Committee on Uniform Medical
Legislation in the United States; of the American
Medical Association at its late meeting at New-
port ; to the recent legislation in New York State,
by which a certain standard of preliminary edu-
cation was required of all medical students : and
to the detailed operations of the law in about
twenty of the States of this country.

In Kentuck}', the law was generally observed,
as it is in North Carolina, In Florida the law
has the great defect of requiring every applicant
to produce a diploma from a recognized medical
college, and all those previouslj- in practice one
from a medical college recognized by the American
Medical Association ; but the latter has no relation
to medical colleges, its membership being made
up from medical societies only. The Virginia
law is effectively carried out by the State Board of
Medical Examiners, but the work of the Board
has not caused the colleges to turn out any better
graduates. The law is operative in Indiana ;
Maine is without any law, -the one passed last
year having been vetoed by the Governor ; and
the effect of the law is salutary in Missouri. The
practical effect of the law has not been satisfactory^
to the State Board until recently the latter was
strengthened by a decision of the Supreme Court.

In South Carolina the law has been slightly
amended to increase its efficiency. In Wisconsin
there is really no law which restricts the right to
practice, although only graduates in medicine or
those connected with organized medical societies
can testify in court or collect fees by law. The
law is efficient in Minnesota, and it is found that
the applicants improve in general ability, intelli-
gence and knowledge of medicine with each ses-
sion of the Board. The law in that State is con-
sidered a great protection to the community, and
has been strengthened by decisions of the courts.
Texas is making strong efforts to secure a good
law. The Tennessee law is not perfect, but is a
decided improvement on the nothing which ex-
isted before it was passed. There is a good law
in Maryland, based on the Illinois Act, but it is
not practically enforced. The West Virginia law
is working well, and that of Alabama is regarded
by the profession in that State as " almost ideally
perfect. ' ' In Arkansas there are numerous County
Boards, but the.se, being appointed by Count\-
Judges, are often totally incapacitated for the duty.

In regard to the registration law in force in
Pennsylvania, a correspondent expre.sses the view
that it is the worst one of all, as the system of
protection is applied for the benefit of the medical
colleges, these being made the executors of the
law, the Faculty of one medical college being
made the absolute judge, without appeal, of the
qualifications of the graduates of a competing
medical college. He thinks unrestricted freedom
is better for the public and the profession than an
unfair law unjustly administered.

1889.]

SOCIETY PROCEEDINGS.

787

Reports were made from the following special
corarQittees :

Committee on Papers for Annual Meeting, Dr.
N. S. Davis, Jr., Chairman.

Committee on Eligible Fellows, Dr. S. J. Jones,
Chairman.

Committee on Publication of Transactions, Dr.
A. L. Gihon, Chairman.

Committee on Preparation of a Catalogue of
the Fellows, Dr. R. J. Dunglison, Secretary of
the Academy.

Committee on Atnendments to the Constitu-
tion, Dr. B. Lee, Chairman.

The following papers were then read :

The Institutes of A/cdicine; the Necessity of their
being Taught in our Schools, by Dr. Cheston
Morris, Philadelphia.

Gymnastic Medicine, by Dr. E. Hitchcock, Jr.,
Ithaca, N. Y. This paper was an interesting
sketch of the influence of gymnastic treatment of
disease, in place of that of mere drugs, and the
writer's experience as Professor in Cornell Uni-
versity was cited in advocac5' of the sound prac-
tical views entertained by him on the subject.

The Academy then adjourned until 3 o'clock
P.M., when, Dr, Traill Green, being called to the
Chair, the President, Dr. Connor, delivered
his Address on

THE .\MERIC.\.N ACADEMY OF MEDICINE, ITS SIGNS

OF PROMISE AND OBSTACLES, ITS FIELD OF

LABOR, AND SOME SUGGESTIONS LOOKING

TO AN INCREASE OF ITS EFFICIENCY.

The paper is one that commends itself to every
friend of liberal education and deserves what it
will doubtless obtain —the general attention of
the medical profession. Dr. Connor alluded to
the fact that this was the first meeting of the
Academy in the West. The idea that the Acad-
emy was founded upon a new idea born of an
aristocratic modern notion was combated, the
facts being that Hippocrates urged that the pre-
liminary training of medical men be made as broad
and deep as possible, while by precept and exam-
ple the same idea has been maintained by all the
famous medical men from Hippocrates to Alonzo
Clark. The effects of such changes as are desired
by the Academy are shown by what was accom-
plished b}- the Harvard Medical School when in
1870 it raised its standard of preliminary- require-
ments; previous to this time the medical .students
were inferior to those of the other departments —
now they are indistinguishable. It is objected by
some that broad education does not pay. To this
it is replied that the pure tradesman has no place
in the temple of medicine ; that the highest hon-
ors and emoluments during all time have come to
the physicians who have sought to uplift the pro-
fession. The Academy is pleased to observe that

the effort made by the College of Physicians and
Surgeons in New York and by other colleges to
advance the requirements of preliminary educa-
tion have yielded most satisfactory results ; that
I a recent enactment b}^ the State of New York
shows that the principles advocated by the Acad-
emy have been adopted by a great commonwealth;
that the enemies of the Illinois State Board of
Health have failed to accomplish its ruin ; that
most encouraging results have been obtained by
the efforts of the Minnesota State Board of Ex-
aminers, as evidenced by a recent enactment of
the Minnesota Legislature ; that similar progress
has been made in Montana, Virginia and North
Carolina ; that earnest efforts in the direction of
educational advancement are being made by the
American Medical Association and by pharma-
ceutical societies.

Among the obstacles opposed to the adoption
of the Academy's designs there is one indicated
by the fact that the proportion of literan,- college
students to the entire population has notably de-
creased. The medical colleges themselves oppose
efforts to advance medical education. The pro-
! fessors of medical colleges are often inefficient!}^
\ educated and hence do not encourage liberality
, of education in their pfupils. The lukewarmncss
' of many members of the Academy is opposed to
the effective prosecution of its work. The great-
est of all the obstacles to be encountered lies in
the extensive general ignorance in the profession
itself.

This part of the paper bristled with important
and even startling facts illustrated by the citation
of man}' important statistical figures. Among
these maj' be noted the fact that among 9,306
■ medical students only 81 1 were possessed of liter-
arj- degrees, of which number one-third emanated
from institutions not recognized by this Academy.
j Contrasted with veterinarj^ colleges the compar-
ison remains greatly in favor of the latter. The
number of A.B's. in the medical profession is di-
minishing. On the other hand, the proportion of
A.B's. in the variouss chools of medical practice
presents a pleasanter picture, there being 94 per
cent, among regulars and 6 per cent, among the
various classes of irregular practitioners.

After a survey of the field of useful activit}^ '
I presented to the Academj^ with various recom-
mendations of plans for adoption, the paper closed
with the necrological reports for the j'ear. The
recommendations were referred to the Council,
with the thanks of the Academy for his able
address.

The following papers were then read and re-
ferred to the Council :

I The Need and Position and Object of the Aiuer-
I ica7i Academy of Medicine, by Dr. Traill Green, of
Easton, Pa., was read bj' title.

Dr. S. J. Jones of Chicago, then read a paper
entitled

788

SOCIETY PROCEEDINGS.

[November 30,

WHAT IS THE PROPER FUNCTION OF AMERICAN
MEDICAL COLLEGES OF THE PRESENT TIME ?

He gave a ver5^ entertaining sketch of the his-
tory of medicine, and particularly medical educa-
tion, in this countr}^ from the earliest times. In
Europe, he said, the requirements and attainments
of medical men varj' from time to time in the va-
rious countries. In this country our political
characteristics are such as to acquire certain pe-
culiar features in our medical institutions. For
thirteen years the Academy has labored to in-
crease the standard of preliminarj- education. It
also aims to assist the student in the progress
of his educational studies. The apprentice sj'S-
tem in medicine, as well as its "office student "
outgrowth, has been abandoned. The student
does best to begin his medical education at the
college doors, without seeking to prepare for his
course by office reading with a so-called precep-
tor. Since the Academy first began its labors
many changes have been inaugurated bj- the
medical schools in order to suit themselves and
the requirements and spirit of the times. The
more advanced portion of the medical course is
the one which has manifested the most improve-
ment. The writer believes that the function of
medical schools should be' restricted to teaching,
leaving the matter of examining and licensing to
the various States, because of the variations in
the requirements of medical practice in the differ-
ent sections of the country. The mixed Board
of Health, as seen in Illinois, has accomplished
much good work.

There is nothing new in the idea of separating
teaching from licensing in this countrj', for such
a separation was seen even in the last centurj' ;
while in New York, in 1839, the State Medical
Society resolved that such separation was advisa-
ble. The question is asked, ' ' Is such a separa-
tion practicable?" There were formerly objec-
tions to such a procedure, but these objections are
no longer valid. The National Government does
not assume the right to do this, but the power is
conceded to the several States.

In the early record of American medical history
it is interesting to observe that Drs. Rush and
Drake were both bound out at a very early age
as medical apprentices. This apprentice sA'stem
ended at about 1810. The historj* of American
medical colleges was traced from the foundation
of the fir.st in 1750 down to the present daj-.

The trouble with our modern colleges is that
their facilities are too few and their numbers too
great. It would be unfair to restrain a college
from teaching because its facilities were not of
the best, and yet at the same time a college di-
ploma is an uncertain quantity and often verj'
deceptive. As matters now are, in most States
the authorities are obliged to treat all diplomas
as though they knew them to be of a high order
of value.

Dr. Henry M. Lyman, of Chicago, then ad-
dressed the meeting on the subject of

INSTRUCTION BY RECIT.A.TION.

He said that during the past eighteen years he
had experimented in the methods of instructing
medical students in the several departments of
chemistry, physiology, ner\'ous and mental dis-
eases, and the practice of medicine. As the re-
sult of his experience, he believed it desirable to
have recitation assignments of lessons made. Re-
garding the difficulties in the way of the practi-
cal application of this method of instruction, he
found that the range of usefulness of this method
is not so wide as in literary colleges. The topics
best adapted to this form of instruction are the
elementary branches, anatomj-, physiology, chem-
istr>' and materia medica. Recitations should be
combined with all necessar)- didactic exhibitions.
In the advanced branches the conditions are dif-
ferent ; here the student can still get the theories
from the books, but it is his desire to learn the
views of his various teachers. Recitation, how-
ever, maj' still be used to some extent even in
the advanced branches. Tutors and tutorships
should be established so that classes may be made
small.

There are several difficulties in the way of the
recitative method ; first, there is the lack of suit-
able text-books. Some are too long, some too
short, some not well balanced. There is a splen-
did field for writers in supplying this deficiencj"-
in medical literature. The second difficulty is to
get well-qualified men to teach by this method.
It is not easj- to obtain tutors who are willing to
work on the necessarily small salaries which have
to be paid. It is not uncommon for students to
request lectures instead of recitations, but at the
end of a fair trial of the recitative method the
students are generallj- well satisfied. One of the
disadvantages in lecturing to large classes is that
it is a verj' difficult matter to fix the attention ol
the students, who are apt to be distracted b\- the
least break in the continuity of a lecture.

Dr. J. C. Morris, of Philadelphia, said that
the plan advocated by Dr. Lj'man had been in
operation in Philadelphia ever since he could re-
member— for the quiz classes are recitative classes.
By this method he, as a quiz master, had taught
chemistr>^ materia medica, physiology, and the
practice of medicine. The better students all at-
tended these classes, the method of teaching be-
ing something like that employed by the privat
doceiitcn of Germany and the tutors of Edinburg.
He said that the apprentice .system in medicine
gave way to the preceptor system, in which the
teacher is expected to give instruction by the
method of recitation. Teaching of this kind is
highly nece.ssary as a means of eliminating from
the student's mind errors obtained from a failure
to properly comprehend lectures, and as a means

1889.

SOCIETY PROCEEDINGS.

789

also of increasing his information. In his expe-
rience as quiz master the examinations were more
rigid than the general examinations, and very
few students who were recommended by the quiz
masters failed in their examinations. He would
go farther than Dr. Lyman, and apply the meth-
od to all the branches of medical instruction.

Dr. S. J. Jones